IDENTIFICATION AND MANAGEMENT OF

PREGNANCY-RELATED LOW BACK PAIN

Jan Perkins, MSc, Roger L. Hammer, PhD, Peter V. Loubert, PhD, PT, ATC

ABSTRACT guidelines to assist the primary contact practitioner, who

is in the best position to offer early intervention and
Back pain is a common complaint of women during preg-
nancy. It is frequently dismissed as trivial and inevitable. This individual advice. It is limited to back pain affecting the
article gives an overview of recent research on pregnancy- lower portion of the spine and pelvis and excludes the
related back pain that documents the impact of this pain on special cases of nocturnal-only back pain and the back
women’s lives, during and beyond the childbearing year. It pain associated with severe diastasis recti. It includes
argues for a more active approach to the prevention and information on differentiating between two common
management of back pain during pregnancy. Two common
back pain types, lumbar pain and posterior pelvic pain, are back pain syndromes and management suggestions for
described and basic management techniques for the woman these syndromes. Treatment suggestions are geared
and her primary caregiver are suggested. Red flag findings that toward low-technology interventions with a focus on
necessitate specialist referral are also highlighted, as are sug- active prevention and self-management. Key “red flag”
gestions for further research. q 1998 by the American findings that may indicate serious pathology requiring
College of Nurse-Midwives.
specialist intervention are also covered.

Low back pain (LBP) is one of the more common CAUSES OF BACK PAIN IN PREGNANCY
musculoskeletal complaints of pregnant women. An
estimated 50 –90% of women will experience some type Although the high frequency of back pain in pregnancy
of back pain during their pregnancies (1– 8), making this has been acknowledged for almost as long as there have
experience so ubiquitous that “treatment” will often been writings about pregnancy, there is surprisingly little
consist of counseling women to be patient and wait for validation of hypotheses regarding causes. This may
postpartum recovery. So closely linked are the concepts proceed from the common perception that the back pain
of pregnancy and back pain that women with pre- of pregnancy is a normal part of pregnancy and some-
existing back pain may fear becoming pregnant (9). thing that must simply be endured. When women report
Some authors suggest that the incidence of generalized back pain to their caregiver, treatment given is often
as well as pregnancy-related back pain may be on the limited to reassurance (5,15,16). Explanations are linked
rise within contemporary society (10,11). to “common sense” analyses of the “obvious” hormonal
In view of the significant negative impact that back and biomechanical changes of pregnancy. The limited
pain can have on women’s functioning and well-being work examining these explanations has shown that the
during pregnancy, dismissing it as inevitable and trivial is traditional explanations are incomplete and at times
simply not acceptable (4,5,7,11). In fact, recent research inaccurate (17).
has documented the severity of back pain and shown During pregnancy, some women may gain as much as
that the back pain of pregnancy may impact the entirety a quarter of their body weight. Their center of gravity
of some women’s lives. Not only does the problem shifts, requiring changes in posture to maintain balance.
persist well beyond pregnancy in a significant number of These changes are not the same in all women. The
women, but many women with chronic back pain link its postures of pregnancy have been divided into two broad
onset to a pregnancy (12,13,14). Moderating or pre- classes: an anterior posture where the weight of the
venting back pain thus becomes an issue of importance uterus is carried anterior to the normal center of gravity
for all concerned with women’s health and not just an and a posterior posture where the weight of the uterus is
issue for those working with women during pregnancy. carried posterior to the normal center of gravity. It was
The purpose of this article is to review some of the found that at the end of pregnancy 75% of women will
recent literature on LBP in pregnancy and synthesize have a posterior posture and suggested that an anterior
posture may be associated with pubic symphysis prob-
lems (18). Unfortunately, studies that actually measure
postural changes through pregnancy are rare, making it
Address correspondence to Jan Perkins, MSc, Physical Therapy,
Pearce Hall 134, Central Michigan University, Mt. Pleasant, MI impossible to predict shifts in an individual client. Not
48859. surprisingly, biomechanical changes have been sug-

Journal of Nurse-Midwifery • Vol. 43, No. 5, September/October 1998 331

q 1998 by the American College of Nurse-Midwives 0091-2182/98/$19.00 • PI S0091-2182(98)00032-9
Issued by Elsevier Science Inc.
gested as a cause of back pain, either because of added pain or positive results in pain provocation testing (26),
strain imposed on weightbearing structures, the alter- pain patterns and intensity do not fully correlate with
ations in posture, or muscle fatigue related to the extra relaxin levels (9,26).
work required to move and balance the altered body. A special case is pain that is present only at night and
It is noteworthy that back pain often begins well before unrelated to position changes. Although this nocturnal
significant weight and body shape changes occur and pain is poorly understood, it is thought to be linked to
does not correlate directly with weight and posture hypervolemia and possible pressure on the inferior vena
changes (9,15). Peak onset is between the fifth and cava in supine lying (17–22,23). This type of pain is
seventh months (4,5,12,15), before the period of great- beyond the scope of this review; however, caregivers
est increase in weight, and prevalence of pain plateaus who identify this pain pattern in their clients may be able
or decreases toward the end of pregnancy (19). In to offer advice on avoiding supine sleeping positions
addition, the frequently hypothesized postural alterations based on this hypothesis (23).
of anterior tilt of the pelvis and increased lumbar lordosis Unfortunately, broad survey studies are rarely able to
have not been consistently observed and have not been distinguish between types of back pain. Neither biome-
shown to correlate with back pain (5,20). While some chanical stress on ligaments and joints, muscle fatigue,
studies have shown an increase in lumbar lordosis over nor joint laxity can alone explain back pain in pregnancy
pregnancy, others have not or have shown a variable (8). Similarly, no one structural component (joint, mus-
effect related to parity (21–24). One study has made the cle, or ligament) is likely to be the sole source of pain (3).
tentative suggestion that women with a deep lumbar Although there are several common presentations, the
lordosis prior to pregnancy may be more prone to back pain women experience in pregnancy is likely to be
pain in pregnancy but was unable to document a change multifactorial (9,15), with one or more factors dominat-
in lordosis depth during pregnancy (8). Studies that ing in an individual case. Therefore, it would be benefi-
looked at factors aggravating back pain during preg- cial to seek common patterns that may be addressed
nancy have noted that the pain tends to increase over with focused treatment.
the day and be eased with rest, a finding that offers
support for the hypothesis of muscle fatigue (9). The
PATTERNS OF LBP
effects of muscle fatigue may be further aggravated by
the muscle imbalances of pregnancy (25). A number of authors have identified two major subtypes
Another factor commonly implicated in the develop- of back pain affecting the lower portion of the spine in
ment of back pain is the effect of hormones, particularly pregnancy. While the terminology varies, as at times
relaxin, which increases ligamentous laxity thereby de- does the proposed mechanism, there is fairly broad
creasing joint support. This would help explain the early agreement on the description and presentation of two
onset of pain in many women; however, while there is main types of lower spinal pain. In this article, the terms
some support for the role of relaxin, including correla- lumbar pain (LP) and posterior pelvic pain (PPP) will be
tions between mean levels of relaxin and complaints of used, following the suggestion of Östgaard and col-
leagues (11), who feel that the uncertain or multifactoral
etiology of the latter pain presentation makes the term
Jan Perkins is an assistant professor of physical therapy at PPP more acceptable than other options. While many
Central Michigan University. She received a diploma in features of the PPP syndrome are suggestive of sacroiliac
physiotherapy from the British Chartered Society of joint problems, referring to it as sacroiliac pain would
Physiotherapists, a BSc in physical therapy and an MSc from
Dalhousie University in Nova Scotia, Canada. She is a member obscure the more complex etiology (7).
of the Women’s Health Section of the American Physical After screening for nonmusculoskeletal problems that
Therapy Association. might require specialist referral, the primary care prac-
Roger L. Hammer is an associate professor and the division titioner can proceed with an examination to differentiate
director of exercise science at Central Michigan University. He between LP and PPP. Uncomplicated LP occurs over
received his PhD in exercise physiology from Brigham Young the area of the lumbar spine and occurs with or without
University, Provo, Utah. He is a certified member of the
American College of Sports Medicine and has conducted radiating pain into the leg. Its presentation is not dissim-
research studies involving exercise in women’s health and fitness ilar from that of LP experienced by women who are not
for twelve years. pregnant and is aggravated by activities such as pro-
longed standing or sitting (11,13,27).
Peter V. Loubert is an associate professor of physical therapy at
Central Michigan University MI. He received a BS in physical PPP is approximately four times as prevalent as LP
therapy as well as a PhD in anatomy and cell biology from the during pregnancy (27). The pattern seen in PPP is
University of Michigan, Ann Arbor, Michigan. He is an active similar to that described by other authors as sacroiliac
member of the American Physical Therapy Association and a
National Athletic Trainers’ Association Certified Athletic Trainer. pain, ligamentous laxity pain, or pelvic insufficiency
pain. It is described as a deep pain felt distal and lateral

332 Journal of Nurse-Midwifery • Vol. 43, No. 5, September/October 1998

 FIGURE 2.
The posterior pain provocation test.

13,23,27). It should be noted that the pain felt with PPP

at night is linked to the stress of turning in bed, distin-
guishing it from the cramp-like nocturnal back pain of
pregnancy (10,17,27). Some authors report that PPP is
FIGURE 1. often found in concert with pubic symphysis pain, but
Typical pain distribution of lumbar pain (A) and posterior pelvic further research is needed to clarify any linkages
pain (B). (1,10,11). PPP may also involve morning stiffness (23).
PPP and LP are distinguished by their location (Figure
1), by their characteristic presentation (Table 1), and
to the L5/S1 vertebrae, over the sacroiliac joint and through the use of pain provocation testing (Figure 2).
posterior superior iliac spine; the pain may also radiate The best test to distinguish the two is the posterior pelvic
to the posterior thigh or knee (7,10,13,23,27). It may pain provocation test (PPPT) (3,10,28). Although addi-
be unilateral or bilateral and is aggravated by such things tional pain provocation testing may increase accuracy
as prolonged postures, particularly at the extremes of hip (3,9), the PPPT provides a simple test accurate enough
or spinal movement, and asymmetrical loading of the for routine clinical practice. It is performed with the
pelvis, leading to problems with walking, prolonged woman supine and the hip on the affected side flexed
sitting, stair climbing, and turning at night (10,11, to 90o. The examiner stabilizes the opposite iliac crest

TABLE 1
Characteristic Features of Lumbar Pain and Posterior Pelvic Pain
Features Lumbar Pain Posterior Pelvic Pain
Pain location Pain over and around the lumbar spine Unilateral or bilateral pain in buttocks and low back
With or without radiation to leg or foot Distal and lateral to the lumbar spine
May radiate to posterolateral thigh, occasionally to
knee and rarely to calf
Does not radiate to the foot
Functional limitations Pain is related to prolonged weight-bearing in Difficulty/pain with activities like turning in bed,
standing or sitting and repetitive lifting climbing stairs, running, walking, getting out of
cars and low chairs, lifting and twisting, getting in
and out of a bathtub
Clinical features Pain may resemble episodes of low back pain Aggravation by jarring activities or strain at
experienced before pregnancy extremes of hip and back range of motion
Erector spinae muscles may be tender on palpation Prolonged postures near the limits of hip and lower
Posterior pain provocation test negative back range of motion aggravate pain (eg, sitting
and leaning forward while using a computer,
sitting in a deep chair seat)
May be acute episodes of pain precipitated by
above activities, with pain peaking some time
after precipitating event
Posterior pain provocation test reproduces pain
May be associated with pubic symphysis pain

Journal of Nurse-Midwifery • Vol. 43, No. 5, September/October 1998 333

while applying vertical pressure through the flexed women who do experience pain are likely to have a
thigh (Figure 2). A positive test reproduces the client’s longer duration of pain than primiparous women (19).
pain. Earlier studies tend to report more back pain and more
Common features of LP and PPP are presented in severe pain in older women and in multiparous women
Table 1. (6); however, several recent studies have found higher
rates of pain and more intense pain in younger women
(4,7,19). One study that followed women throughout
PREVALENCE OF PAIN pregnancy reported that the difference in pain severity
between older and younger women disappeared during
Numerous studies have looked at how common back the third trimester (19). The differences in studies may
pain is during pregnancy. Rates range from 25% to relate to difficulties in controlling for the combination of
almost 90%, being lowest in population surveys that ask
age and parity, or to how and when in pregnancy pain is
about back pain retrospectively and highest in those that
measured.
follow women through pregnancy asking about any level
The link between job demands and pain is even less
of pain (1– 8). The majority of studies report that over
clear. While work has been shown to be a risk factor in
one half of women will experience back pain during a
some studies (1), others have shown that the link is less
pregnancy and that for about one third the pain will be
severe enough to have a substantial impact on their daily with overall work or job demands than with specific
lives (4 –7). One study found that back pain was the most features of work, such as sustained postures, having to
common cause of sick leave during pregnancy (19). twist or bend several times in an hour, lifting with
Although back pain may begin as early as the 12th twisting, and inability to pace work or take breaks (7,10).
week of their pregnancy (7,27) or even earlier, for most PPP risk is increased with work postures involving
women it will begin between the fifth and seventh month flexion of the upper part of the body (10), perhaps
(4,5,12,15). Duration is variable, with some women because this may stress lower parts of the spine and
experiencing only brief periods of pain and others pelvis by placing them near the limit of their range. PPP
having many months of severe pain. A longer duration has also been particularly associated with work involving
of pain is associated with more severe pain (4) and back lifting with twisting (1), perhaps because it loads the
pain during pregnancy is the best predictor of postpar- spine asymmetrically. Some authors have speculated
tum back pain (17,29). For the majority, the pain will that the current idea that healthy women should be able
resolve within 4 months of giving birth; but for others the to maintain their maximum working capacity throughout
pain will persist for months to years. Of women with a pregnancy causes women, their partners, and their
chronic back pain, 10 –20% report that the pain began employers to have unrealistic performance expectations
with a pregnancy, making back pain during pregnancy a that may increase their risk for problems (5,23).
risk factor for general or chronic back pain (13,14,25). Recent surveys have examined the links between the
Given the high frequency of complaints of back pain in subtypes of back pain mentioned above, various risk
the general population, some of the pain experienced by factors, and level of disability. PPP, which is more likely
women during pregnancy may not be related to the to be triggered by pregnancy, is more common than LP
pregnancy at all (5,19); this is particularly true for LP. during pregnancy and also regresses more readily post-
Although there are a few women who find that back
partum than LP (11,13). However recent studies have
complaints disappear with pregnancy (5,16), there is no
shown that, on average, PPP is more disabling during
doubt that there is an increased incidence of back pain in
pregnancy than LP and that with both types of pain a
pregnancy; moreover, there are particular patterns of
high pain intensity during pregnancy is predictive of
pain that are specifically linked to pregnancy.
persistent pain up to one year postpartum (1,8,13). Sick
leave for back pain correlates with both pain intensity
and with PPP (8). It has been suggested that if PPP has
RISK FACTORS
not resolved within three months of delivery a very slow
Although there are some accepted risk factors for back recovery will usually ensue (10).
pain in pregnancy, it is not possible accurately to predict LP shows a stronger link with back pain prior to
who will be at greatest risk (30). Consistently found risk pregnancy (1,10,11). Relative risk of LP and related sick
factors for back pain in general include back pain in a leave are lower in women with higher levels of fitness
previous pregnancy and any history of back pain (7,10). prior to pregnancy (1,10,11), making this analogous
A general history of back pain is also predictive of pain to back pain in the general population. On the other
of longer duration and severity (19). While studies on hand, fitness does not appear to protect women from
parity and pain have been conflicting, multiparous PPP (11).

334 Journal of Nurse-Midwifery • Vol. 43, No. 5, September/October 1998

GENERAL BACK CARE FOR PREVENTION OF minimize lifting or bending or rearranging a kitchen so
BACK PAIN that frequently used items are accessible without bend-
ing. In later pregnancy, as increasing size of the abdo-
While prevention of all pregnancy-related low back pain men makes biomechanically sound lifting more difficult
is unlikely to be possible, advice on back care should be for many women, heavy lifting should be shared or
available to all pregnant women and their active partic- discontinued. When carrying lighter loads such as shop-
ipation in daily back care activities should be encour- ping, it is also imporant to distribute the weight so that
aged. First, it is important that women maintain proper the load may evenly stress the spine.
posture, which can prevent unnecessary mechanical Suggestions on back care and pain prevention for the
stress on the low back. Secondly, an exercise program pregnant woman are readily available. Those given are
that improves the strength and flexibility of supporting derived from a number of sources as well as from clinical
soft tissue structures and includes moderate intensity experience; particularly useful sources for the clinician
aerobic conditioning should be prescribed, preferably include Bookhout and Boisonnault (20), Mantle (5),
prior to a planned pregnancy. Health care providers can, Noble (31) and Polden and Mantle (16).
for example, instruct their pregnant patients to perform
physical activities in the neutral spine posture and then
observe them while simulating daily movement patterns. MANAGEMENT OF PREGNANCY-RELATED
In general, women should attempt to pace work, using MUSCULOSKELETAL LOW BACK PAIN
breaks to vary static body positions and physically de- Management of back pain during pregnancy should
manding tasks. For example, a clerk in a large store may begin with acknowledgment that pain is not a trivial
be able to alternate check-outs to balance muscle work matter for many women. As presentation and particular
involved. Bending with spinal rotation should be circumstances vary, so should the treatment. When a
avoided, with activities such as vacuuming and mopping woman complains of back pain a retrospective evalua-
being possible sources of this type of stress. Simple tion of aggravating and easing factors can help guide
backache from muscle fatigue may be avoided or mini- initial management suggestions (16). Early identification
mized if a midday rest is possible to give tired muscles a and treatment provide the best opportunity for good
chance to recover. results (20) and simple comfort measures are often
Women should strive to use seats that support their effective (22), both for relieving pain and giving the
spine and begin early to use cushions to support the top woman a sense of control over her situation, which in
leg and abdomen for sleep in side-lying to avoid twisting itself will assist in coping with pain.
and stress on the spine. In a soft bed, a towel roll or The value of good posture and regular exercise should
cushion at the waist may provide additional support and be an integral component of any prenatal counseling.
comfort. Comfortable sleep is important. Of equal im- This can be supplemented by advice on resting positions
portance is getting in and out of bed without straining the for comfort. Lying with feet supported on a stool, sitting
spine and pelvis; this can be done by rolling to the side backwards in a chair with the chair back providing
with hips and knees bent, and then sitting up by using the support, and standing and stretching back with the
arms to push up while lowering the lower legs over the hands in the small of the back are all suggested to help
edge of the bed. ease tired back muscles (16). Low-heeled supportive
Walking is better than static standing; however, if shoes and use of props such as footstools for helping
required to stand a woman may find that weight-shifting maintain a posterior pelvic tilt for lumbar and postural
from one foot to the other or using a small stool for one backache are frequently recommended. The use of
foot (alternating feet periodically) helps. In any work supportive back cushions and brief periods of rest are
situation, stooping should be avoided; raising the work also reported to be of benefit to many women (6,30).
surface or using a stool to lower the worker may help. Hot or cold packs (but not whirlpools or saunas) and
Where work or home demands pose a problem, the massage are other common measures suggested for
primary practitioner’s role may include advocacy as well back pain (27,32). Most prenatal education classes en-
as back care education. courage pelvic tilt and pelvic floor exercises in a variety
Lifting advice is also important from very early in the of positions, including sitting, lying, and on all fours.
pregnancy. If a woman does not begin to develop the Relaxation exercises are also incorporated into prenatal
habit of using her legs to lift early they may not be strong exercise classes, and can be adapted for coping with pain
enough for her to adopt good lifting practices late in the in pregnancy and with many of the associated stresses
pregnancy. If bending and lifting correctly becomes that can enhance the experience of pain.
difficult, women should consider strategies that may Although such general measures are useful for many
minimize such efforts as their pregnancy advances. This women, aggravating and relieving factors differ among
may mean such things as reorganizing work surfaces to individual women (6). This means that caregivers cannot

Journal of Nurse-Midwifery • Vol. 43, No. 5, September/October 1998 335

rely on a cookbook approach to management of back TABLE 2
pain. Some work has been done on the use of back Basic Management of Lumbar Pain
education classes to manage back pain. A study that did Use of a back support such as a small pillow in sitting
not distinguish between types of back pain found that Postural correction by “standing tall”—aim for a neutral spine
availability of two classes early in pregnancy that gave rather than flattened lumbar spine or a hyperlordotic spine
ergonomic advice and taught simple pain management Avoidance of prolonged sitting or standing—interrupting
techniques decreased the incidence of intense back pain these activities with walking or stretching
Pacing activities by taking short breaks to rest in a position
significantly in women who attended both classes (30). of comfort with spine supported
Unfortunately, many women did not attend both classes. Taking a rest at midday to relieve tired muscles
Perhaps reinforcement and individual advice from a Use of a small footstool for one foot in sitting or standing,
primary caregiver could increase compliance or offer alternate feet
some benefit to women who are unable to fit classes into Fitness activities such as walking or swimming at a level
appropriate for the individual client
their schedule. This could also assist individual women in Pelvic tilting exercises in a variety of positions including
developing creative options for coping with environ- supine lying, standing, sitting, and on hands and knees
ments or activities that aggravate their pain.
More recent work in Europe has examined a variety of
treatment protocols for both LP and PPP. This research
has supported some of the suggestions clinical experts for one foot in sitting or standing. An acute episode of
have made regarding the management of pain and lumbar pain may benefit from a period of decreased
shown the importance of treating the different syn- activity, either rest or avoidance of aggravating activities,
dromes accordingly. In Sweden, the combination of followed by a gradual introduction of back exercises and
routine education classes and individualized treatment activity, with pool exercises often being an enjoyable and
including ergonomic advice has been shown to be a comfortable option (16).
cost-effective way of reducing sick leave and associated Back support in sitting is also encouraged. A small
costs (10). Another study has shown that while education pillow or rolled toweling offers a low-cost or trial option.
can help, generic information is not very effective unless Women should be encouraged to pace work to avoid
supplemented by specific information tailored to the muscle fatigue if possible, taking short breaks, during
individual woman’s situation, particularly for women which they can use the comfort positions previously
with PPP (11). The study found that although interven- described. One position of comfort for many women late
tion could not eliminate the pain, it could reduce pain in pregnancy is sitting backward astride a chair and
problems, decrease short-time sick leave, and reduce leaning onto the chair back for support (16). Changing
pain intensity postpartum, although this latter effect was posture frequently and avoiding prolonged sitting or
seen more in LP than PPP (11). standing may also help. General exercise such as walking
or swimming within tolerance is likely to be of benefit.
For a small number of women, maternity supports for
TREATMENT OF LUMBAR PAIN
the abdomen and spine may help with recalcitrant pain
Lumbar pain commonly presents as similar to back pain or when the abdominal muscles cannot control the
experienced before pregnancy. Ideally, when planning a position of the spine as long as needed.
pregnancy women should try and resolve back pain Some management suggestions for LP are summa-
through usual treatment methods and through maintain- rized in Table 2. These are likely to be of value as part of
ing or increasing fitness, as this may be a protective a general back care program for women during preg-
factor (1,10,11). While women are now encouraged to nancy and for an initial trial of management for LP
continue many fitness activities in pregnancy, it is not without complicating features. This program, with its
usually the optimum time to begin a program; however, emphasis on lumbar support and lumbar flexion with pelvic
recent guidelines suggest that interested women without tilting, may help with pain from strained lumbar facet joints
complications may start an exercise program in the in women who develop an increased lumbar lordosis, as
second trimester. Guidelines for exercise in pregnancy well as women with pain from postural fatigue.
are available and should be followed (33,34), and specific
exercises for the uncomplicated pregnancy are also
TREATMENT OF PPP
readily available (31). When a pregnant woman presents
with lumbar pain she can use the comfort measures and Women with PPP may find some of the above methods
exercises mentioned above, in essence treating the prob- useful but may have to modify some and adopt other
lem as it would be treated in a nonpregnant population, techniques. For these women, weight-bearing activities
with posture, exercise, and fitness (10). Pelvic tilts and such as running, walking, and stair climbing are more
rocking often are of benefit, as is the use of a footstool likely to cause pain. The pain is often felt for some time

336 Journal of Nurse-Midwifery • Vol. 43, No. 5, September/October 1998

after the activity ends, so asking about activities over the TABLE 3
past few days is useful in a woman presenting with PPP. Basic Management of Posterior Pelvic Pain
As pelvic instability may be an important component of Minimize activities that exacerbate the pain (eg, high impact
PPP, these activities may need to be modified to avoid exercise; asymmetric spinal loading)
excess stress on the pelvis. Asymmetric loading of the Use of a sacral belt for walking and other painful activities
pelvis should be avoided, making use of a single leg Support legs in lying with pillows and squeeze the legs
footstool with standing less likely to be of benefit. together for rolling
Brief rest may be indicated for acute episodes of pain
Modification of fitness activities may be required, and Modify seating to decrease overflexion of the hips and lower
after an acute episode a brief period of rest may be spine
needed to resolve the pain and allow a return to normal Minimize stair climbing and single leg standing
activities (5,22). The woman may need to choose fitness Shift fitness activities to low-impact exercises
activities that do not involve jarring and unbalanced Avoid exercises at the limits of hip and spine range of
motion
loading of the pelvis. For example, a runner with PPP Consider avoiding a return to high impact activities for
may find that swimming, an exercise machine, or a several months postpartum
low-impact exercise class offers an acceptable way of
maintaining fitness while minimizing pain. Exercises
should also avoid extremes of hip and spine movement,
which are likely to aggravate the problem. Aerobic pelvis. Squeezing the knees together while turning in bed
routines that involve movements taking the hips to the has been suggested for decreasing pain (16), and the
limits of their range, particularly if momentum is involved careful getting in and out of bed is also needed. Women
are examples of exercises likely to give these women may choose to avoid low, soft chairs because getting out
pain. When carrying weight such as shopping or a of them causes pain.
briefcase, dividing the load into a parcel for each hand One author suggests that in view of the probable
may help decrease asymmetric loading of the pelvis (16). connection between PPP and pelvic instability, women
Sacral belts are one of the most commonly suggested with severe PPP should be cautioned not to return to
interventions for PPP. They have been shown to in- strenuous activity too early (10). Returning to asymmet-
crease walking tolerance and decrease complaints of ric loading and overloading of the pelvis before recovery
PPP (1,10,11). For a minority of women, they appear to occurs may predispose a woman to persistent postpar-
increase pain. If a belt does not produce pain relief, its tum pain or provoke a relapse. Individual practitioners
positioning may need to be adjusted. If this does not and their patients must decide how long this will be,
help, or if pain is increased, a belt should not be used as either based on symptoms or on Östgaard’s recommen-
it may be adding stress to affected structures rather than dation that women who have experienced PPP during
supporting them. The belt can be used in any situation pregnancy should avoid strenuous work for a minimum
where activity that may aggravate the pain is anticipated, period of six months postpartum (10).
or to reduce pain from previous activity. Basic management suggestions for PPP are summa-
As with other back problems, pacing of work is likely rized in Table 3.
to be helpful if this is possible. With PPP, any prolonged
position may cause pain and so position changes as well
ADDITIONAL TREATMENT MODALITIES
as avoidance of extremes of posture should be encour-
aged. Support for the lower back in sitting may help Some women will present with both PPP and LP. In
some women, but not all. Another seating suggestion general, if the woman presents with both pain syn-
possible for those whose work requires sitting may be to dromes, it is better to manage the pain with the ap-
tip the front of an adjustable seat downward so that hip proach used for PPP, as it requires a limitation of some
flexion is decreased. A cushion raising the back of the of the exercise interventions that would be appropriate
seat slightly is another way of decreasing hip flexion in for pure LP (13).
sitting. Twisting while lifting and sitting with the upper While simple measures may enable many women to
body flexed should also be avoided or interrupted with manage pain successfully, there are times when other
frequent short breaks. A practitioner can make addi- intervention is indicated. For women with recurrent or
tional suggestions based on the individual woman’s severe episodes of pain not amenable to simple mea-
aggravating factors and work situation. sures, referral to another practitioner with special skills in
Women with PPP may benefit from the general posi- the treatment of the musculoskeletal complaints of preg-
tion of comfort suggested for pregnancy. For pain with nancy may be valuable. The muscle imbalances that
position and turning stresses at night, emphasis should accompany pregnancy may cause other pain syndromes
be placed on supporting the top leg and abdomen with (35), or the problem may require a different form of
extra pillows when side-lying to minimize strain on the intervention. Treatment of tight or weak muscles, or

Journal of Nurse-Midwifery • Vol. 43, No. 5, September/October 1998 337

short-term joint mobilization (either administered by a TABLE 4
practitioner or taught to the patient) may be effective Screen for Nonmusculoskeletal Causes of Low
options for some women (1,5,16,35–37). Back Pain (LBP) During Pregnancy
A number of simple self-mobilization and pain relief 1. LBP that does not change with movement or changes of
strategies are suggested for PPP with a hypermobile position
sacroiliac joint. DonTigny (38) describes one mobiliza- 2. LBP that does not improve with rest
tion for a rotated sacroiliac joint that has the person 3. Persistent disabling pain that does not respond to
conservative management
sitting or standing with the affected hip and knee flexed 4. Signs of vaginal-, uterine-, or pregnancy-related
and the foot placed on a chair or stool. The person then dysfunction:
rocks forwards onto the knee of the affected side and Recent unexplained weight lost
back. Other mobilizations or self-help stretches are ref- Vaginal discharge or bleeding
Vaginal burning or itching
erenced or described in a number of sources, including
Back pain concurrent with prelabor contractions
Polden and Mantle (16) and Mantle (5). Members of any 5. Signs of urinary disease:
of the professions in which the scope of practice includes Pain, difficulty, or urgency with urination
manual therapy may be resources for women whose Unusual change in frequency or volume of urine
back pain does not respond to simpler measures. Other Incontinence other than mild stress incontinence
Cloudiness or blood in urine
frequently overlooked possibilities for relieving discom- 6. Signs of gastrointestinal disease:
fort include various forms of massage, mobilization, and Nausea and vomiting not characteristic of pregnancy
relaxation exercises (5,16,32). These may be used as an Changes in stool color or blood in the stool
initial approach to avoiding or reducing pain, or as an Constipation beyond that characteristic of pregnancy
or diarrhea
additional strategy to try with pain that does not respond 7. Signs of cardiovascular disease:
to simple self-management techniques. Many profes- Chest pain
sional groups have special interest groups in women’s Fainting or dizziness upon rising
health that may be able to suggest a professional with Pulsating/throbbing LBP
Intermittent leg pain concurrent with LBP
expertise in women’s health, who may be a valuable
Palpitations
resource for the careprovider. Uncharacteristic shortness of breath
Alternative therapies may be useful adjuncts to basic Persistent cough
back care with the pregnant woman. Here, a discussion Excessive fatigue
with individual women regarding their preferred health Excessive swelling of distal extremities
8. Signs of neurological involvement with LBP:
care strategies may be invaluable. Acupuncture, acupres- Changes in sensation in the perineum, buttocks or
sure, massage therapy, or other alternative therapies lower limbs
may be options some women are familiar with or Muscle weakness in the lower limbs
desirous of trying. The careprovider’s knowledge of Bowel or bladder dysfunction
Change in lower limb reflex responses
pregnancy, in combination with the expertise of other
practitioners, can help with the selection of safe treat-
ment options. The relaxation aspect of many therapies
may also be valuable. Stress and anxiety at work or in the and told to wait for the end of pregnancy for relief. While
home, or fears related to the pregnancy itself, can this article argues against such a laissez-faire approach
enhance the perception of pain. Comprehensive man- for all pregnancy-related back pain, there are specific
agement should address these other issues that may situations where more aggressive intervention is essen-
contribute to the woman’s experience of pain. tial. One such case is that of disk herniation. There are
few studies of the incidence of disk herniation in preg-
nancy. Recent studies using magnetic resonance imag-
CLINICAL RED FLAGS
ing suggest that the incidence is probably higher than the
The first step in any evaluation of back pain should be 1 in 10,000 figure often cited (23). Rare as it may be, it
the ruling out of nonmusculoskeletal dysfunctions that is those very serious cases requiring surgery that are of
may require referral for evaluation by physicians with greatest concern. Gamel et al (39) presented the case
expertise in areas such as internal medicine or neurol- history of a woman whose back pain was severe enough
ogy. Details of this are beyond the scope of this article, to require a walking frame. It was dismissed by emer-
but a basic screening form is provided in Table 4 and gency room staff as being the “normal” pain of preg-
an algorithm to assist in structuring the evaluation nancy. She subsequently required urgent surgery for
and management of LBP in pregnancy is presented in neurologic complications, including urinary retention.
Figure 3. Back pain associated with sensory or motor changes,
As previously mentioned, women who complain of reflex changes, or bowel or bladder dysfunction requires
back pain in pregnancy are frequently given reassurance immediate specialist evaluation.

338 Journal of Nurse-Midwifery • Vol. 43, No. 5, September/October 1998

FIGURE 3.
Identification and management of pregnancy-related low back pain.

In any evaluation of back pain, it is important to ask extent of back pain morbidity and begin to clarify
about changes in micturation or perineal sensation that diagnosis and treatment options, it is particularly impor-
do not fit with the common changes of pregnancy, such tant that pregnant women and their caregivers not
as frequency or stress incontinence. Changes in reflexes ignore pregnancy-related back pain. The techniques
are also important. Either finding should lead to imme- suggested here are those that can readily be applied in
diate referral for medical evaluation. In addition, persis- the primary care setting, where uncomplicated pain
tent disabling pain that does not respond to conservative problems can be identified early and treated with active
measures should lead to further investigation. self-management strategies. Pregnant women deserve to
have their complaints taken seriously and their back pain
assessed and treated. Although it may not be possible to
CONCLUSION
eliminate back pain in susceptible women, the literature
The back pain of pregnancy is not trivial. For some suggests that it is possible to reduce it and ameliorate its
women it may be the beginning of lifelong chronic back effects. A systematic approach is recommended in the
pain; for others it may cause considerable disability and evaluation and management of LBP in pregnancy. This
distress during and for a variable period after pregnancy. is summarized in Figure 3.
In light of newer research studies that document the Although research is beginning to yield data that

Journal of Nurse-Midwifery • Vol. 43, No. 5, September/October 1998 339

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needs to address the issue of prevention as well as
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340 Journal of Nurse-Midwifery • Vol. 43, No. 5, September/October 1998