Low Back Pain management among Pregnant lady

The Management of Low Back Pain in Pregnancy

1. The Management of Low Back Pain In Pregnancy

2. Introduction Around 45% to 75% of pregnant women are said to experience low back pain (LBP) at some point during their pregnancy. This type of LBP can be present in the pelvic girdle, between the posterior iliac crest , gluteal fold and/or in the general lumbar spine region. It is thought to occur due to hormonal, circulatory and mechanical changes and as a result, the quality of life of the pregnant woman is affected.

3. Sagittal Section of the Lumbar Spine

4. Introduction Prenatal  is a term to describe the time frame prior to birth. It is a critical phase for fetal development therefore, it is important that the mother’s nutritional needs are met to ensure the healthy growth of the embryo or fetus.

5. The term Postpartum (also known as postnatal) refers to the first six weeks immediately after birth of an infant. This is a significant phase in the mothers and babies’ lives, it is the period of adjustments to parenthood and the start of a life long bond within the family and the wider community. Introduction

6. Epidemiology The global prevalence of LBP in pregnancy is high yet ranges from 25-90% in the United States of America, Europe and Africa, with the highest rates recorded in Brazil and Sweden. This is because there is currently no universally recognized classification system for the condition. LBP usually occurs in the second trimester (gestational 22 week average), although  pain continues for up to three years in 20% of women postpartum .

7. Epidemiology It is estimated that one third of women will suffer from severe pain, reporting that 80% impacts their quality of life , sleep and 10% causing an inability to work. A cross-sectional study consisting of 400 pregnant women found that 75.3% (300 pregnant women) experienced LBP, reporting a mean Visual Analog Scale (VAS) score of 4.91 ±1.88. Despite a sufficient sample size, the generalisability is limited and the classification of pain, type and localisation were subjectively assessed.

8. Etiology The etiology is poorly understood due to the multifactorial nature, but suggested theories are associated with biochemical, vascular and hormonal changes during pregnancy. Although there are no true consensus regarding the risk factors, those most common include- Young Age Pelvic Trauma Hunchback Posture Gestational Weight Gain Chronic LBP Previous History of LBP in Pregnancy.

9. HUNCHBACK POSTURE

10. Management Techniques The management of LBP in pregnancy includes a number of non-pharmacological treatment options. It is treated differently depending on the stage of pregnancy, the underlying cause , aggravating factors and the involvement of other medical conditions such as diabetes or heart problems.

11. Medical Management It is important to encourage the patient to receive regular checkups by her obstetrician. During the therapy session, continually check on pain levels and any aches radiating from the low back or stomach. Some patients tolerate pain and discomfort better than others and will therefore mask their distress – Use a chart for Rate of Perceived Exertion to determine the patient's true status and take note of any changes that occur between the begging and end of the session. Although there are numerous interventions promoted for low back pain during pregnancy, the most common and widely used is a specific exercise program designed by a physical/physiotherapist . Another intervention that is getting tractions and shows prominent research is acupuncture. Recent studies show that a week of continuous acupuncture at specific auricular points can decrease pain and increase the capacity for some physical activity which can help diminish the need for drugs.

12. Restore biomechanics during daily activities Improve lumbo-pelvic stabilization Educate and prevent Physical Therapy Goals

13. Treatment/management options may include: Postural correction Supported side-sleeping Lumbar roll while sitting Limiting standing and walking Antenatal exercises. Healthy pregnant women can exercise for at least 150 minutes per week or 20-30 minutes of moderate to intense aerobic activity Aquatic therapy Acupuncture Yoga Any low intensity, relaxation activity

14. Other Interventions Side lying while sleeping or resting using a wedge shaped pillow to support stomach Use of pillow between the legs while side lying (squeeze the pillow/legs together while rolling) Compression socks to promote venous return and decrease edema Support belt Soft tissue massage Acetaminophen as proscribed by physician Intra-articular sacroiliac joint injections (under imaging guidance) for ankylosing spondylitis can be recommended. There are indications that acupuncture during pregnancy may reduce pain, but high quality studies are required for sacroiliac joint therapeutic injection therapy. Most therapeutic strategies encourage preventive measures among pregnant women and those who are planning to become pregnant. It has been shown that women who participate in prophylactic education and strengthening programs during early pregnancy can avoid problems from low back pain.

15. Physical Therapy Management Conservative management is the ideal option . Treatment starts with education and activity adjustments. Educational strategies focus on back care measures, such as ergonomics, which teaches women correct posture ; pregnant women learn how to stand, walk, or bend properly, without causing stress on the spine. Accurate posture is essential to improve low back pain. Braces that ensure correct body posture are also available if the instructions are not enough. In regard to activity modifications, scheduled rest during the day is helpful for relieving muscle spasms and acute pain. During this time, posture is again important as both feet should be elevated , which will help flex the hips and decrease the lumbar lordosis of the spine.

16. Studies have found that pregnant women with low back pain, who participate in both education and physical therapy, have less pain and disability, higher quality of life, and improvement on physical tests. Physical therapy encompasses several factors such as postural modifications, back strengthening , stretching , and self-mobilization techniques. Functional stability can be maintained throughout pregnancy by strengthening the muscles around the lumbar spine through various back exercises. Treatment depends on the diagnosis and timing of pregnancy (before or after childbirth). The patient should understand her own symptoms and be motivated to remain active. Physical Therapy Management

17. Patient Instructions It’s important to communicate with the patient and provide information about the relevant anatomy, ergonomics,   back education   (to prevent unnecessary mechanical stress on the back), and how to manage ADL activities (walking, standing, sitting, lying, and work position, learning how to control pain). Research shows that when the symptoms are explained, patients can feel more at ease and their anxiety may decrease.

18. 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 hyper lordosis 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 foot stool for one foot in sitting or standing, alternate feet” Avoiding spine twisting while lifting Patient Instructions

19. Even though most pregnant patients will be advised to exercises within their safe and pain free range, studies show that less than 50% will actually do so.  Furthermore it has also been proven that training the rectus abdominus muscles will be useless due to his weakness during the pregnancy. Stability, coordination and functional preservation should be trained with active back exercises – endurance training for back muscles stabilization. Pelvic tilts , knee pull , straight leg raising, curl up , lateral straight leg raising and water aerobics are recommended because these exercises could relieves lumbar pain in pregnancy. Relaxation exercises while paying close attention to proper respiration also show to be beneficial. Management includes specific interventions to address pain, weakness, and mobility in the low back region. The Ottawa Panel also recommends massage therapy in order to treat subacute and chronic low back pain Active Back Exercises

20. Manual Therapy Techniques Posterior/Anterior mobilizations in side lying position Addresses pain and mobility (Grades 1-4)

21. Corrects anterior innominate rotation .   Muscle Energy Technique by resisting hip flexion in side laying while stabilizing the sacrum

22. Position the patient in a side lying and place an elastic around both legs above the knees. Ask the patient to 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. Strengthening Gluteus Medius

23. Ask the patient to sit on a physio ball 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. Abdominal Drawing in Maneuver with Physio ball (ADIM)

24. The patient will be positioned on a physio ball, which will force the pelvic, abdomen and back muscles to stay active in order to find a balanced sitting position. This part of the exercise will provoke a contraction of the glutei to increase the strength of the posterior oblique sling muscles which compress the SIJ. In the meantime the patient will perform a latissimus dorsi pull-down by bringing the strait arms with the arms positioned in front and above the head to a position with flexed arms with the arms in front of the chest and bring the arms back to the prior position. This second part of the exercise will improve the latissimus dorsi muscle strength. Keep the back straight during the whole exercise. Latissimus dorsi pulldowns

25. 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. Angry Cat

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

27. Yoga is a form of complementary and alternative medicine , incorporating fluid transitions of poses to promote increased joint range of motion , flexibility , muscular strength and balance. This is coupled with deep breathing exercises and meditation to facilitate mental relaxation, concentration.  Yoga is widely recognized having 300 million people practicing worldwide, encompassing 7% of women during pregnancy. Yoga

28. Yoga A Cochrane Review investigated various interventions for preventing and treating low back and pelvic pain during pregnancy. This included 34 randomised controlled trials (RCTs) consisting of 5121 pregnant women aged 16-45 years old. Primary outcome measures were pain intensity, back or pelvic related functional disability, sick leave and adverse effects.

29. Yoga It revealed that an 8-12 week exercise programme with yoga reduced the risk of pregnant women reporting LBP by 44% and sick leave by 24%. However, a systematic review recently conducted by Koukoulithras et al. (2021) finding that yoga was not effective to improve long-term pregnancy related LBP nor statistically significant. But, the small population sample size limited conclusions able to be drawn.

30. A RCT of 60 pregnant women ranging from 14-40 years old found that 1 hour of Hatha yoga practice per week for 10 weeks significantly lowered lumbo-pelvic pain on the Visual Analog Scale (VAS) compared to postural orientation exercises. Also, lumbar pain provocation tests showed a gradual decreased response throughout the sessions. Yoga was shown to be of most benefit in women suffering from LBP coupled with anxiety, depression, stress and sleep disturbances. Also, associated with more comfort and shorter duration of first stage labour. It concluded that yoga is a safe and fetal tolerated therapeutic intervention for LBP in both first time and higher risk pregnancies , with no adverse events reported. YOGA

31. YOGA A Systematic Review (SR) of 15 articles including 2566 participants meeting the inclusion criteria to evaluate the literature about non-pharmacological, easily accessible management strategies for pregnancy-related LBP. The types of Yoga were Iyengear -based , Hatha and modified yoga based, incorporating progressive muscle relaxation as a tranquility aspect. Findings indicated that 8 weeks of yoga for 20 minutes twice daily showed statistically significant improvements in LBP, with additional improvements in mental health, physical and social function.

32. Pilates Pilates is defined as “ a mind–body exercise that focuses on - Strength Core Stability Flexibility Muscle Control Posture And Breathing Pilates was created in the 1980’s by Joseph Pilates, a German exercise instructor. 

33. In a randomized control study completed in 2021 by Sonmezer et al, it was found that not only was low back pain significantly improved , functional disability, sleep, mobility and lumbopelvic stabilization also improved. The group completed Pilates based exercises twice a week for eight weeks and results showed that pain and disability significantly improved. Evidence Behind Pilates

34. In a study completed by Mazzarino, Kerr and Morris in 2018, there were a few Pilates exercises and positions which were recommended to be avoided or modified by pregnant women. These include: Modification of abdominal exercises; this is to avoid significant divarication of the rectus abdominus muscle which can be split from pressure from the uterus. Flexion should be performed while seated to avoid this. Exercises in the supine position should be avoided as it can prevent and obstruct venous return due to the growing uterus compressing the vena cava ; this can cause the mother to feel dizzy . Positions can be modified to include side-lying, seated or standing exercises. This study also found that opinion of Pilates instructors on the type of exercises to be included and excluded and the average duration and frequency was discordant with the advice from the ACOG published in 2015 Positions to be Avoided

35. Manual Therapy Techniques There is a growing evidence in support of the use of manual therapy as a safe treatment to effectively treat low back pain, especially massage and spinal manipulation .

36. Massage therapy can be helpful for stress relief, well-being and pain reduction among women during pregnancy, and is also used to relieve LBP during pregnancy.  A small study explored the impact of deep tissue massage for low back pain in women, the intervention included twice a week deep tissue massage for 2-months ; the massage included: appropriate pressure, lengthening movements, movements in intermuscular grooves, anchor and stretch technique and releasing muscle tension and found it decreased pain and improve functionality of the pregnant participants . Massage

37. A systematic review was conducted in 2017, which explored osteopathic manipulative treatment/ spinal manipulation therapy for low back pain during and after pregnancy, and it was concluded that it had a significant medium-sized effect on decreasing pain and increasing functional status in women with low back pain during pregnancy, but had low quality evidence that it decreased pain and functional status postpartum.  Additionally, it was found that there are physical and mental health benefits and can minimize pharmacological treatment options for low back pain. Spinal Manipulation

38. Aquatic therapy utilizes the beneficial properties of water and has been used as a treatment method for the management of lower back pain. There is limited evidence in its effectiveness in the management of lower back pain during pregnancy, however it is still used as a treatment method. Aquatic Therapy

39. A small scale prospective quantitative study conducted in Australia found aquatic physiotherapy sessions reduced low back pain in 70% of participants . Exercises included focused on thoracic mobility , transverse abdominus and pelvic floor muscle strengthening , aiming to improve core stability and a component of aerobic exercise to maintain general fitness. A systematic review concluded that there was sufficient evidence to suggest that aquatic therapy does provide some benefits to patients suffering from LBP during pregnancy. A randomized clinical trial containing 129 participants found that participants who completed 60 minute aquatic therapy classes three times a week reported reductions in lower back pain. Aquatic Therapy

40. Maternal Benefits Improved cardiovascular function Lowers risk of developing gestational diabetes. Improved psychological well-being. Improvement in sleep. Reduction in musculoskeletal pain associated with pregnancy e.g., low back pain. Helps with weight management: excessive weight gain during pregnancy can lead to maternal complications such as hypertension, preeclampsia, and gestational diabetes. Benefits of Exercise During Pregnancy

41. Fetal Benefits Decreased resting fetal heart rate. Increase viability of the placenta. Lower birth weight. Increase gestational age. Improved neurodevelopment. Benefits of Exercise During Pregnancy

42. Vaginal bleeding Dizziness/feeling faint Shortness of breath Chest pain Headache Muscles weakness Calf pain or swelling Uterine contractions Decreased fetal movement Vaginal fluid leakage Neurological symptoms Red Flags

43. Contraindications to Exercise During Pregnancy Persistent vaginal bleeding in the 2nd and 3rd trimester. Preeclampsia or pregnancy induced hypertension. Cardiovascular disease. Cervical Weakness. History of fetal growth restriction. History of preterm labour. Multiple gestation. Premature contractions or labour. Premature rupture of membranes. Severe anemia. Chronic bronchitis. Poorly controlled diabetes. Poorly controlled seizures. Poorly controlled thyroid disease. Placenta previa after 26 weeks. These contraindications are taken from the American College of Obstetricians and Gynecologists, no distinction was made between absolute and relative contraindications.

44. Clinical Relevance Pregnancy-related LBP is prevalent, disabling and costly to both the individual and the society. There is growing evidence in support of the use of yoga, pilates, aquatic therapy and manual therapy as safe treatment options to effectively manage pregnancy-related LBP. Although the evidence base is of low quality, these management strategies are safe and recommended interventions. However, further research is required to determine the extent of benefits in clinical practice. It is the responsibility of clinicians to ensure evidence-based practice when providing holistic patient centred care . Future investigations should focus on higher quality research to explore the effects of LBP in the long term and on quality of life in pregnant women .

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