Low back pain during pregnancy is caused by lumbar pain and pelvic girdle pain. Low back pain is very common in pregnancy and 2/3rd of pregnant females complain of mild to severe lumbar backache.1 Half of the low back pain is caused by lumbar backache, which originates from lumbar vertebrae between L2 and S1. Cause of remaining 50% of the low back pain is pelvic girdle pain, which originates from circumference of pelvic girdle.2 Twenty five percent of the pregnant patients suffer with serious pain during pregnancy.2 Twelve month study involving 693 patient suggests significant number of patient continue suffering with low back pain after delivery. Pain was recurrent in 65% patient and continuous in 15% of the patient following pregnancy.2 Pregnancy is associated with increased level of hormone relaxin, which helps to relax the pelvic ligaments. Relaxin hormone assists in increasing the diameter of pelvic girdle, which is essential for accommodation of placenta, amniotic fluid and fetus. Inadequate or abnormal relaxin hormone secretion causes tight pelvic girdle and initiates pelvic girdle pain.
Causes of Low Back Pain During Pregnancy
Pelvic Girdle Pain: A Cause Of Low Back Pain In Pregnancy-
- Low Relaxin Level3– Causes inadequate relaxation of pelvic ligaments and restricts the expansion of pelvis resulting in low back pain during pregnancy.
- Weight Gain– Weight gain is associated with increased fat deposition and interferes with relaxation of pelvic girdle resulting in low back pain.
- Weight Distribution– Abnormal pelvic tilt during pregnancy can cause increased pelvic girdle pain. Pelvis is tilted forward in normal individual female. Large fetus increases amniotic fluid secretions as in diabetes, and over relaxed pelvis causes imbalance in weight distribution of pelvic organs resulting in abnormal tilt of pelvis and pelvic girdle pain.
Other Causes of Low Back Pain During Pregnancy-
- Hormonal Changes3– Hormonal changes in pregnancy can influence low back pain. Correction of natural lumbar lordosis is necessary to accommodate fetus and amniotic fluid in abdomen. Relaxin hormone is essential to modify the lumbar lordosis. Inadequate relaxin hormone maintains normal lumbar lordosis and results in low back pain.
- Osteoporosis4– Osteoporosis is a generalized disease of bone caused by low calcium deposits. Osteoporosis causes weak bones and weak skeletal system. Pregnancy often leads to fracture of lumbar vertebrae in osteoporotic pregnant patient resulting in low back pain.
- Weight Gain– Weight gain causes excessive and abnormal weight transmission through lower lumbar vertebrae resulting in mild to severe low back pain in pregnancy.
- Postural Changes– Pregnancy changes the angle of pelvic tilt and angle of normal lordosis of lumbar vertebrae. The center of gravity shifts from normal position resulting in persistent paravertebral muscle contractions. Persistent muscle spam, additional stress on ligaments and disc causes pain.
- Rectus Abdominal Muscle Separation– Expansion of uterus causes separation of rectus abdominal muscles. Lack of support anteriorly results in stress over facet joint and paravertebral muscles posteriorly. Abnormal facet joint twist and paravertebral muscle contraction causes persistent low back pain in pregnancy.
Symptoms Of Low Back Pain During Pregnancy
Pelvic Girdle Pain During Pregnancy
- Severe intractable pain over pelvic girdle.
- Pain originates from pelvic ligament, pelvic muscles from continuous contraction and pressure on pelvic nerves.
Lower Lumbar Backache During Pregnancy
- Severe pain is localized over lower back.
- Pain is increased with activities and bending lower back.
- Pain is caused by paravertebral muscle spasm, overstretching of paravertebral ligaments, stretching of facet joints, and lumbar disc abnormalities.
Character of Chronic Pain During Pregnancy
- Moderate to severe pain is observed during second and third trimester.
- Pain is less severe at rest
- Pain intensity is increased during ambulation and sitting position.
- Pain is severe in supine (lying on back).
- Pain becomes severe after rolling during sleep.
Muscle Spasm During Pregnancy
- Severe paravertebral or pelvic muscle spasm causes severe paravertebral muscle pain or pelvic pain
- Muscle spasm felt during palpation examination.
Treatment for Low Back Pain During Pregnancy
1. Conservative Treatment for Low Back Pain During Pregnancy
Sleep on Side
- Pain is less severe while lying on side than on back.
- Keep one or both knee bent while lying down on one side.
- Use pillow between leg and under abdomen while lying on side.
Support Back With Braces
- Use back braces while standing, sitting and walking.
- Back support decreases pain while standing, sitting and walking.
- Back support should not be used while sleeping or lying down.
Local Application of Ice or Heat
- Ice or Heat is used for 20 to 30 minutes for 3 to 4 times a day.
- Ice therapy is useful for mild and moderate pain during first and second trimester.
- Sitting- use pillow or back support to maintain near normal lordosis position of lower back. Rest your feet on small stool so as to relax your back muscles.
- Walking- Use braces to maintain posture while standing and walking.
Low Heel Shoes
- High heel shoes causes change in angle of weight distribution and lumbar vertebral curvature.
- Low heel or flat shoe improves weight distribution and does not modify lumbar lordosis.
2. Exercises5 for Low Back Pain During Pregnancy
- Regular exercise during first and second trimester helps to strengthen back and abdominal muscles.
- Exercise can be performed in gym or swimming pool. A therapist supervises exercise in gym during initial few sessions. Exercise may include daily swimming during first, second and third teamster.
- Stationary cycling is difficult during third trimester but possible during first and second trimester. Stationary cycling helps to strengthen leg, back and lower abdominal muscles.
3. Acupuncture1 for Low Back Pain During Pregnancy
- Acupuncture is beneficial for lower back pain. Acupuncture is also used for pelvic girdle pain.
- An experienced physician must perform acupuncture, since the identification of acupuncture point depends on knowledge and past experience.
- Complications are negligible when sterile needle are used.
4. Massage Therapy6 for Low Back Pain During Pregnancy
- Massage therapy has been used for over several centuries for lower back pain caused by pregnancy.
- Massage therapy helps to maintain the muscle tone, which is compromised by relaxin hormone.
- Abdominal and pelvic muscles massage therapy is often tried for pelvic girdle pain.
5. Chiropractic7 Treatment for Low Back Pain During Pregnancy
- Chiropractic therapy has been used for low back pain and pelvic girdle pain in USA for last several years. Chiropractic manipulation of the spine is safe during pregnancy when performed by experienced and well-trained chiropractor.
- Chiropractic treatment should be avoided during pregnancy when back pain is caused by disease of the disc and facet joint. Detailed examination by chiropractor is essential before treatment.
- Consult Ob-Gyn if in doubt regarding treatment.
6. Physical Therapy8 (PT) for Low Back Pain During Pregnancy
- Physical therapy is mostly advised for severe pain and muscle spasm.
- Physical therapy is most helpful during first and second trimester.
- Physical therapist will teach specific exercises, which could be continued during third trimester.
7. Medications9 for Low Back Pain During Pregnancy
Precautions for Low Back Pain During Pregnancy
- Medications are avoided during first trimester and if possible during entire pregnancy.
- Medications can cause side effects to mother and may induce fetal birth defects.
- Fetal side effects of medications may result in premature birth, malnourished baby and stillborn birth.
- In few cases, babies may be born with anatomical defects, which is permanent impairment.
Nonsteroidal Anti-inflammatory Medications (NSAIDs) for Low Back Pain During Pregnancy
- NSAIDs have been used during pregnancy for last several years.
- NSAIDs are reasonably safe during second and third trimester but should be avoided in first trimester
- Fetal Side effects of NSAIDs and aspirin are as follows-
- Constriction of the Ductus Arteriosus results in persistent pulmonary hypertension
- Necrotizing Enterocolitis
- Intracranial Hemorrhage
- Higher rate of cardiac malformations are observed, when NSAIDs are used regularly during pregnancy.10
Opioids11 for Low Back Pain During Pregnancy
- Opioid used during first trimester causes neural tube abnormalities.
- Diseases caused by neural tube abnormalities are Spina Bifida and Cerebral Palsy.
- Opioids are useful for severe intractable pain not responding to any other treatment.
Muscle Relaxants for Low Back Pain During Pregnancy
- Muscle relaxants are regularly used for muscle spasm during second and third trimester.
- Muscle relaxants are avoided during first trimester.
- Research suggests very few side effects are seen with carisoprodol (Soma)12 and Flexeril when prescribed for short period of time.
Prevention of Low Back Pain During Pregnancy
Prevention of recurrence of Lumbar and Pelvic Girdle Pain is as important as treatment of the pain. Following precaution and therapy can prevent low back pain.
Standing Posture for Low Back Pain During Pregnancy
- Try to stand straight and prevent a forward or backward bend while standing.
- Maintain posture with relaxed shoulder and tilted back.
- Do not bend or twist abruptly.
- Do not arch the lower back while carrying objects in your hand.
- Use flat shoes or slippers.
- Stand in comfortable position with legs stretched out from center of the body for maintaining the balance.
- Do not lift heavy objects while bent or twisted at the lower back.
- While Lifting or carrying groceries, keep back straight and use leg muscles.
Sitting Posture for Low Back Pain During Pregnancy
- Choose a chair, which has a back support.
- Sit straight with pillow supporting the back when necessary.
- Rest feet on a low step stool while sitting.
- Frequently change position while sitting.
- Avoid siting for long periods of time.
- Take a frequent break.
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