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13 Articles in Volume 11, Issue #4
Diagnosing and Managing Hand Osteoarthritis
Difficult Migraine Patient
Electromagnetic Applications In Biology and Medicine
Excerpt from the Book Avoiding Opioid Abuse While Managing Pain
Hormone Therapies: Newest Advance in Pain Care
Make the Family Your Best Friend
Medications for Chronic Pain—Opioid Analgesics
Nonpharmacologic Remedies for Back Pain During Pregnancy
Reconsidering and Revising Evidence-Based Practice in Pain Medicine: Steps Toward Sustaining the Profession?
The Value of Blood Analysis for Compliance Monitoring
Treatment of Neuropathic Pain: The Role of Unique Opioid Agents
Understanding Potential Complications Of Epidural Steroid Injections
Unmasking Post-traumatic Headache

Nonpharmacologic Remedies for Back Pain During Pregnancy

Back pain is a common, often undertreated, complaint among pregnant women. Treatment programs that target weakened muscle tone and posture can help treat some of the common causes of back pain.

During pregnancy, a multitude of new stressors are introduced to the female body as it undergoes physiologic changes. One of the most common complaints is low back pain, which has been reported to affect between 50% and 80% of all pregnant women.1 Additionally, between 10% and 33% of these women experience back pain severe enough to interfere with their daily activities and, at its worst, require prolonged bed rest.2 Despite its prevalence, back pain in this population is severely undertreated because only about 50% of women who experience pain during pregnancy actually seek treatment.3

The etiology of back pain during pregnancy is multifactorial, demonstrating that many evolving physiologic systems contribute to this condition. The management of back pain in this population is obviously very different from the management of back pain in non-pregnant patients, yet physicians need not be apprehensive about treating pregnant women because of concerns about interfering with the pregnancy or harming the fetus. There are a number of safe and effective options available that providers can recommend for these patients.

Musculoskeletal Changes

To best understand the options available to treat back pain during pregnancy, it is important to review some of the postural and hormonal physiologic changes that may be contributing factors. As the pregnancy advances, the increasing weight of the gravid uterus and breast tissue cause a woman’s center of gravity to be displaced anteriorly. To compensate, the head and upper body shift posteriorly over the pelvis, introducing a hyperlordosis of the lumbar spine.4 It is thought that this weight shift causes stress on the intervertebral joints, facet joints, and ligaments, stimulating inflammation of these joints and leading to back pain in the lumbar spine.5 Mogren et al reported that the average onset of back pain was 22.1 weeks into the pregnancy—approximately the fifth or sixth month.1 This is expected because the enlarging abdomen becomes large enough at this time to trigger these compensatory musculoskeletal changes.

The abdominal musculature strength cannot be ignored when considering its role in the development of back pain in this population. The sheer volume and weight of the enlarging uterus place increased stress on the abdominal wall to support it. Eventually, the abdominal muscles weaken as they are stretched to capacity and can no longer support the weight of the fetus, forcing the lumbar musculature to assume additional responsibility in maintaining stability.6

Hormonal Changes

It is not only postural changes that are at the root of back pain. Because some women begin to experience low back pain during their first trimester, when biomechanical changes have not yet occurred, there must be another physiologic factor that results in pain.1 Early studies have pointed to a 10-fold increase in the serum levels of relaxin, a polypeptide hormone released by the corpus luteum, as a potential cause for back pain.3,7 In fact, there appears to be a direct correlation between the level of serum relaxin and the severity of one’s back pain.8

The primary target in the body on which the relaxin hormone exerts its effects is connective tissue; it stimulates collagen turnover by upregulating the production of collagenase enzymes and by modulating collagen synthesis at the cellular level of the fibroblast.9 This state of continuous collagen remodeling may have profound effects on the entire musculoskeletal system, most notably the pelvic girdle.10 For example, it triggers systemic laxity of the joints and decreased tensile strength of the ligaments, both of which lead to increased range of joint motion.11 Lumbar muscles increase in tone to counteract the weakening of the pelvic girdle, causing stiffness and pain in this region. Although these changes are necessary to accommodate the growing fetus and allow for delivery, the low back bears most of the responsibility of compensating for them.10

There are many pharmacologic treatments for back pain in non-pregnant women; however, the risk of harming the fetus precludes the use of drugs other than acetaminophen, which is quite safe and is the drug of choice to treat pain during pregnancy. Despite this, there are still a number of nonpharmacologic treatments a physician can offer that are both effective and safe for mother and child, many of which can be done in one’s own home. Most treatments center on maintaining good posture and directly strengthening weakened muscles, but some use the body’s own physiology to restore and maintain an equilibrium typically lacking during the dynamic period of pregnancy.

Exercise Brings Relief

With regard to relieving or preventing back pain in the pregnant patient, it is essential to attain and maintain proper posture, secondary to increased muscle tone. Preventive measures are best because treatment for back pain late into pregnancy tends to be less successful.3 In addition, women who are more physically fit prepartum experience less back pain during pregnancy.12 That is not to say that women who are physically unfit prior to pregnancy are completely helpless; according to one study, patients who began an individualized training program before or early in pregnancy experienced less overall back pain than those who did not.13 Included in this training program were simple exercises that targeted potentially weakened muscles to lessen the compensatory burden of the lumbar spine. These exercise regimens do not have to be onerous or time consuming; one study showed that one can achieve lumbar pain relief in only 45 minutes of exercise per week.14

Two exercises that every pregnant woman can easily work into her exercise regimen are the pelvic tilt and Kegel exercises. The pelvic tilt can be performed seated, standing, or on all fours and improves posture and eases tension on the low back by strengthening the abdominal muscles. Kegel exercises, easily performed by contracting the muscles that would stop the flow of urine during urination, are important in strengthening the weakened muscles of the pelvic floor. The reinforced pelvic floor provides necessary support for the enlarging abdomen. Kegel exercises may have the additional benefit of relieving urinary incontinence, a common complaint of many pregnant women. Of course, there are countless other exercises women can do for back pain relief; a pamphlet released by the American Congress of Obstetricians and Gynecologists illustrates some examples (see Figures, page 53-55).15

In addition to being shown to relieve back pain, aquatic exercises may provide added benefits compared with land-based exercises. Exercising in water may prevent falls due to an altered center of gravity, and it encourages the use of both flexor and extensor muscle groups in order to remain afloat.16,17 Also, during body immersion, the increased hydrostatic pressure promotes venous return to the heart, thereby reducing edema and increasing urinary elimination.18 There have been no studies to date comparing the degree of back pain relief in pregnant women who exercise in water with those who exercise on land.

Exercises to Relieve Pregnancy Back Pain 1

Exercises to Relieve Pregnancy Back Pain 2

Exercises to Relieve Pregnancy Back Pain 3

Other Treatment Options

If exercise does not help to alleviate the patient’s back pain during pregnancy, there are a number of other options that may provide relief. One option is to wear body supports, which are commercially available and come in several types. Abdominal belts support the weight of the abdomen, doing the job the weakened abdominal muscles cannot. This essentially reduces the compensation needed by the low back to maintain proper posture and decreases strain on the lower back. Sacroiliac and trochanteric belts may be used to reinforce the unstable pelvic girdle. Berg et al showed that low back pain relief was achieved in 71% of women who used a sacroiliac belt and in 82% of women who wore a trochanteric belt.19 However, additional research testing the effectiveness of maternity support belts has found that they provide no statistically significant back pain relief whatsoever, so more investigation is necessary to clarify their role during pregnancy.20

Another treatment modality is osteopathic manipulative treatment (OMT), a hands-on body-based modality that assesses and treats each patient as a whole, integrating structure and function to encourage normal physiologic functioning and eliminate any impediments to the healthy state.21 Because all patients are not exactly alike, there is no standardized osteopathic manipulative treatment that works for every patient; instead, treatments must be individualized using various manipulative techniques to meet the structural and functional needs of each person. With that being said, there are certain “problem areas” that can be targeted in a pregnant woman, for example, the lumbar spine, sacrum, innominates, paraspinal muscles, and joints of the pelvic girdle.

Since the beginning of osteopathy, there have been case reports describing the positive effect of OMT on reducing back pain in pregnant women. More recently, a limited number of evidence-based studies assessing the value of OMT in treating back pain in the pregnant patient have shown positive results. One prospective study found a statistically significant reduction in overall musculoskeletal pain in 45 women who received OMT compared with 52 women who did not.22

A landmark study, the first randomized, placebo-controlled, clinical study on the topic, was published in 2010 by researchers at the Texas College of Osteopathic Medicine. Using Roland-Morris Disability Questionnaire scores and an 11-point subjective pain scale to assess back-specific pain and function in 3 treatment groups: 1) “usual obstetric care and OMT,” 2) “usual obstetric care and sham ultrasound treatment,” and 3) “usual obstetric care only,” researchers concluded that OMT decreases back pain and slows the deterioration of back-specific functioning in the third trimester.23 Additionally, there were no adverse events or injuries reported by the patients who received OMT. More trials investigating the efficacy of OMT should be done so that eventually it may become included in routine obstetric care.

In addition to all of the aforementioned treatments that have been studied in randomized controlled trials (RCTs) and proven to provide statistically significant back pain relief in pregnant women, there are a host of other simple recommendations that medical professionals can suggest to their pregnant patients. Although none of these tips specifically has been scientifically studied in RCTs, they theoretically will provide relief while not exacerbating one’s back pain and are backed by plenty of anecdotal evidence.

Because good posture is paramount, it is suggested that these women avoid wearing high-heeled shoes or other footwear that does not provide adequate body support. Good posture when sitting is just as important as good posture when standing; for women whose jobs require that they sit for hours at a time, a combination of a lumbar support pillow and a footstool (leg elevation while sitting can reduce pressure on the lower back) can improve posture and ease pain.

Taking the weight of the abdomen off the low back—for example, by sleeping on one’s side, specifically the left side, rather than on the back and by bending at the knees instead of at the waist to pick up something off the floor—can be therapeutic. Direct application of alternating hot and cold packs can relieve back pain in anyone, not just pregnant women; the hot packs relax the muscles while the ice packs serve to numb the painful area. There have been a handful of limited preliminary clinical trials touting modalities that fall into the category of alternative medicine, such as yoga and acupuncture, though more research likely needs to be done to fully study their efficacy in alleviating back pain during pregnancy.

Conclusion

Low back pain does not have to be a difficult-to-treat, inevitable by-product of pregnancy that remains unaddressed. There are many safe and effective nonpharmacologic options available from which patients and healthcare providers can choose. Though caused by different mechanisms, the two main causes of back pain in pregnant women, weakened musculature and distorted posture, are the primary targets of most of the treatments. It should be noted that when a pregnant woman presents with back pain, she should be given a full workup to rule out any sinister causes of the pain. As soon as they are excluded and the back pain is attributed to the musculoskeletal changes of the pregnancy itself, the physician can begin a treatment regimen by incorporating one or a combination of the above mentioned remedial options.

Note: Steven Ross and Dr. Leonard Goldstein have no financial information to disclose.

Last updated on: September 13, 2011
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