Management of low back pain in pregnancy

Dr Rohit Lahori
Low back pain (LBP) is a common complaint amongst women during pregnancy, having a great impact on their quality of life. Most women consider LBP as an inevitable, normal discomfort during pregnancy.
Only 50% of women suffering from pregnancy related LBP will seek advice from a health care professional and 70% of them will receive some kind of treatment. It has been estimated that about 50% of pregnant women will suffer from some kind of low back pain at some point during their pregnancies or during the postpartum period (post pregnancy 6 weeks). Literature clearly indicates that LBP in pregnancy may be disabling, limiting everyday activities, impacting productivity and should not be ignored or left untreated. Pregnancy related low back pain, seems to be a result of quite a few factors, such as mechanical, hormonal and others. Low back pain presents either as pelvic girdle pain (PGP) or as a lumbar pain (LP) . The source of the pain should be diagnosed and differentiated early. The appropriate treatment aims to reduce the discomfort and the impact on the pregnant woman’s quality of life.
PGP and LP are two different patterns of LBP during pregnancy, although, a small group of women suffer from combined pain. PGP is common during pregnancy and postpartum period and approximately four times as prevalent as LP. It is described as deep, stabbing, unilateral or bilateral, recurrent or continuous pain, presenting below umbilicus and hip area and sometimes, possibly going into lower limb, but not to the foot. PGP is more intense during pregnancy than during postpartum period. LP during pregnancy is very similar to low back pain experienced by women who are not pregnant and it appears as pain over and around the lower back . It may or may not radiate to lower limb, in contrast with PGP. LP aggravates at postpartum period and usually exacerbates by certain activities and postures (e.g. prolong sitting) but it seems to be less disabling than PGP . Pregnancy related LBP usually begins between the 20th and the 28th week of pregnancy, however it may have an earlier onset. One of the most frequent mechanisms suggested, is associated with the mechanical factors, due to weight gaining during pregnancy, to the increase of the abdominal sagittal diameter and the consequent shifting of the body gravity centre anteriorly causing lordosis and increasing stress on the lower back, a biomechanical process suggests that the abdominal muscles of the pregnant woman stretch to accommodate the enlarging uterus, causing muscle fatigue and resulting to an extra load on the spine. Some pregnancy induced hormones like Relaxin causing ligamentous laxity, in pelvic joint, and also generalized discomfort. Sciatica is rare clinical entity of LBP during pregnancy, appearing in only 1% of women.
The diagnosis of LBP during pregnancy and the differentiation between LP and PGP is usually based on symptoms, due to the few existing diagnostic tools. Physical examination, can distinguish LP and PGP, since these entities present differences in the location of pain and the results of provoking tests. . It is not possible to estimate the risk, or to predict who will suffer from LBP during pregnancy, however, women with a history of LBP before pregnancy, are most likely to suffer from more severe pain and of a longer duration after childbirth. LP is more strongly connected with back pain history before pregnancy, compared to PGP
Early identification and treatment, taking under consideration the individuality of every woman and pregnancy, provide the opportunity for the best possible outcome. Pregnant women should be educated on how they can maintain a proper posture, while doing everyday activities, so that their back is not overloaded and misaligned. That can be easily performed if practiced and can be enhanced by exercises and Yoga under guidance. Physical activity before pregnancy is correlated with a decreased risk of developing LBA.. It is also very important for women to learn how to lift weights without stressing their backs, a habit that can prove very useful throughout pregnancy. Women should be advised to use proper seats, cushions and beds, as well as techniques for getting in and out of bed, so that the body maintains in a proper position and the spine is supported and not stressed. Women are also encouraged to take a midday rest to relieve their muscles and to avoid prolonged walking or standing. Everyday activities and exercising, which aggravate symptoms, should be avoided. A good nutritious diet less of fat rich in vital minerals is the key for good health in pregnancy. During acute episodes of PGP, brief rest and lying in bed can be useful. Some exercises for bed rest, such as using pillows to support the legs and squeezing the legs together when rolling, can be useful as well. Over flexion of the hips and the spine should also be avoided, while sitting. The use of a sacral belt helps to alleviate symptoms. In the line of an individualized treatment program, massage might be helpful. Conservative management of LBP is the treatment of choice. A correct diagnosis and a differentiation between PGP and LP are of the utmost importance, since the treatment is different. Weight loss strategies during postpartum and prevention of weight gain may help to prevent the risk and the severity of LBP.
(The author is Pain Specialist Govt Hospital Gandhinagar Jammu)