Pregnancy-Related Back Pain

Low back pain (LBP) and pelvic girdle pain (PGP) during pregnancy are often accepted as normal and even though multiple research studies suggesting that the quality of life for women is adversely affected, many are still advised to self-manage.

Low Back Pain

Low back pain characterised by PGP and generalised lumbar pain (LP) are common complaints during pregnancy.

For many women, the level of pain experienced is high enough to significantly impact their quality of life, interfere with sleep and compromise their ability to work. As Katonis et al. (2011) suggest it’s also a common reason for induction of labour, or elective caesarean section.

Pregnancy has a profound effect on the human body, especially within the musculoskeletal system. Hormonal changes cause laxity in the joint ligaments, weight gain and a shift in the centre of gravity also lead to lumbar spine hyperlordosis and anterior tilting of the pelvis which can cause discomfort (Casagrande et al. 2015).

PGP is described as a deep, stabbing, unilateral or bilateral, recurrent or continuous pain, presenting between the posterior iliac crest and the gluteal fold (Katonis et al. 2011).

Whereas LP is described as a more generalised pain in the lumbar region. LP is also the most common musculoskeletal complaint in pregnancy with approximately half of pregnant women experiencing this type of pain, frequently rating it as moderate to severe.

LP can also extend into the postpartum period, with the severity of pain typically being about half of that experienced during pregnancy (Shiri, Coggon and Falah-Hassani 2017).

Both types of pain can have a significant impact on women during their pregnancy and should be diagnosed and differentiated as soon as possible (Dianne Liddle et al. 2019).

Half of Pregnant Women Suffer from LBP

Of the many studies conducted into pregnancy-related back pain, the majority suggests that about 50% of pregnant women will suffer from LBP, with one-third suffering from a level of pain severe enough to reduce their quality of life.

Key points emerging from the research suggest that:

• The majority of women are affected in their first pregnancy.
• 80% of women suffering from LBP claim that it affects their daily routine.
• 10% of women report that they are unable to work due to the severity of the pain.
• 20% of pregnant women will experience PGP.
• Pregnancy-related LBP usually begins between the 20th and the 28th week of gestation.
• LBP during pregnancy is the most important risk factor for postpartum LBP.
• LBP is the leading reason for sick leave for pregnant working women.

(Katonis et al. 2011)

Multimodal Management is Common

Effective management of LBP can be challenging, not least because many of the treatment options are outside the scope of professional practice for most midwives and birthing assistants. This means that self-help techniques and multimodal management are common (Bishop et al. 2016).

As Katonis et al. (2011) point out, most women consider LBP as an inevitable, normal discomfort during pregnancy with only 50% choosing to seek advice from a healthcare professional.

Close et al. (2016) picks up on this point, suggesting that a general sense of dissatisfaction with routine advice and treatment resulted in many women seeking alternative solutions to cease their discomfort.

Filling the Treatment Gap

With relatively few effective treatment options available within conventional maternity care, many women are turning to self-help measures and complementary therapies to find relief.

In a few special cases, midwives may be in a position to refer onwards to another professional such as an acupuncturist or massage therapist.

For most midwives however, giving advice about a therapy they are not specifically trained in could place them in breach of their professional code of conduct.

The answer for many women is either self-help or private complementary or alternative healthcare. In either case, even though midwives may not be able to prescribe alternative therapies, it can be helpful to have a broad idea of how certain evidence-based therapies can be of help.

The most popular therapies and self-help techniques women turn to for relief include:

Exercise

Exercise during pregnancy is widely reported to reduce low back pain but there is still no clear evidence of benefits for pelvic girdle pain (Shiri, Coggon and Falah-Hassani 2017).

Even for low back pain, the protective effect is small, but given the other general benefits of exercise, it seems to be a safe and popular option for primary care practitioners to suggest.

Manual Therapies

There is some limited evidence to support the use of manual therapies such as osteopathy and massage as an option for managing LBP and PGP during pregnancy.

In the view of Hall et al. (2016) however, further high-quality research is needed to determine the effectiveness of these treatments.

Complementary Therapies

Hughes et al. (2018) point out that over half of women who sought treatment from a GP or physiotherapist were dissatisfied with the outcome of their care.

Overall, 81% of women used CAM (complementary and alternative medicine) to manage their lower back pain and 85% found it useful.

The most commonly used CAM treatments during pregnancy are:

• Aromatherapy 21%;
• Acupuncture 21%;
• Reflexology 15%.

Aromatherapy

Shirazi et al. (2016) comment on an interesting study into the efficacy of topical rose oil in the carrier almond oil, in women with pregnancy-related low back pain.

The results showed that rose oil was beneficial as well as being a popular and pleasant treatment option, reducing the intensity of pregnancy-related low back pain without any significant adverse effects.

Acupuncture

The use of acupuncture for the management of persistent non-specific low back pain is generally considered beneficial even though its use in the management of pregnancy-related low back pain remains limited.

A few maternity units may have the benefit of an on-site acupuncturist but as Waterfield et al. (2015) suggest, physiotherapists, who often provide acupuncture services can be reluctant to treat pregnant women due to a pervasive professional culture of caution, with fears of inducing early labour and risks of litigation.

Reflexology

Reflexology is also a popular treatment option and has been shown to help nonspecific low back pain and may be equally valuable in the management of pregnancy-related low back pain, however as Close et al. (2016) suggest further research is needed to confirm this.

Can More be Done?

With LBP causing physical and emotional distress to so many women in pregnancy, the question needs to be asked ‘could more be done to provide effective treatment within the scope of traditional maternity care?’.

Perhaps women themselves need a better awareness of how to manage low back pain, as fear and anxiety can also add to the perception of pain.

Maybe it’s time to embrace this problem within the scope of traditional maternity care, offering a wider range of evidence-based care options, so that fewer women need to suffer in silence.

References

• Bishop, A, Holden, M, Ogollah, R and Foster, N 2016, ‘Current Management of Pregnancy-Related Low Back Pain: a National Cross-Sectional Survey of UK Physiotherapists’, Physiotherapy, 102(1), pp.78-85, viewed 3 December 2019, https://www.sciencedirect.com/science/article/pii/S0031940615037712
• Casagrande, D, Gugala, Z, Clark, S and Lindsey, R 2015, ‘Low Back Pain and Pelvic Girdle Pain in Pregnancy’, Journal of the American Academy of Orthopaedic Surgeons, 23(9), pp.539-549.
• Close, C, Sinclair, M, Liddle, D, Mc Cullough, J and Hughes, C 2016, ‘Women's Experience of Low Back and/or Pelvic Pain (LBPP) During Pregnancy’, Midwifery, 37, pp.1-8, viewed 3 December 2019, https://www.sciencedirect.com/science/article/abs/pii/S0266613816300171
• Close, C, Sinclair, M, Cullough, J, Liddle, D and Hughes, C 2016, ‘A Pilot Randomised Controlled Trial (RCT) Investigating the Effectiveness of Reflexology for Managing Pregnancy Low Back and/or Pelvic Pain’, Complementary Therapies in Clinical Practice, 23, pp.117-124, viewed 3 December 2019, https://www.sciencedirect.com/science/article/abs/pii/S1744388115000419
• Dianne Liddle, S, McCullough, J, Sinclair, M and Hughes, C 2019, ‘Healthy Backs in Pregnancy: an Online Survey of 92 Women’s Lived Experiences of Pregnancy-Related Low Back and/or Pelvic Girdle Pain’, The Royal College of Midwives, Evidence Based Midwifery 17(3): 74, 17(3), p.92, viewed 3 December 2019, https://www.rcm.org.uk/media/3564/ebm-sept-19-fullcropped.pdf
• Hall, H, Cramer, H, Sundberg, T, Ward, L, Adams, J, Moore, C, Sibbritt, D and Lauche, R 2016, ‘The Effectiveness of Complementary Manual Therapies for Pregnancy-Related Back and Pelvic Pain’, Medicine, 95(38), p.e4723, viewed 3 December 2019, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5044890/
• Hughes, C, Liddle, S, Sinclair, M and McCullough, J 2018, ‘The Use of Complementary and Alternative Medicine (CAM) for Pregnancy Related Low Back and/ or Pelvic Girdle Pain: An Online Survey’, Complementary Therapies in Clinical Practice, 31, pp.379-383, viewed 3 December 2019, https://www.sciencedirect.com/science/article/abs/pii/S1744388117303638
• Katonis, P, Kampouroglou, A, Aggelopoulos, A, Kakavelakis, K, Lykoudis, S, Makrigiannakis, A and Alpantaki, A 2011, ‘Pregnancy-Related Low Back Pain’, Hippokratia, 15(3), pp.205–210, viewed 3 December 2019, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3306025/
• Shiri, R, Coggon, D and Falah-Hassani, K 2017, ‘Exercise for the Prevention of Low Back and Pelvic Girdle Pain in Pregnancy: A Meta-Analysis of Randomized Controlled Trials’, European Journal of Pain, [online] 22(1), pp.19-27, viewed 3 December 2019, https://onlinelibrary.wiley.com/doi/full/10.1002/ejp.1096
• Shirazi, M, Mohebitabar, S, Bioos, S, Yekaninejad, M, Rahimi, R, Shahpiri, Z, Malekshahi, F and Nejatbakhsh, F 2016, ‘The Effect of Topical Rosa damascena (Rose) Oil on Pregnancy-Related Low Back Pain’, Journal of Evidence-Based Complementary & Alternative Medicine, [online] 22(1), pp.120-126, viewed 3 December 2019, https://journals.sagepub.com/doi/full/10.1177/2156587216654601
• Waterfield, J, Bartlam, B, Bishop, A, Holden, M, Barlas, P and Foster, N 2015, ‘“Physical Therapists” Views and Experiences of Pregnancy-Related Low Back Pain and the Role of Acupuncture: Qualitative Exploration’, Physical Therapy, [online] 95(9), pp.1234-1243, viewed 3 December 2019, https://academic.oup.com/ptj/article/95/9/1234/2686474