Extracted from The Physician
and Sports Medicine
Back Pain and Pregnancy: Active Management Strategies
Julie Colliton, MD
In Brief: For about half of all pregnant women, low-back
pain is inevitable. Physicians who can specify what type of back
pain the patient has--lumbar, sacroiliac, or nocturnal--can institute
targeted treatment that addresses the relevant pathophysiology.
Acetaminophen and certain modalities such as icing the area are
the basis of acute treatment in conjunction with ergonomic adaptation
and a good low-back exercise program. This will help decrease stress
on the low back, making back pain less likely. Before a woman becomes
pregnant, encouraging her to become fit and resolving existing back
problems is the key to back pain prevention.
If the discomfort of back pain during pregnancy can be severe enough
to warrant sick days and disrupt sleep, it's easy to deduce that
it could be an obstacle to activity for women who want to reap the
health benefits of exercise during pregnancy. In the past, women
were told that biomechanical low-back pain was simply part of pregnancy.
Now, though, it is known that the causes of low-back pain during
pregnancy are specific and that effective treatment should be geared
toward the precise pathology.
Formal study of the incidence of low-back pain in pregnancy has
been very limited. The overall prevalence of back pain during the
9-month period is thought to be approximately 50% (1,2). Pain can
begin before week 12 and continue up to 6 months postpartum.
Various studies (1,3-6) have examined the risk factors that contribute
to the development of low-back pain during pregnancy. Prepregnancy
back pain and multiparity seem to be risk factors, whereas age,
height, weight, race, fetal weight, and socioeconomic status do
not seem to correlate.
Low-back pain during pregnancy can be classified into three types:
- Lumbar pain can occur with or without radiation to the legs.
True sciatica is rare and thought to account for a small percentage
of low-back pain in pregnancy (7,8).
- Sacroiliac pain is felt distal and lateral to the lumbar spine
near the posterior superior iliac spine, and may radiate to the
posterolateral thigh, usually to the level of the knee and rarely
to the calf. It is four times more common than lumbar pain (9).
Symptoms of sacroiliac joint pain typically continue several months
after delivery. It is thought that 20% to 30% of pregnant women
experience both lumbar and sacroiliac pain (10).
- Nocturnal pain occurs in the low back only at night while recumbent.
Why Does Her Back Hurt?
Understanding the normal musculoskeletal changes that occur during
pregnancy is useful for targeting and treating the sites of a patient's
back pain.
Lumbar pain. Lumbar pain during pregnancy can stem from
multiple sites, most commonly the facet joints, paraspinal muscles,
supporting ligaments, or discogenic sources.
Posture changes that occur during pregnancy help the woman maintain
balance in the upright position as the fetus grows. The increasing
weight is distributed primarily in the abdominal girth. After 12
weeks of pregnancy the uterus expands out of the pelvis and moves
superiorly, anteriorly, and laterally. The abdominal muscles become
less effective at maintaining neutral posture (shoulders back, avoiding
hyperlordosis) because the growing uterus stretches the muscles,
reducing their tone. Initially, however, studies have shown that
lumbar lordosis remains the same or increases only slightly (11).
The center of gravity as a whole, though, shifts more posteriorly
and inferiorly as the spine moves posterior to the center of gravity.
As pregnancy progresses, the hormone relaxin, which allows pelvic
expansion to accommodate the enlarging uterus, increases tenfold,
reaching its peak at the 14th week (12,13). Joint laxity is more
pronounced in multiparous women than it is during the first pregnancy.
In the lumbar spine, joint laxity is most notable in the anterior
and posterior longitudinal ligaments, both of which are pain-sensitive
structures. As these static supports in the lumbar spine become
more lax, they can't as effectively withstand shear forces, and
discogenic symptoms and/or pain from the facet joints may increase.
As the abdominal muscles stretch to accommodate the growing fetus,
their ability to help stabilize the pelvis decreases. The burden
shifts to the paraspinal muscles, which become strained at a time
when they may be shortened from the increased lordosis of the lumbar
spine.
Sacroiliac pain. In the pelvis, joint laxity is most prominent
in the symphysis pubis and the sacroiliac joints. The symphysis
pubis widens throughout pregnancy from its normal width of .5 mm
to a maximum of approximately 12 mm. With widening comes the possibility
of vertical displacement of the pubis and rotatory stress on the
sacroiliac joints.
In the nonpregnant state, the sacroiliac joints are extremely stable
with tight anterior and posterior ligament support and a sigmoid
articular surface that limits movement. During pregnancy, however,
movement in the sacroiliac joints can increase dramatically, causing
discomfort when the pain-sensitive ligamentous structures are stretched.
Nocturnal pain. Some women have night back pain exclusively,
others have both night pain and lumbar or sacroiliac pain. There
are many theories about why night pain develops. One theory is that
muscle fatigue accumulates throughout the day and culminates in
back pain at night. Another is that daylong biomechanical stress
from sacroiliac dysfunction or mechanical low-back pain from altered
posture produces symptoms in the evening. Circulatory changes during
pregnancy may also contribute to low-back pain at night.
Extracted from 'Back Pain During Pregnacy' from www.women.com
Dear Toni,
Unfortunately, many women experience lower back pain during pregnancy.
I can truly empathize with your condition. Luckily, I didn't need
a TENS unit during my own pregnancies, but at times I was close.
It will get better once you deliver, but that clearly is a ways
away. Apply heat. Many women are afraid of heat during pregnancy;
however, you would really have to fry yourself to damage the child.
Try sitting in a warm tub or jacuzzi. You don't want the water too
hot, but a nice 100° F tub will work wonders.
Wear a support gadget.
There are abdominal support straps (they look like school crossing
guard straps) that help support the pregnant uterus. These may help
you move more freely. Also, if you have access to a swimming pool,
go for it -- swimming is wonderful exercise for pregnancy, and water
will also help support your pregnant uterus. Do strengthening exercises.
Pelvic-tilt exercises help strengthen the back, relieving pain.
And, often, just putting yourself into the knee-chest position to
get the baby out of the pelvis and off of your pelvic nerves may
make you more comfortable.
Take medications cautiously. Certain medications can be used safely
during pregnancy. Although I discourage my patients from taking
non-steroidal anti-inflammatories during pregnancy, tylenol in standard
doses is allowable. For severe pain, narcotics such as codeine will
not hurt the baby. The good news is that I have not found that labor
is significantly worse for women with bad backs, and very rarely
do back problems prevent the use of the epidural anesthesia. Remember,
there is an end in sight!
Further information can be found at:
Natural
remedies during pregnacy
I
have Scoliosis, does pregnacy increase the curvature of the spine?
How
the Alexander Technique can help during pregnacy
