Physical Therapy for Lower Back and Pelvic Pain During Pregnancy
By Maricel Briones, DPT
Approximately three-fourths of pregnant women have lower back pain during the 2nd trimester. Some risk factors include increased parity, higher end pregnancy weights, low back pain prior to pregnancy, periods of amenorrhea, and history of hypermobility. Contributers to lower back pain may include the growth of the uterus, poor posture, increased stress and weight gain. Also, the body undergoes multiple hormonal changes, such as the production of relaxin. Its name and function are one in the same, which relaxes the ligaments, to prepare the joints for the growing baby and delivery. Mechanical involvement then occurs secondary to hormonal.
Mechanical instability of the whole spine and pelvic region contributes to lower back and pelvic pain during pregnancy. A few mechanical disorders include sacroiliac joint hypermobility, disc involvement, pubic symphysis separation, facet joint dysfunction, or dislocation of the coccyx. Physical therapists would also consider other disorders such as sciatica, Meralgia Paresthetica, thoracic/rib pain, osteomyelitis, osteoarthritis, and Diastasis Recti. A statistical reference states that 67% of women develop a Diastasis Recti Abdominus which is a trough of the linea alba, due to the growth of the uterine. The abdominal wall separates at the origin, which runs down the center of the stomach, and weakens the abdominals.
Furthermore, postural changes occur during pregnancy. This includes forward head and shoulder, increased thoracic kyphosis and lumbar lordosis, wide base of support, and center of gravity change to anterior to the acetabulum. Poor posture, weakened muscles and relaxed ligaments increase stress to the weightbearing joints, primarily around the center of gravity, increasing anterior forces of the ilium on the sacrum. In addition, the round ligament holds the uterus to the abdomen and has sharp stabbing pain down to the lower right quadrant, to the groin area. Although ligaments cannot be strengthened, physical therapy can help strengthen the dynamic stabilizers around the joints and assist with correcting the spine and pelvic impairments.
Exercise within moderation during pregnancy is safe. The American College of Obstetricians and Gynecologists recommend for pregnant women to exercise 3-4 times per week for 15 minutes at a time at a heart rate of 140 beats per minute. Physical therapists have the skills to derive an all-inclusive specific program tailored to the pregnant patient. Pelvic asymmetry, posture, movement dysfunctions, and core weakness are assessed and corrected. A few exercises include transverse abdominus isometrics with marching while sitting on a theraball, gluteus and hip strengthening using a theraband, pelvic tilts, pelvic floor strengthening, and/or progression of repeated lumbar extension or flexion exercises. Furthermore, one study suggested a modified McKenzie Approach may be beneficial as there is a mechanical origin with most women with lower back pain during pregnancy. This study found that most of the subjects had a posterior derangement and responded well to lumbar extension. Evidence shows aquatic therapy may also reduce low back pain while strengthening the core muscles as there is less weightbearing on the joints. Manual therapy may include muscle energy techniques and mobilizations to correct pelvic or spinal asymmetries. Pain may be referred to the sacrum, hip, groin, and lower extremities if active or latent trigger points exist in the lower back or gluteus muscles. Manual therapy also includes soft tissue massage or trigger point release which can also be performed by dry needling. Other treatment can include specific Kinesio taping to inhibit or facilitate muscles, or provide mechanical stability. An SIJ belt may also assist with mechanical support as well if indicated. Education is significantly important for pregnant women in terms of posture, body mechanics with lifting and daily mechanics, form with exercises, and sleeping position with proper support. Modalities such as hot packs and cold packs may possibly be beneficial to decrease pain, however with caution. However, physical agents that are contraindicated are electrical stimulation, ultrasound, mechanical traction, shortwave diathermy, and microwave diathermy. Other contraindications are highly considered for each treatment during pregnancy.
The various physical therapy treatments are beneficial for lower back and pelvic pain during pregnancy and may also be beneficial after pregnancy. Instability continues shortly after delivery, therefore proper body mechanics for lifting and other daily activities are necessary. Physical therapy has a significant role for management of back and pelvic pain as well as other musculoskeletal conditions during and after pregnancy.
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