The High Prevalence Of Pregnancy Back Pain Suggests That It Is A Major Public Health Issue.

Back pain during pregnancy is mostly regarded as normal and is expected to spontaneously disappear after delivery. Half or more of pregnant women report pregnancy back pain at some time during maternity, and it is also a common reason for sick leave.

Low back pain and pelvic pain is a common symptom during pregnancy, and the prevalence has been reported to vary from 24% to 90% in different studies.

In one third of pregnant women, back pain is a severe problem compromising normal everyday life. Peripartum pelvic pain interferes with most activities of daily living and with intimacy. Back pain in pregnancy occurs twice as often in women with a history of back pain and women who have been pregnant previously.

Younger women tend to have increased risk for back pain. Occurrence of pelvic pain is associated with twin pregnancy, first pregnancy, larger weight of the fetus, forceps or vacuum extraction, and a flexed position of the woman during childbirth. Women who experienced pelvic pain during a previous pregnancy report a relapse in 85% during a subsequent pregnancy.

Women experiencing pelvic pain during pregnancy have been found to have normal height and weight and normal weight gain during pregnancy; however, body mass index has been reported to be significantly increased among first pregnant women with low back pain.

• A 2021 German study found low back pain is a common finding in pregnant women, accounting for increasing suffering and lack of mobility and leads to an increased cesarean section risk during labor.

What Causes This Pregnancy Back Pain?

Although pregnancy back pain and pelvic pain is a most common complication of pregnancy, its cause is unknown and the mechanism is poorly understood. Some models propose increased spinal load and decreased stability in the pelvic girdle as major causes. Increases in abdominal diameter, fetal weight, and muscular dysfunction have been found to be associated with lower back pain and pelvic pain during pregnancy.

A general increase in mobility of joints during pregnancy has also been described. Different attempts to investigate the cause of increased joint mobility during pregnancy have been made; the hormone relaxin was reported to be associated with pelvic pain during pregnancy. Reproductive hormones and procollagen in serum have been found to be associated with pelvic pain during late pregnancy. Oral contraception has also been investigated in relation to low back pain and pelvic pain during pregnancy with contradictory findings and it’s use has been reported to influence the collagen metabolism.

Some authors consider back pain and pelvic pain to be a normal condition of pregnancy. The symptoms may vary highly, and individuals are affected to different degrees. Nevertheless, referring to the actual scientific knowledge, this condition should be considered a complication of pregnancy for women with substantial impairment. For a small proportion of the affected women, the symptoms will not regress, and instead, the condition may progress into chronic low back pain and pelvic pain after pregnancy.

• According to a 2005 study in the journal Spine, low back pain or pelvic pain during pregnancy was defined as recurrent or continuous pain for more than 1 week from the lumbar spine or pelvis during actual pregnancy.

There is a lack of a uniform classification of low back pain and pelvic pain during pregnancy. Low back pain is commonly defined as pain referred to the area between the twelfth rib and the gluteal folds. This anatomic area also includes the sacroiliac joints, which probably can be considered as a separate functional entity in the pathophysiology of pain in the pelvis. Other terms that are used are posterior pelvic pain, pelvic pain, pelvic girdle relaxation, and pelvic joint instability.

The changes relating to back pain are often mechanical strains from the enlarging uterus and the compensating lumbar lordosis (increase in curve). Weight gain along with laxity of the ligaments can impede normal anatomical and biomechanical function. The resulting increase in loading is often focused on the lumbar discs and increased back strain is also placed on the muscles.

• A 2019 study in Clinical Biomechanics found the motion of standing to sitting is complicated by an increase in the curvature or lordosis of the lumbar spine during the initial standing posture. This would be termed “gestational lordosis” and limits the motion of the hips. Shifting motion away from the hips and towards the upper body helps explain increased back pain as well as fall rates when transitioning from standing to sitting.

Are Pregnant Women At Higher Risk Of A Herniated Disc?

• There is sometimes a pinched nerve or symptoms of sciatica, however, it is usually due to a compression neuropathy from the pregnant uterus. Notably, a 2008 report in the journal Analgesia & Anasthesia indicates that pregnant women have an incidence of a lumbar herniated disc of 1 in 10,000, which is NOT increased compared to the general population.

What Are Risk Factors For Pregnancy Back Pain?

History of previous low back pain and pelvic pain during pregnancy was associated with recurrence of low back pain and pelvic pain. Parity was a risk factor for low back pain and pelvic pain. Young women have been found to have more pain than older women; however, in other studies maternal age was not associated with level of pain or with prevalence of low back pain and pelvic pain during pregnancy. Prolonged pregnancy has been demonstrated to be significantly associated with low back pain and pelvic pain; however, gestational age per se was not related to low back pain and pelvic pain, and the prevalence at post-term was lower than the prevalence of at term.

Women developing low back pain and pelvic pain weighed significantly more and had a significantly higher body mass index. The prevalence of hypermobility among women with pelvic pain has been estimated to be 12.8% to 17.3%. Diagnosed hypermobility or a family history of hypermobility was associated with an increased risk for low back pain and pelvic pain. This indicates the importance of hypermobility as a contributing factor during pregnancy.

A family history of low back pain and pelvic pain is associated with an increased risk for low back pain and pelvic pain. This association may correspond to inheritance or/and lifestyle factors.

The above study 2005 in Spine indicated a majority of pregnant women report low back pain and pelvic pain. Parity, previous low back pain and pelvic pain, body mass index, a history of hypermobility and amenorrhea are factors influencing the risk of developing low back pain and pelvic pain.

The high prevalence of low back pain and pelvic pain during pregnancy makes it a major public health issue, and efforts should be made to promote causal studies with the future aim of prevention and therapy of low back pain and pelvic pain. Different methods such as histologic examinations, immunology characterizations, and investigation of distribution of different hormone-receptors in connective tissue and muscle tissue may be possible attempts in discriminating deviating patterns in women with low back pain and pelvic pain during pregnancy.

• A 2019 study in the British Journal of Neurosurgery found an association with spinal degeneration, a common cause of back pain, and number of children in young women. Women giving birth to only one child were at higher risk. The most significant type of degenerative condition was Schmorl’s nodes. Other related factors were disc disease and Modic changes. It seems having more children is protective against spinal degeneration compared to just one.

• A 2021 study in BMC Musculoskeletal Disorders found women who worked more than 8 hours per day, as well as women who lifted heavy objects at work on a regular basis, were more likely to experience pregnancy related lower back pain.

• A 2023 study in Somatosensory & Motor Research foun intensity of low back pain, level of disability, level of physical activity, and body awareness are significantly correlated with kinesiophobia (an excessive irrational and debilitating fear of movement) in pregnant women with lower back pain. The authors indicate kinesiophobia can be an important issue in pregnancy education programs.

What Helps?

• According to another 2005 study in Spine, giving information about the condition along with a maternity support belt is beneficial, and exercises do not seem to have additional value when treating pregnant women. A non elastic pelvic support belt located just above the hips enhances stability.
• A 2019 study in the Journal of Gynecology Obstetrics and Human Reproduction pregnancy related changes in ligament laxity are associated with various disorders such as back pain or pelvic floor disorders. The authors indicate this laxity reaches its maximum at the second trimester, indicating a time frame for when to consider using a maternity belt.
• It is perhaps impossible to get any benefit from stabilizing exercises of the muscles around the pelvic girdle during pregnancy due to many natural changes in the body and limited time to exercise. Performing exercises has no additional value above giving a support belt and information. In fact, in a previous 1994 study in Spine, it was shown that reduction of posterior pelvic pain by a pelvic support belt was experienced by 82% of the women with posterior pelvic pain.
• A 2007 study in the International Journal of Nursing Studies states “Promoting good posture and regular exercise can be recommended as a method to relieve back pain in pregnancy women.” Advice to stay active within limits and use of maternity or pregnancy body pillows to help with postural support while sleeping is reasonable. There are also leg pillows and knee pillows that help with postural alignment and relieve back strain.
• A 2020 study in Gait & Posture found that pregnant women in the third trimester take fewer steps and walk at a slower pace compared to second trimester and 12 weeks postpartum, indicating that total level and intensity of physical activity are altered during pregnancy.
• A 2009 study in the journal Applied Ergonomics. relating pregnancy and low back pain in working women indicates that staying in a “confined area” and “having restricted space” were positively correlated with severity of back pain at 34 weeks of pregnancy. The study suggests that allowing pregnant women to take more rest breaks and to have more job autonomy may reduce the severity of back pain during early pregnancy, and that allowing movement outside the working area and providing less restricted space may reduce pregnancy back pain during late pregnancy.

• A 2021 study in the Journal of Obstetrics and Gynaecology Canada found 76% – 80% of participants with low back pain and pelvic girdle pain were pain free at 1, 3, and 6 months postpartum. Pregnancy related back pain was the only risk factor associated with postpartum related pain at the 1 to 6 month time interval. The authors indicate, “Identification of site-specific postpartum-related back pain may assist in determination of management and treatment plans for this population.

Educational strategies, such as ergonomics, learning correct posture to reduce stress on the spine. Braces that ensure correct body posture are also available. Rest scheduled during the day is helpful to relieve muscle spasms and more acute pain. Both feet should be elevated, which flexes the hips and helps reduce the lumbar lordosis.

• Evidence delineated in a 2007 comprehensive review in Physical Medicine and Rehabilitation Clinics of North America indicates most patients respond positively to postural and activity modifications.

If these measures for pregnancy related back pain are not enough, studies indicate pregnant women with lower back pain that also participate in reasonable physical therapy have less pain, disability, and a higher quality of life. Therapy often includes stretching, strengthening, and self-mobilization techniques. Flexion increases strength of the abdominal muscles and decrease the lumbar lordosis, while extension increases strength of the paraspinal muscles. These are often accomplished with water therapy or Yoga.

Doctors Note:

• Chiropractic care can certainly help and a 2008 systematic review in the Journal of Manipulative & Physiological Therapeutics indicates it’s polarity and effectiveness. I have treated many patients, usually a sitting mobilization/adjustment approach is effective. I would use a flexion-distraction table with an abdominal drop piece for more complicated cases.
• A 2019 study in the Nordic Journal of Psychiatry indicates that physical discomfort in early pregnancy, like back or pelvic pain, is a risk for postpartum depressive symptoms. The authors indicate vulnerable mental health, present in early pregnancy, explained most of the associations found in the study.

Pregnancy can be difficult time when pain is experienced. How much the pain was related as a causal factor of increased psychological vulnerability translating into postpartum depression is not indicated, however, early treatment and education should be indicated to help ease anxiety and discomfort. Professional counseling should always be considered in concordance with symptoms, treatment response and results of any appropriate assessment questionnaires.

• A 2020 study in BMC Pregnancy & Childbirth regarding sleep complaints and early pregnancy (5 to 16 weeks) concluded that it is common and due to both physical as well as mental symptoms. Addressing both depression and mood in relation to sleep problems during pregnancy is recommended.

At least one of three complaints was reported by 38% of women; taking a long time to fall asleep (23%), waking up too early (47%), and lying awake most of the night (14%). Moderate or severe complaints were reported by (21%) and were associated with pregnancy related physical symptoms, like back pain and pelvic girdle/cavity pain. Only the association with pelvic cavity pain remained significant after adjustment for depression.

A 2019 meta-analysis in JAMA Network Open found that women in the third trimester who sleep on their back (supine position) was associated with reduced birth weight and lower birth weight percentile. The authors indicate, “Public health campaigns that encourage women in the third trimester of pregnancy to settle to sleep on their side have potential to optimize birth weight.”

So, using good body pillows and/or a side sleeping pillows is a recommended method to assist comfortable side sleeping, which is better for your baby after 28 weeks of pregnancy. Leg pain may be due to varicose veins.

• A 2020 study in Gait & Posture found there was smaller gluteus maximus muscle use during the second trimester and post-partum. Because this muscle contributes to dynamic stability of the low back and pelvis, disuse along with increased joint loads may contribute to pain during and after pregnancy.

Fortunately, there are many ways to increase the strength of this muscle. The above example (Glute Bridge) is just one. Raise and hold as long as possible without pain, then gradually increase hold time. Keep your spine straight and knees together.

• A 2021 study in the journal Orthopaedic Surgery found women with asymmetrical paraspinal muscles prior to pregnancy can be an indication of abnormal biomechanics that can lead to lumbar and pelvic pain during pregnancy. The authors indicate that early treatment may help decrease the occurrence and severity of this condition. Strengthening weak muscles and stretching contracted ones are helpful. Addressing segmental biomechanics and muscular balance would be my method of choice.

• A 2021 study in the Journal of Family Medicine and Primary Care found patients with pregnancy related low and upper back pain, leg cramps, coccyx pain and sacro-iliac joint pain were advised to do exercise, postural correction, regular walking, and electrotherapy throughout their pregnancy. The impact of on both ante-natal and post-natal women with fitness related health problems showed significant improvement. The authors concluded, pain during pregnancy are common complaints that start early and may persist throughout life if treatment does not start early.

• Always treat women with respect and kindness. You never know when a woman may be pregnant, so helping women can promote a better and healthier next generation.

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