Back pain and pregnancy: a review

Prevalence and risk factors associated with musculoskeletal disorders among pregnant women in Enugu Nigeria

Background

Pregnancy usually triggers a wide range of changes that result in a variety of musculoskeletal disorders (MSDs). The scope and burden of these disorders in Nigeria are not known.

Aim

The study aimed to determine the prevalence and risk factors of pregnancy-related MSDs in Enugu.

Patients and Methods

A cross-sectional study of pregnant women attending antenatal clinics at three tertiary hospitals in Enugu, Nigeria, was done using an observer-administered questionnaire. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 22.

Results

A total of 317 participants were studied. A majority of the participants (93.1%) had one or more MSDs. Low back pain (LBP) and muscle cramps were the two most common pregnancy-related MSDs with prevalence rates of 56.8 and 54.8%, respectively. Increasing gestational age (P = 0.001), previous pregnancies (P = 0.027), and occupation (P = 0.018) were associated with increased risk of MSDs. A majority of the MSDs were of mild and moderate severity and 10.4% of the participants had significant impairment of their daily activities.

Conclusion

MSDs are common in pregnancy with LBP and muscle cramps as the most prevalent conditions. Increasing gestational age, multigravidity, and occupation increased the risk of MSDs among our cohorts. Preventive and therapeutic measures should be instituted when necessary to ensure optimal maternal health during pregnancy.

The prevalence and risk factors of chronic low back pain among adults in KwaZulu-Natal, South Africa: an observational cross-sectional hospital-based study

Background

Globally, chronic low back pain (CLBP) is the leading cause of disability associated with economic costs. However, it has received little attention in low-and-middle-income countries. This study estimated the prevalence and risk factors of CLBP among adults presenting at selected hospitals in KwaZulu-Natal.

Methodology

This cross-sectional study was conducted among adults aged ≥18 years who attended the selected hospitals in KwaZulu-Natal during the study period. A self-administered questionnaire was used to collect data on socio-demographic, work-related factors, and information about CLBP. The SPSS version 24.0 (IBM SPSS Inc) was used for data analysis. Descriptive statistics were used for demographic characteristics of participants. CLBP risk factors were assessed using multivariate logistic regression analysis. A p-value of ≤0.05 was deemed statistically significant.

Results

A total of 678 adults participated in this study. The overall prevalence of CLBP was 18.1% (95% CI: 15.3 – 21.3) with females having a higher prevalence than males, 19.8% (95% CI: 16.0 – 24.1) and 15.85% (95% CI: 11.8 – 20.6), respectively. Using multivariate regression analysis, the following risk factors were identified: overweight (aOR: 3.7, 95% CI: 1.1 – 12.3, p = 0.032), no formal education (aOR: 6.1, 95% CI: 2.1 – 18.1, p = 0.001), lack of regular physical exercises (aOR: 2.2, 95% CI: 1.0 – 4.8, p = 0.044), smoking 1 to 10 (aOR: 4.5, 95% CI: 2.0 – 10.2, p < 0.001) and more than 11 cigarettes per day (aOR: 25.3, 95% CI: 10.4 – 61.2, p < 0.001), occasional and frequent consumption of alcohol, aOR: 2.5, 95% CI: 1.1 – 5.9, p < 0.001 and aOR: 11.3, 95% CI: 4.9 – 25.8, p < 0.001, respectively, a sedentary lifestyle (aOR: 31.8, 95% CI: 11.2 – 90.2, p < 0.001), manual work (aOR: 26.2, 95% CI: 10.1 – 68.4, p < 0.001) and a stooped sitting posture (aOR: 6.0, 95% CI: 2.0 – 17.6, p = 0.001).

Conclusion

This study concluded that the prevalence of CLBP in KwaZulu-Natal is higher than in other regions, and that it is predicted by a lack of formal education, overweight, lack of regular physical exercises, smoking, alcohol consumption, sedentary lifestyle, manual work, and a stooped posture.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04790-9.

Chronic pain during pregnancy: a review of the literature

BACKGROUND AND PURPOSE

The majority of the reviews and studies on chronic pain in pregnancy have primarily focused on the pharmacological and non-pharmacological treatment options. The purpose of our review was to identify evidence-based clinical research for the evaluation and management of preexisting chronic pain in pregnancy, chronic pain associated with pregnancy, and chronic pain in relation to mode of delivery.

METHODS

A literature search was undertaken using the search engines PubMed, CINAHL, EBSCOhost, and Web of Science. Search terms used included "chronic pain" AND "pregnant OR pregnancy" OR "pregnancy complications" from inception through August 2016.

RESULTS

The basis of this review was the 144 articles that met inclusion criteria for this review. Based on our review of the current literature, we recommend 7 guidelines for chronic pain management during and after pregnancy: 1) complete history and physical examination; 2) monitor patients for alcohol, nicotine, and substance use; 3) collaborate with patient to set treatment goals; 4) develop a management plan; 5) for opioids, use lowest effective dose; 6) formulate a pain management plan for labor and delivery; and 7) discuss reproductive health with women with chronic pain.

CONCLUSION

The management of chronic pain associated with pregnancy is understudied. Obstetrical providers primarily manage chronic pain during pregnancy. Some general guidelines are provided for those health care providers until more information is available.

Risk of Chronic Low Back Pain Among Parturients Who Undergo Cesarean Delivery With Neuraxial Anesthesia: A Nationwide Population-Based Retrospective Cohort Study

To investigate the risk of chronic low back pain (LBP) in parturients undergoing cesarean delivery (CD) with neuraxial anesthesia (NA). LBP is common during pregnancy and also after delivery, but its etiology is poorly understood. Previous studies that investigated the correlation between epidural labor analgesia and chronic low back pain were inconclusive. These studies lacked objective diagnostic criteria for LBP and did not exclude possible confounders. We performed this nationwide population-based retrospective cohort study to explore the relationship between CD with NA and subsequent LBP. From the Taiwan National Health Insurance Research Database (NHIRD), we identified all primiparas who had given birth between January 1, 2000 and December 31, 2013. Using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes, we identified the women who had vaginal delivery (VD) and those who had CD. The mode of anesthesia was ascertained by the NHI codes. Multivariable logistic regression was used to estimate the odds of postpartum LBP in women undergoing CD with NA compared with those having VD. The outcome was a diagnosis of LBP according to the first ICD-9-CM diagnosis code. The patients were observed for 3 years after delivery or until diagnosis of postpartum LBP, withdrawal from the NHI system, death, or December 31, 2013. Of the 61,027 primiparas who underwent delivery during the observation period, 40,057 were eligible for inclusion in the study. Of these women, 27,097 (67.6%) received VD, 8662 (21.6%) received CD with spinal anesthesia, and 4298 (10.7%) received CD with epidural anesthesia (EA). Women who received CD with EA were found to have higher risk of LBP than did women who received VD, with the adjusted OR being 1.26 (95% CI: 1.17-1.34). CD with EA might increase the risk of subsequent chronic LBP.

Prevalence of musculoskeletal dysfunctions among Indian pregnant women

Background and Objectives. Pregnancy triggers a wide range of changes in a woman's body leading to various musculoskeletal dysfunctions. Most commonly reported musculoskeletal discomforts by pregnant women are low back pain and symphysis pubis pain. The culture and the environmental factors may influence the discomforts experienced by a pregnant woman. There is a dearth of literature in India, regarding the common musculoskeletal dysfunctions experienced by a pregnant woman, and hence this study. Method. A questionnaire to identify the musculoskeletal dysfunction was developed; content was validated and was translated to local languages through parallel back translation. 261 primiparous pregnant women participated in the study and filled the questionnaire in their native language. Results. Among the musculoskeletal dysfunctions reported by the pregnant women, 64.6% reported calf muscle cramps, 37.1% reported foot pain, and 33.7% experienced low back pain in their third trimester. In the second trimester, common musculoskeletal dysfunctions experienced by the women were that of calf pain (47.8%), low back pain (42%), and pelvic girdle pain (37%). Conclusion. Musculoskeletal dysfunctions and general discomforts very commonly affect the activities of daily living of pregnant women. Understanding the common discomforts during various trimesters of pregnancy will help to develop a comprehensive program for prevention and cure.

Treatment of a patient with post-natal chronic calf pain utilizing instrument-assisted soft tissue mobilization: a case study

Musculoskeletal pain is commonly reported by pre- and postnatal women, with the most common complaint being low back pain. However, lower leg pain is also frequently reported by women particularly in the third trimester. The purpose of the case study is to illustrate how instrument-assisted soft tissue mobilization (ISTM) can be used to treat a patient with a 2-year history of chronic calf pain. The subject was a 35-year-old female who developed calf pain during the last trimester of her pregnancy following severe lower leg edema. The calf pain was present for the 2 years following delivery and was described as a dull ache, typically aggravated by direct pressure on the calf, prolonged standing, and stairs. An X-ray, magnetic resonance imaging (MRI) with contrast, and ultrasound Doppler study prior to referral ruled out tumors, vascular, lymphatic, or skeletal bone abnormalities. However, her MRI did show a dense superficial venous tissue asymmetry in the same location of her symptoms. Impairments were minimal; the only asymmetrical objective findings were calf length, strength, and soft tissue restrictions detected on palpation. After nine treatments incorporating an ISTM approach, soft tissue mobility, pain, calf strength, and lower extremity functional scale score all improved and her symptoms were abolished.

Pregnancy-related lumbopelvic pain: prevalence, risk factors, and profile in Kuwait

OBJECTIVE

To determine prevalence and risk factors of pregnancy-related lumbopelvic pain (PRLPP) in women in Kuwait.

DESIGN

The study was designed as a multisite, cross-sectional design in which self-administered surveys were distributed. Setting and Participants.  Public locations and health care facilities in Kuwait. Pregnant women (400) were invited to participate.

OUTCOME MEASURES

Demographics, history of PRLPP, risk factors for PRLPP, location of pain, absenteeism due to LPP, management of previous LPP, and functional disability due to PRLPP.

RESULTS

Two hundred eighty questionnaires were returned. Mean age was 29.5 years; mean body mass index (BMI) was 29.69 kg/m(2) . Of the participants, 91% reported LPP, 78.8% reported history of menstrual pain, and 58.7% reported previous LPP, and 59% reported PRLPP during previous pregnancies, 42.8% reported activities of daily living were limited. Risk factors included a history of back pain (P = 0.00), PRLPP in a previous pregnancy (P = 0.01), and being in the third trimester of pregnancy (P = 0.02). BMI was not associated with PRLPP.

CONCLUSIONS

Clinicians in Kuwait need to screen for risk factors and detect PRLPP early and intervene as needed. Although overweight and obesity may not contribute largely to PRLPP in women in Kuwait, weight control is a major concern for healthy pregnancy. Physical therapy has a role in preventing and addressing this condition.

Avaliação da lordose lombar e sua relação com a dor lombopélvica em gestantes

O objetivo deste trabalho foi avaliar a magnitude da lordose lombar, sua influência na dor lombopélvica e a qualidade de vida em gestantes. Para tal, foi realizado um estudo com 20 mulheres não gestantes (C) e 13 gestantes ao longo dos trimestres gestacionais (G1, G2 e G3). Todas as mulheres foram submetidas à avaliação inicial para registro dos dados pessoais, hábitos de vida, antecedentes pessoais, uso de medicamentos, história ginecológica e obstétrica. Posteriormente, as voluntárias do grupo controle foram avaliadas uma vez e as gestantes foram avaliadas em três momentos distintos, no 10, 20 e 30 trimestres gestacionais. A avaliação do grau de lordose lombar foi realizada por meio de técnica fotogramétrica; a avaliação de locais de dor, o tipo de dor e sua intensidade foram feitas por meio do Questionário McGill de dor; e a avaliação da qualidade de vida foi feita pelo Questionário WHOQOL-bref. Neste trabalho, não foi possível observar padrão de alteração da curvatura lombar no decorrer da gestação. Também não foi observada relação entre a curvatura lombar e a dor lombopélvica relacionada à gestação.

THE GAIT ANALYSIS OF PREGNANT WOMEN

During pregnancy, a woman changes obviously in body weight, body shape, and endocrine system. Those changes make the posture and gait pattern of the pregnant women different from those of the non-pregnant women. At the same time, activities of daily living become more difficult. But there was still no published paper discussing the posture and gait changes of the pregnant women in details and in a whole.

In this study, we used the optimization method to define the hip joint center of the pregnant women. The optimization method could compensate the lack of the anthropometric data of the pregnant women. Due to the variations of physiological changes in the pregnant women, it was difficulty to standardize the gait analysis of pregnant women, even in the same gestational age. The results revealed that there really was some correlation between the significant finding of gait analysis and sacroiliac pain of the pregnant women. The sacroiliac pain often occurred in the following conditions of gait analysis: (1) when the hip extension moment increased; (2) when the knee extension moment decreased; (3) when the angle of ankle plantar-flexion decreased; and (4) when the sacroiliac ajoint torsion increased. The gait analysis of the pregnant is a feasible, but complicated method for study. The data of gait analysis were also compare with questionnaires for further analysis.

Head load carriage and pregnancy in West Africa

BACKGROUND

The postures of the trunk and of the head relative to the trunk adopted during the specific task of head load carriage were measured for a group of pregnant women and a control group of non-pregnant women because this activity was identified as a risk factor for back pain during pregnancy.

METHODS

The postural data of the trunk and of the head relative to the trunk were collected using two inclinometer devices and an electrogoniometer, respectively.

FINDINGS

During walking, the load on the head caused significantly larger upper trunk extension and smaller flexion of the head relative to the trunk. The amplitude of motion of the upper trunk and of the head relative to the trunk, as measured by the standard deviation of walking angles, was found to decrease as a result of carrying a load on the head and compensated by increased motion at the sacrum. Pregnant women showed larger upper trunk movements than their counterpart in the frontal and sagittal planes during the unloaded walking trials.

INTERPRETATION

These posture modifications were believed to be adopted by the subjects to provide better stability for the load during walking. These prolonged postural strains caused by the trunk being displaced from its normal position can lead to muscle fatigue and ultimately to musculoskeletal injuries. The larger movements of the upper trunk for the pregnant women were hypothesized to be due to the enlarged abdomen of pregnant women as it creates a larger moment about L5/S1 and increases instability.

Chiropractic treatment of a pregnant patient with lumbar radiculopathy

OBJECTIVE

The purpose of this report is to describe chiropractic treatment of lower back and unilateral leg pain in a pregnant patient.

CLINICAL FEATURES

A 26-year-old woman in her second trimester of pregnancy had severe pain in her lower back that radiated to her hips bilaterally and to her right leg. She reported tingling down her right lower leg to the dorsum of her foot. Although no diagnostic imaging was performed, her differential diagnoses included lumbalgia with associated radiculopathy.

INTERVENTION AND OUTCOME

Treatment consisted of manual traction in the side-lying position using a specialized chiropractic table and treatment technique (Cox flexion-distraction decompression) modified for pregnancy. Relief was noted after the first treatment, and complete resolution of her subjective and objective findings occurred after 8 visits.

CONCLUSION

When modified, this chiropractic technique appears to be an effective method for treating lower back pain with radiation to the leg in a pregnant patient who cannot lie prone.

Influência dos sistemas sensoriais na manutenção do equilíbrio em gestantes

INTRODUÇÃO: Existe um grande número de fatores interferindo na atuação do equilíbrio, porém a importância dada a cada um dos sistemas sensoriais durante a gestação ainda é desconhecida. O objetivo deste estudo foi investigar a influência dos sistemas visual, somatossensorial e vestibular no equilíbrio em diferentes fases da gestação. MÉTODO: Para a realização deste estudo foram avaliados dois grupos: grupo de gestantes (GG), e grupo de mulheres não gestantes (GC). O equilíbrio corporal foi mensurado por meio das seis condições do Teste de Organização Sensorial (TOS), utilizando-se uma plataforma de força AMTI®. As variáveis relacionadas com a manutenção da estabilidade corporal foram a amplitude do deslocamento do centro de força nas direções ântero-posterior (COPap) e médio-lateral (COPml). Para comparação entre os grupos e entre os testes sensoriais, utilizou-se Anova One-Way, e para a identificação das diferenças utilizou-se o teste post hoc HSD de Tukey. O nível de significância adotado para todos os testes foi de 5%. RESULTADOS: As diferenças nas oscilações corporais são mais evidentes a partir do segundo trimestre de gestação, e a manipulação sensorial se mostra como fator agravante sobre essas oscilações. CONCLUSÃO: O processo de gestação influencia o equilíbrio em ambas as direções avaliadas (COPap e COPml) e as oscilações corporais aumentam com a dificuldade da tarefa (manipulação sensorial) e com o avançar da gestação.

The preoperative assessment of obstetric patients

The importance of early identification and management of the high-risk obstetric patient is emphasised in the Confidential Enquiry into Maternal and Child Health (CEMACH) report. High-risk patients who need anaesthetic input include those with airway problems, cardiorespiratory disease and rare genetic conditions, such as malignant hyperthermia and suxamethonium apnoea. Anaesthetic options for labour analgesia as well as anaesthesia for operative delivery will need to be discussed in detail with the patient if a delivery management plan is to be constructed. Input from other medical teams, such as cardiologists or haematologists, are often needed. Ultimately, these measures should reduce maternal morbidity and mortality.

Back pain of working pregnant women: identification of associated occupational factors

The objective of this study was to identify major occupational factors that were significantly correlated with back pain in pregnant women working in higher education, health care and service areas. A total of 73 working pregnant women were surveyed using questionnaires specifically designed for evaluating correlations between occupational factors and severity of back pain; 37 women were interviewed at both 20 and 34 weeks of pregnancy, 17 at 20 weeks only, and 19 were interviewed at 34 weeks only. "Rest breaks allowed" and "job autonomy" were negatively correlated with severity of back pain at 20 weeks of pregnancy. "Staying in a confined area" and "having restricted space" were positively correlated with severity of back pain at 34 weeks of pregnancy. The study suggests that allowing pregnant women to take more rest breaks and to have more job autonomy may reduce the severity of back pain during early pregnancy, and that allowing movement outside the working area and providing less restricted space may reduce back pain during late pregnancy.

Common symptoms during pregnancy to predict depression and health status 14 years post partum

OBJECTIVE

To examine the prospective association between symptoms commonly experienced during pregnancy and the mental and general health status of women 14 years post partum.

METHODS

Data used were from the Mater-University of Queensland Study of Pregnancy, a community-based prospective birth cohort study begun in Brisbane, Australia, in 1981. Logistic regression analyses were conducted.

RESULTS

Data were available for 5118 women. Women who experienced a higher burden of symptoms during pregnancy were at greater risk of becoming depressed and reporting poorer health status 14 years post partum. Women who experienced major problems during pregnancy were 4 times more likely to be depressed and nearly 8 times more likely to report poorer health status 14 years after the index pregnancy compared with women who experienced few problems.

CONCLUSIONS

Findings suggest that pregnant women who experience common symptoms during pregnancy are likely to experience poorer mental and self-reported general health 14 years after the pregnancy.

Acupuncture for pelvic and back pain in pregnancy: a systematic review

The objective of our study was to review the effectiveness of needle acupuncture in treating the common and disabling problem of pelvic and back pain in pregnancy. Two small trials on mixed pelvic/back pain and 1 large high-quality trial on pelvic pain met the inclusion criteria. Acupuncture, as an adjunct to standard treatment, was superior to standard treatment alone and physiotherapy in relieving mixed pelvic/back pain. Women with well-defined pelvic pain had greater relief of pain with a combination of acupuncture and standard treatment, compared to standard treatment alone or stabilizing exercises and standard treatment. We used a narrative synthesis due to significant clinical heterogeneity between trials. Few and minor adverse events were reported. We conclude that limited evidence supports acupuncture use in treating pregnancy-related pelvic and back pain. Additional high-quality trials are needed to test the existing promising evidence for this relatively safe and popular complementary therapy.

Non-Obstetric Pain in Pregnancy

The hormonal and mechanical changes which result from pregnancy have the capacity to exacerbate existing chronic pain conditions as well as produce pain unique to this physiological and anatomical state.Pain in pregnancy is very common and can impact negatively on maternal satisfaction with the pregnancy.Management of pain requires a multidisciplinary, biopsychosocial approach. The possible presence of co-existing pathology and obstetric conditions must be borne in mind when assessing pain in pregnancy.Treatment of pain in pregnancy should focus on non-pharmacological interventions in the first instance with due consideration of the risk of medications to the mother, fetus and the course of the pregnancy.

Interventions for preventing and treating pelvic and back pain in pregnancy

BACKGROUND

More than two-thirds of pregnant women experience back pain and almost one-fifth experience pelvic pain. The pain increases with advancing pregnancy and interferes with work, daily activities and sleep.

OBJECTIVES

To assess the effects of interventions for preventing and treating back and pelvic pain in pregnancy.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Review Group's Trials Register (February 2006).

SELECTION CRITERIA

Randomised controlled trials of any treatment to prevent or reduce the incidence or severity of back or pelvic pain in pregnancy.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data.

MAIN RESULTS

We found no studies dealing specifically with prevention of back or pelvic pain. We included eight studies (1305 participants) that examined the effects of adding various pregnancy-specific exercises, physiotherapy, acupuncture and pillows to usual prenatal care. For women with low-back pain, participating in strengthening exercises, sitting pelvic tilt exercises (standardised mean difference (SMD) -5.34; 95% confidence interval (CI) -6.40 to -4.27), and water gymnastics reduced pain intensity and back pain-related sick leave (relative risk (RR) 0.40; 95% CI 0.17 to 0.92) better than usual prenatal care alone. The specially-designed Ozzlo pillow was more effective than a regular one in relieving back pain (RR 1.84; 95% CI 1.32 to 2.55), but is no longer commercially available. Both acupuncture and stabilising exercises relieved pelvic pain more than usual prenatal care. Acupuncture gave more relief from evening pain than exercises. For women with both pelvic and back pain, in one study, acupuncture was more effective than physiotherapy in reducing the intensity of their pain; stretching exercises resulted in more total pain relief (60%) than usual care (11%); and 60% of those who received acupuncture reported less intense pain, compared to 14% of those receiving usual prenatal care. Women who received usual prenatal care reported more use of analgesics, physical modalities and sacroiliac belts.

AUTHORS' CONCLUSIONS

All but one study had moderate to high potential for bias, so results must be viewed cautiously. Adding pregnancy-specific exercises, physiotherapy or acupuncture to usual prenatal care appears to relieve back or pelvic pain more than usual prenatal care alone, although the effects are small. We do not know if they actually prevent pain from starting in the first place. Water gymnastics appear to help women stay at work. Acupuncture shows better results compared to physiotherapy.

Intrapartum analgesia and its association with post-partum back pain and headache in nulliparous women

BACKGROUND

The effect of intrapartum analgesia on post-partum maternal back and neck pain, headache and migraine, is uncertain.

AIMS

To determine if nulliparous women having epidural analgesia during labour have a similar incidence of the above-mentioned post-partum symptoms compared with women managed using other forms of pain relief.

METHODS

Secondary analysis of cohort data from a randomised trial in which nulliparous women intending to deliver vaginally were randomised to either epidural analgesia (EPI) or continuous midwifery support (CMS) at admission for delivery. Because of high cross-over rates, groups were initially defined by the randomised treatment allocation and the actual treatment received (CMS-CMS n = 185, EPI-CMS n = 117, EPI-EPI n = 376 and CMS-EPI n = 314). Univariate analysis showed no difference between groups, so final analysis was based on the actual treatment received.

RESULTS

Six hundred and ninety women received epidural analgesia (EPIDURAL) and 302 received other methods of pain relief including CMS. Back pain was common before, during and after pregnancy, and risk factors for post-partum back pain at six months were back pain prior to pregnancy or at two months post-partum. Epidural analgesia, mode of delivery, spontaneous or induced labour, birthweight and back pain during pregnancy had no significant relationship with post-partum back pain at six months. Headache was significantly more common in the EPIDURAL group during pregnancy and at two months post-partum, but not at six months. Migraine was not associated with intrapartum analgesia.

CONCLUSIONS

This analysis supports previous research suggesting that epidural analgesia is not a significant risk factor for persisting post-partum back pain, headache or migraine.

Complementary and alternative medicine for low-back pain in pregnancy: a cross-sectional survey

OBJECTIVE

To identify common treatments used for low-back pain (LBP) during pregnancy.

DESIGN

A two-part anonymous survey.

SETTING/LOCATION

New Haven, Connecticut.

SUBJECTS

Pregnant women and providers of prenatal health care (nurse educators, nurse midwives, and obstetricians).

RESULTS

We found that the majority of pregnant women who participated in our survey (61.7%) reported that they would accept complementary and alternative medicine (CAM) therapy as treatment for LBP during pregnancy. Similarly, 61% of providers of prenatal health care in our sample reported that they would consider using CAM as treatment for LBP during pregnancy. Massage (61.4%), acupuncture (44.6%), relaxation (42.6%), yoga (40.6%), and chiropractic (36.6%) were the most common CAM therapies recommended for LBP in pregnancy by the providers of prenatal health care in our sample.

CONCLUSIONS

This two-part survey study found that both providers of prenatal health care and pregnant women in New Haven county are likely to use CAM treatments for pregnancy-induced LBP. Further investigation should focus on whether it is a nationwide phenomenon, as well as if various CAM therapies are an efficacious treatment for LBP during pregnancy.

Pregnancy-related pelvic girdle pain (PPP), I: Terminology, clinical presentation, and prevalence

Pregnancy-related lumbopelvic pain has puzzled medicine for a long time. The present systematic review focuses on terminology, clinical presentation, and prevalence. Numerous terms are used, as if they indicated one and the same entity. We propose "pregnancy-related pelvic girdle pain (PPP)", and "pregnancy-related low back pain (PLBP)", present evidence that the two add up to "lumbopelvic pain", and show that they are distinct entities (although underlying mechanisms may be similar). Average pain intensity during pregnancy is 50 mm on a visual analogue scale; postpartum, pain is less. During pregnancy, serious pain occurs in about 25%, and severe disability in about 8% of patients. After pregnancy, problems are serious in about 7%. The mechanisms behind disabilities remain unclear, and constitute an important research priority. Changes in muscle activity, unusual perceptions of the leg when moving it, and altered motor coordination were observed but remain poorly understood. Published prevalence for PPP and/or PLBP varies widely. Quantitative analysis was used to explain the differences. Overall, about 45% of all pregnant women and 25% of all women postpartum suffer from PPP and/or PLBP. These values decrease by about 20% if one excludes mild complaints. Strenuous work, previous low back pain, and previous PPP and/or PLBP are risk factors, and the inclusion/exclusion of high-risk subgroups influences prevalence. Of all patients, about one-half have PPP, one-third PLBP, and one-sixth both conditions combined. Overall, the literature reveals that PPP deserves serious attention from the clinical and research communities, at all times and in all countries.

Low Back Pain During Pregnancy

OBJECTIVE

To estimate the severity of the low back pain (LBP) during pregnancy, including prevalence, risk factors, impact on daily living, and health provider management.

METHODS

An anonymous survey consisting of 36 questions was distributed to pregnant women participating in various prenatal care clinics and educational classes in New Haven County, Connecticut. A total of 950 surveys was returned from May 2002 through October 2003. At each site, a researcher was available each week to answer questions and gather surveys.

RESULTS

Six hundred forty-five (68.5%; 95% confidence interval [CI] 65-72%) respondents reported experiencing LBP during their current pregnancy. The prevalence was not affected by gestational age (P =.56). Low back pain during the current pregnancy was predicted by age (younger women were more likely to develop it; P =.004), history of LBP without pregnancy (P =.002), during menstruation (P =.01), and during a previous pregnancy (P =.002). The majority of respondents reported that LBP during pregnancy caused sleep disturbances (58%; 95% CI 54-62%) and impaired daily living (57%; 95% CI 53-62%). Average pain was moderate in severity. Nearly 30% of respondents stopped performing at least one daily activity because of pain and reported that pain also impaired the performance of other routine tasks. Only 32% (95% CI 28-36%) of the respondents with LBP during pregnancy informed their prenatal care providers of this problem, and only 25% (95% CI 21-28%) of prenatal care providers recommended a treatment.

CONCLUSION

Low back pain during pregnancy is a common problem that causes hardship in this population. Further studies are indicated in the areas of prevention and treatment.

Use of a maternity support binder for relief of pregnancy-related back pain

OBJECTIVE

To examine the feasibility, acceptability, and effectiveness of a support binder for low back pain in pregnancy.

DESIGN

Pilot study, using a prospective, two-group design with repeated measures.

SETTING

Ambulatory maternity clinic in a tertiary care teaching hospital.

PARTICIPANTS

Women of at least 20 weeks gestation with low back pain, but no preexisting back or disc disease. Thirty women assigned to the intervention group and 10 to a comparison group.

INTERVENTIONS

Participants completed a pain assessment at pretest. Intervention participants received a maternity support binder to wear while awake for 2 weeks. At an appointment 2 weeks later, a posttest questionnaire and a taped interview were administered. The comparison group participants received the support binder after the second appointment.

MAIN OUTCOME MEASURES

Back pain intensity, duration, and effect on daily activities were assessed using a pain in pregnancy questionnaire.

RESULTS

The intervention group had significant reduction in mean pain scores and effect of pain on daily activities, including family, house and yard, recreational, exercise, and sleep. Interaction of group by time was significant for change in pain and effect on family, house and yard, and exercise activities.

CONCLUSION

The use of a support binder for pregnancy-related low back pain is a promising intervention and was well-accepted by the participants.

Low back pain in pregnancy

The aim of this case report is to discuss the subject of acupuncture in pregnancy and which acupuncture points, or areas, are safe to needle. Low back pain in a 21-year-old Caucasian primigravida at 24 weeks gestation was incapacitating and acupuncture was offered. Prior to pregnancy investigations had excluded a serious organic cause and acupuncture was employed successfully to control pain and improve function. Acupuncture can be offered to sufferers of low back pain in pregnancy after risk / benefit analysis is undertaken and informed patient consent is obtained.

Backaches related to pregnancy: the risk factors, etiologies, treatments and controversial issues

PURPOSE OF REVIEW

There is no clear documentation in either the anesthetic/pain or obstetric literatures regarding the management of backache related to pregnancy. Backache can occur during pregnancy, in labor, and postpartum; different stages should be managed differently. The purpose of this review is to discuss the different types of backache, to provide an overview of diagnosis and treatment options, and to address several controversial issues related to pregnancy-related backaches.

RECENT FINDINGS

Gestational backache is a substantial problem and can have a significant impact on a pregnant woman's daily activities. Non-pharmacological/complementary treatments such as posture adjustment, acupuncture, physical therapy, physiotherapy, yoga, and chiropractic may become the first line of treatment options. In labor backache the posture of the parturient can have an effect in decreasing the intensity of pain. Allopathic medicine, regional techniques (epidural), and complementary interventions are routinely given to parturients. However, there is a major perception of differences among midwives, obstetricians and anesthesiologists in terms of the risks and benefits of labor epidural analgesia. Postpartum backache is usually self-limited, but for some mothers the pain can last from a few months to several years. Early literature suggested that this problem was associated with the use of epidurals, but recent data in the literature deny such an association.

SUMMARY

Overall, backache related to pregnancy is a significant problem. Education is still the first line of intervention for preventing backaches related to pregnancy. Both allopathic and complementary medicines are frequently used as treatments for backache related to pregnancy.

Static trunk posture in sitting and standing during pregnancy and early postpartum

OBJECTIVE

To investigate the postural alignment of the upper body in the sagittal plane during sitting and standing postures as pregnancy progressed and then in the postpartum period.

DESIGN

Longitudinal, repeated-measures design.

SETTING

Biomechanics laboratory in an Australian university.

PARTICIPANTS

A volunteer convenience sample of 9 primiparous and multiparous women and 12 nulliparous women serving as a control group.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Subjects were filmed while sitting and during quiet standing at intervals throughout pregnancy and at 8 weeks postpartum. A repeated-measures analysis of variance was used to assess systematic changes in the alignment of the pelvic, thoracic, and head segments, and the thoracolumbar and cervicothoracic spines. Student t tests were used to compare the postpartum and nulliparous control groups.

RESULTS

There was no significant effect of pregnancy on the upper-body posture, although there was a tendency in some subjects for a flatter thoracolumbar spinal curve in sitting as pregnancy progressed. Postpartum during standing, the pelvic segment had a reduced sagittal plane anterior orientation, and the thoracolumbar spine was less extended, indicating a flatter spinal curve compared with the control group.

CONCLUSIONS

There was no significant effect of pregnancy on upper-body posture during sitting and standing, although individuals varied in their postural response. A flatter spinal curve was found during standing postpartum.

Postpartum stress: current concepts and the possible protective role of breastfeeding

OBJECTIVE

To review stress during the postpartum and the research supporting that a unique, protective biology exists in breastfeeding mothers that may reduce reactivity to stress.

DATA SOURCES

Publications from nursing and biomedical literature.

STUDY SELECTION

Studies reviewed were those that have contributed to concurrent conceptualizations of postpartum stress. Additionally, studies with sufficient participants were analyzed for common findings. Animal literature was reviewed for studies on the stress response in lactating and nonlactating animal models.

DATA EXTRACTION

Stress during the postpartum may be conceptualized as physical, intrapersonal, and interpersonal. Animal data and a few recent human studies suggest that the neuroendocrinology of the lactating mother may down-regulate the magnitude of the stress response.

DATA SYNTHESIS

A diminished stress response may serve to protect the breastfeeding maternal-infant dyad from environmental stimuli and to direct the physiology of the mother toward milk production, energy conservation, and nurturance.

CONCLUSION

Nurses understand the benefits of breastfeeding for optimal infant health, but new research suggests that maternal health may also be benefited in a biologic and as yet unexplored way.

Interventions for preventing and treating pelvic and back pain in pregnancy

BACKGROUND

More than a third of women experience back pain during pregnancy. The pain can interfere with work, daily activities and sleep.

OBJECTIVES

The objective of the review was to assess the effects of preventive interventions and treatments for pelvic and back pain in pregnancy.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register (October 2001) and the Cochrane Controlled Trials Register (The Cochrane Library, Issue 3, 2001).

SELECTION CRITERIA

Randomised trials of any treatment to reduce the incidence or severity of pelvic/back pain in pregnancy, or to prevent pelvic/back pain arising in pregnancy.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed and data were extracted independently by two reviewers.

MAIN RESULTS

Three trials are included in this review involving 376 women. One randomized trial compared water gymnastics from 20 weeks with no treatment. The authors report less pain in the treatment group but the data are hard to interpret; there was a difference in rates of absence from work after 32 weeks of pregnancy (odds ratio 0.38, 95% confidence intervals 0.16-0.88). In another trial, acupuncture was rated as giving 'good' or 'excellent' help more frequently than physiotherapy (odds ratio 6.58, 95% confidence intervals 1.0-43.16) but this may reflect the benefit of individual compared with group therapy. One trial of 109 women compared the use of a special shaped pillow to fit under the woman's abdomen (Ozzlo pillow) with a standard pillow. Fewer women rated the Ozzlo pillow of 'little help' compared with the standard pillow (odds ratio 0.32, 95% confidence interval 0.18 to 0.58).

REVIEWER'S CONCLUSIONS

Water gymnastics appear to reduce back pain in pregnancy. More women are able to continue at work. Specially shaped pillows help reduce back pain in late pregnancy and improve sleep. It is a pity that the Ozzlo pillow seems no longer to be available. Both physiotherapy and acupuncture may reduce back and pelvic pain. Individual acupuncture sessions were rated as more help than group physiotherapy sessions.

[Conceptual bases supporting the obtention of knowledge about back pain in pregnancy]

Low back pain is a problem that is faced by 50% of pregnant women and causes important social trouble. In spite of this, the problem is considered to be normal and is expected during pregnancy, which has contributed to the lack of prophylactic and relief measures. This work aims at under standing the historical and conceptual bases that have given rise to such naturalization as outlined by midwifery and by using world literature indexed on the topic from 1987 to 1997 as a theoretical framework. We have apprehended that a deterministic view related to this issue is supported by the biomedical model. Therefore, the adoption of effective solutions requires the incorporation of a new paradigm.

The long-term effects of analgesia in labour

Women frequently use a mixture of analgesics to gain relief from the distress of childbirth and antenatally require information on their effectiveness and side-effects. One such example would be the reported long-term neonatal behavioural changes following systemic opioids such as pethidine. The most frequently reported maternal effects of epidural or spinal analgesia are prolonged symptoms of headache, backache and neurological sequelae. Large retrospective studies of postpartum symptomatology have focused on correlations with regional nerve blockade rather than on other more commonly used analgesics. Post-dural puncture headache is a recognized long-term complication of epidural nerve blockade. However, prospective studies have not confirmed any causal relationship between epidural analgesia and backache and neurological complications are five times more common after childbirth itself than after regional nerve blockade. Postpartum symptomatology describes significant morbidity in the community but its relationship to analgesia in labour is still to be proved.

Back pain in relation to pregnancy: a 6-year follow-up

STUDY DESIGN

A prospective randomized controlled 6-year follow-up study of women with back pain during pregnancy.

OBJECTIVES

To describe the long-term development of back pain in relation to pregnancy and to identify the effects of a physiotherapy and patient education program attended during pregnancy.

SUMMARY OF BACKGROUND DATA

Pain incidence and intensity during pregnancy can be reduced by physiotherapy. No study has described the development of pain experienced for a period of years after delivery or the long-term effect of physiotherapy.

METHODS

Pregnant women, registered consecutively, were randomly assigned to one control group and to two intervention groups and were observed throughout pregnancy, with follow-up after 3 months and 6 years.

RESULTS

The first phase of the study was completed by 362 women. After 3 months, 351 and after 6 years, 303 women had been observed. Back pain among 18% of all women before pregnancy and among 71% during pregnancy declined to 16% after 6 years. Pain intensity was highest in Week 36 (visual analog score, 5.4) and declined markedly 6 years later (visual analog score, 2.5). Slow regression of pain after partus correlated with having a back pain history before pregnancy, (r = 0.30; P < 0.05), with high pain intensity during pregnancy (r = 0.45; P < 0.01), and with much residual pain 3 months after pregnancy (r = 0.41; P < 0.01). These correlations were not found in the intervention groups. Furthermore, frequency of back pain attacks at 6 years correlated with frequency of attacks during pregnancy (r = 0.41; P < 0.01) and with a vocational factor (r = -0.25; P < 0.01). Physiotherapy and patient education had no effects on back pain development among women without pain during pregnancy.

CONCLUSIONS

Back pain during pregnancy regressed spontaneously soon after delivery and improved in few women later than 6 months post partum. Expected correlations between back pain in relation to pregnancy and back pain 6 years later were not present in the intervention groups who had attended a physiotherapy and education program during pregnancy. The program had no prophylactic effects on women without back or pelvic pain during pregnancy.