Low Back Pain and Pregnancy

General info

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Summary

Data about the condition

Pregnancy related low back pain is a common complaint that occurs in 60-70% of pregnancies and can be defined as pain between the 12th rib and the gluteal folds/pubic symphysis during the course of pregnancy, possibly radiating to the posterolateral thigh, to the knee and calf, but not to the foot.  This pain is not the result of a known pathology such as disc herniation and can begin at any point during pregnancy.

Although most cases are mild, approximately one third of women experience severe pain. Pregnancy related low back has been coined multiple times and can be referred to as one of the following patters: Low Back Pain (LBP), Peripartum Posterior Pelvic Pain (PPPP), Pregnancy-related low back pain (PLBP) or pregnancy-related pelvic girdle pain (PPGP). The last two patterns can occur separately or combined.

The lumbar region is constituted of five unique vertebrae that are designed to withstand increased weight and retain a lordotic curve. The vertebral canal of the lumbar region houses the tail end of the spinal cord and the cauda equina.

To maintain stability and provide support, the lumbar region is connected and held secure by an intricate web of ligaments: ligamentum longitudinale anterior and superior, ligamentum flava, ligamentum interspinata, ligamentum intertransversarium and the ligamentum supraspinale.

All the mentioned ligaments will provide stability, whereas the longitudinal ligament will also be attached to the intervertebral disc in order to keep the discs in position. Additionally, the lumbar region is supported by strong low back muscles, pelvic muscles and abdominal muscles.

Simptomes

• Severe pain
• Difficulty urinating
• Tingling feeling in the legs

Causes

Mechanical

There are several possible mechanisms of injury which could be causing pregnancy related LBP. During pregnancy, changes occur in the facet joints, in the back muscles, and in ligaments. This is mainly caused by the increased release of the hormone relaxin,which causes ligament laxity, and therefore can affect the stability of the spine and lead to back pain.

During pregnancy, the enlarging gravid uterus changes the load and body mechanics. It’s shifts the centre of gravity forwards, increasing the stress on the lower back. Postural changes can be used to balance the anterior shift possibly causing an extra lordosis. This increases the natural inward curvature of the spine, which increases the mechanical strain on the lower back. It also puts an extra stress on the intervertebral disc, possibly causing a decreased height an overall compression of the spine. 

Another contributor is the increase in weight that comes with pregnancy. On average, about 11-15 kilograms are gained during pregnancy. The weight gain increases the amount of force placed across joints, changes the center of gravity, and forces the patient into an anterior pelvic tilt.

The anterior displacement of the center of gravity will cause women to shift their heads and upper body posteriorly over the pelvis, causing hyperlordosis of the lumbar spine. This in turn, places additional stress on the intervertebral discs, ligaments, and facet joints and can lead to joint inflammation. In addition, abdominal muscles are stretched and weakened, and the added weight can compress on the lumbosacral plexus.

Hormonal

A significant portion of women first experience pain during the first trimester of pregnancy. At that moment mechanical changes do not yet play a significant role in the onset of pain. This suggests that hormonal changes during pregnancy can cause inflammation and pain in the back.

It has been suggested that the hormone relaxin increases 10-fold in concentration during pregnancy, softening the collagen and causes ligamentous laxity and discomfort. The sacroiliac ligaments, but also other ligaments who surround the pelvic girdle become loose. This causes a decrease in the stability and brings on a potential strain in the pelvic girdle and low back area.

Circulatory

The expanding uterus can press on the vena cava, particularly at night when the patient is lying down. The pain is possibly severe enough to wake the patient up. This combined with the increased fluid volume from fluid retention during pregnancy leads to venous congestion and hypoxia in the pelvic and lumbar spine.

Psychosocial Factors

Psychosocial factors can also increase low back pain. Pain-related catastrophizing, depression, pain intensity and time result in an increases in pain interference. The findings support the potential utility of the biopsychosocial model. Pain catastrophizing can be considered as a risk factor in the third trimester of pregnancy.

The objectives of the Recovery Program

• pain relief, 
• biomechanical restoration,
• lumbopelvic stabilization,
• lumbopelvic coordination
• functional preservation and prevention.

The content of the Recovery Program

Streching

Lower Back Stretch: it is plausible that stretching lower back and hip extensor muscles can lead to increased lower back and pelvic flexibility.

Instructions:

1. Clasp your fingers around your right knee.
2. Gently pull your knee as close to your chest as possible. Relax your lower back and try to let your glutes (butt) roll of the floor as you pull.
3. Hold for a slow count of 3.
4. Release.
5. Repeat steps 1-4, 12-15 times.
6. Now, grasp your left knee, put the right foot flat on the floor and repeat steps 1-5
7. Finally, grasp both knees with your hands, and pull both knees close to your chest (or outside your stomach)
8. Repeat steps 2-5.

Exercises:

Angry Cat – Starting from the hands-and knees-position the patient will move her back up and down. 
During this exercise it is important to keep the arms stretched out with the hands positioned right under the shoulders and to keep the stomach muscles tight throughout the entire exercise.

Pelvic Tilt – Lay down with flexed knees and move the pelvic in an anterior and posterior position.

Strengthening Gluteus Medius  – Position the patient in a side lying and place an elastic around both legs above the knees.  the patient will perform an external rotation of her leg in order to strengthen the Gluteus Medius. Perform this exercise on both sides. Feet need to be kept together during the whole exercise. Also, prevent the pelvis from externally rotating.

Abdominal Drawing in Maneuver with Physioball (ADIM). – the patient will sit on a physioball and simulate a walk movement with the lower extremities. This will encourage the back muscle memory to stabilize back during ADL’s.

The patient will have to keep her back strait during the whole exercise.

Methodical Indications

• Using a small pillow between the legs while sitting and rolling in order to stabilize the back.
• Postural correction by standing upright with a neutral posture, avoiding hyperlordosis
• Do not sit or stand for a long time, alternate it with walking or stretching
• Taking breaks and resting in a comfortable position, with the back supported to relieve tired muscles^.
• Sleeping lying on one side with the top leg on a pillow
• “Use of a small footstool for one foot in sitting or standing, alternate feet”
• Avoiding spine twisting while lifting

Proper Lifting Techniques

1. Plan The Lift: Know how heavy the object is. Clear a path and know where the object is to be placed.
2. Lift Close to the body: This will make the body stronger and more stable. Ensure there is a firm hold on the object and balance it close to the body.
3. Feet shoulder width apart: This allows for a solid base of support.
4. Bend the knees while keeping the back straight: Avoid any twisting motions.
5. Tighten the stomach muscles: This will hold the back in good alignment and prevent excessive force on the spine. Avoid breath holding.
6. Lift with the legs: The leg muscles are stronger than the back so use them.
7. Avoid straining, get help: Get help if the object is too heavy or it is in an awkward position.

Did you know?

The majority of pregnant women experience low back pain. Appropriate examination, interventions and follow up, can help in managing the pain. There are many physiotherapy treatments for pregnant woman with low back pain. Our research suggested a combination of instructions, manual therapy, active exercises, aerobic exercises and stretching.

Key questions must be asked and special modifications must be made for more complex patient experiencing pregnancy related back pain. As patient centered practitioners, it is our job to research and implement evidence based practice to increase outcomes with minimal number of treatments.

You can also read about Lumbar disc herniation