Low back pain (LBP) during pregnancy is often accepted as normal - and even though multiple research studies suggest that the quality of life for patients is adversely affected, many are still advised to self-manage.
Low Back Pain
Low back pain characterised by pelvic girdle pain (PGP) and/or generalised lumbar pain (LP) is a common complaint during pregnancy (Katonis et al. 2011).
PGP is described as a deep, stabbing, unilateral or bilateral, recurrent or continuous pain, presenting between the posterior iliac crest and the gluteal fold
LP, on the other hand, is described as a more generalised pain in the lumbar region.
(Katonis et al. 2011)
Both types of pain can significantly impact the patient during their pregnancy and should be diagnosed and differentiated as soon as possible (Liddle et al. 2019).
For many patients, 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 profoundly affects 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, which also leads to lumbar spine hyperlordosis and anterior tilting of the pelvis. These changes can all cause discomfort (Casagrande et al. 2015).
LBP is the most common musculoskeletal complaint in pregnancy, with an estimated prevalence of 4 to 84% (Walters et al. 2018). Patients frequently rate the pain as moderate to severe (Shiri et al. 2017).
LBP can also extend into the postpartum period, with the severity of pain typically being about half of that experienced during pregnancy (Shiri et al. 2017).
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 patients consider LBP as an inevitable, normal discomfort during pregnancy, with only 50% choosing to seek advice from a healthcare professional.
Close et al. (2016) pick up on this point, suggesting that a general sense of dissatisfaction with routine advice and treatment results in many people seeking alternative solutions to cease their discomfort.
Filling the Treatment Gap
With relatively few effective treatment options available within conventional maternity care, many patients 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 onward to another professional such as an acupuncturist or massage therapist.
For most midwives, however, giving advice about therapies they are not specifically trained in could place them in breach of their professional code of conduct.
The answer for many patients 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 patients 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 et al. 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 patients who seek treatment from a GP or physiotherapist are dissatisfied with the outcome of their care.
Their study found that 81% of women use complementary and alternative medicine (CAM) to manage their lower back pain, and 85% found it useful (Hughes et al. 2018).
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 patients 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 patients 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.
Other Self-Help Techniques
Patients may be able to manage LBP by:
Avoiding lifting heavy objects
Maintaining good posture
Avoiding activities that may cause pain, such as bending, twisting, climbing ladders or walking up steep hills
Sleeping on their side with a pillow between their knees
Wearing shoes with low heels, as they provide arch support
Wearing a maternity support belt
Sleeping on a firm mattress.
(Pregnancy, Birth and Baby 2022)
Can More be Done?
With LBP causing physical and emotional distress to so many people during pregnancy, the question needs to be asked: could more be done to provide effective treatment within the scope of traditional maternity care?
Perhaps patients 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 patients need to suffer in silence.
Topics
References
Bishop, A, Holden, M, Ogollah, R & Foster, N 2016, ‘Current Management of Pregnancy-Related Low Back Pain: aA National Cross-Sectional Survey of UK Physiotherapists’, Physiotherapy, vol. 102, no. 1, pp.78-85, viewed 19 December 2022, https://www.sciencedirect.com/science/article/pii/S0031940615037712
Hall, H, Cramer, H, Sundberg, T, Ward, L, Adams, J, Moore, C, Sibbritt, D & Lauche, R 2016, ‘The Effectiveness of Complementary Manual Therapies for Pregnancy-Related Back and Pelvic Pain’, Medicine, vol. 95, no. 38, p.e4723, viewed 19 December 2022, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5044890/
Hughes, C, Liddle, S, Sinclair, M & 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, vol. 31, pp.379-383, viewed 19 December 2022, https://www.sciencedirect.com/science/article/abs/pii/S1744388117303638
Liddle, S, McCullough, J, Sinclair, M & 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’, Evidence Based Midwifery, vol. 17, no. 3, viewed 19 December 2022, https://www.rcm.org.uk/media/3564/ebm-sept-19-fullcropped.pdf
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, vol. 22, no. 1, pp.120-126, viewed 19 December 2022, https://journals.sagepub.com/doi/full/10.1177/2156587216654601
Shiri, R, Coggon, D & 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, vol. 22, no. 1, pp.19-27, viewed 16 December 2022, https://onlinelibrary.wiley.com/doi/full/10.1002/ejp.1096
Waterfield, J, Bartlam, B, Bishop, A, Holden, M, Barlas, P & Foster, N 2015, ‘Physical Therapists’ Views and Experiences of Pregnancy-Related Low Back Pain and the Role of Acupuncture: Qualitative Exploration’, Physical Therapy, vol. 95, no. 9, pp.1234-1243, viewed 19 December 2022, https://academic.oup.com/ptj/article/95/9/1234/2686474