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Introduction
In approximately 80% of women who are pregnant, back pain is
prevalent. Back pain and the causes in pregnant patients are
not entirely understood. Therefore, the treatment recommendations
are poor. By educating both the physician and the patient, treatment
options can be improved.
Peripartum Pelvic Pain
Pain in the pelvic region, for which a clear-cut diagnosis has
not been made, is termed peripartum pelvic pain. This pain may
start during pregnancy, or within three weeks of delivery.
Anatomically, pain presents itself
most commonly in the following areas: sacroiliac joints at the
posterior superior iliac spine (42%), the groin areas (53%),
coccyx (33%), pubic symphysis anteriorly (77%), and occasionally
other areas of the pelvic and upper legs. Rarely does pain occur
below the knee. Pain tends to be influenced by posture and is
associated with a waddling gait.
In approximately 80% of pregnancies,
back pain is usually localized, but the site may vary. Although
long-term pain is very rare, short-term pain tends to be dominant.
Usually during the third trimester, 50% of pregnant patients
will experience back pain. The prevalence of postpartum period
pain falls to approximately 9% in decreasing order as follows:
sacral, lumbosacral, lumbar, cervicothoracic, and remaining areas.
Disk Herniation
The prevalence of pain during the first nine months is thought
to be 90% versus non-pregnant controls for the same period of
time to be approximately 20%. Although the pain may be severe,
disk herniation, which is exceedingly rare during pregnancy,
is not to be blamed. Disk herniation presents at the same rate
as non-pregnant women or at approximately 1:10,000 (one in 10,000).
Pain Indices
With respect to age and smoking, there has been no demonstrated
difference in pain indices. However, a slight increase in peripartum
pain has been demonstrated with higher body mass, more pregnancies,
a previous history of pain during pregnancy. Also, younger women
tend to have more intense pain when compared to older women.
A third of women describe their pain as disabling, restricting
their activity, and a costly handicap. Approximately 10% of women
describe their pain as extremely disabling.
Etiology of Pain
The etiology of pain is probably related to a combination of
mechanical, metabolic, circulatory, and psychosocial contributing
factors. One-third of the patients who experience pain starting
during the first trimester when mechanical forces are not a significant
force, are highly indicative that the most probably cause is
due to a change in hormonal influence.
It is believed that hormones
cause change at the insertion point of ligaments to the bone.
A higher concentration of ligaments in the lower spine may suggest
the cause for a higher incidence of back pain in the multiparous
mother who has had more exposure to hormonal influences.
Furthermore, an increase in premenstrual
pain has occurred in a large majority of women whose pain has
been suggestively influenced by hormonal changes. There has also
been found to be higher serum relaxin levels in women with peripartum
pelvic pain. There is some evidence to suggest that a different
set of receptors is sensitized in the lower spine during pregnancy
by hormones. Therefore, it is believed that most of the pain
is secondary to hormonal changes rather than actual chemical
stresses.
Lumbar Lordosis
It has been thought that lumbar lordosis is increased during
pregnancy. However, in reality with x-ray studies, it has been
demonstrated that lordosis decreases during pregnancy. Therefore,
overall pain may be due to the muscles and ligaments combined
with some alteration in blood flow to the pelvic musculature
and ligaments.
Treatment
The treatment recommendations for pelvic pain in most obstetrical
and gynecological textbooks are poor. Patients are instructed
to avoid excessive weight gain, exercise to strengthen the back
muscles, maintain correct posture, and to wear sensible shoes
(not high heels).
Some activities do cause or aggravate
pain. The most common are: 30 minutes of standing or walking,
carrying a full bag of groceries, standing on one leg, climbing
stairs, turning over in bed, intercourse, bending forward, stepping
in or out of bed, and driving for 30 minutes.
Many treatment options are available
including a pelvic belt (by prescription), exercise, appropriate
rest, medication, massage, and standard back exercises. It is
interesting to note the percentage of women who found relief
using these treatments.
The pelvic belt helped approximately
50% of women during pregnancy and 66% after pregnancy.
Bed rest and exercise appeared
to be the best treatments resulting in the rapid recovery of
65%.
Bed rest alone: only 40% got
better
Exercise alone: only 35% improved
-- 20% of the patients worsened without appropriate bed rest
included
Manual Therapy: 20% of the patients
indicated their pain was worse
Medication and Massage: 70% of
experienced only temporary relief
Good News
The good news is that the median time for back pain
to resolve was within six months. Approximately 35%
of patients continued to describe intermittent back
pain lasting 1-1/2 months after partum. At the first
postpartum visit, only 15% of patients continued to
have low back pain regardless when the symptoms started
during pregnancy. Therefore, in most cases, pain does
improve after the postpartum period.
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SpineUniverse
Editorial Board Comments;
"This article provides a nice overview of the
back problems encountered during pregnancy.
It also provides useful information for pregnant
ladies with back pain, both regarding treatment
and prevention."
Edward
C. Benzel, M.D.
- Editorial Board, SpineUniverse.com
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