Low Back Painin Pregnancy: The Realityandthe Challenge

Olushola Ayanniyi
Department of Physiotherapy, College of Medicine, University of Ibadan, Ibadan, Nigeria.

Abstract
Pregnancy-related low back pain is highly prevalent among women of child bearing age and it also
constitutes a source of significant discomfort to the sufferers. There are multiplefactors contributing to these
symptoms during pregnancy and the post-delivery period in some others. Attitudes towards it varied, some
see it as inevitable syndrome associated with pregnancy which may or may not attract serious consideration
from health care professionals while others see it as a problem that must be addressed by the health care
professionals for the wellbeing of pregnant women. This article presents an overview of epidemiology,
causes, risk factors, diagnosis, and management and discusses the merit of active management of
pregnancy-related low back pain.
Keywords: Low back pain, Pregnancy, Lumbopelvic pain, Pelvic girdle pain

Introduction
Management of back pain in pregnancy poses a
big challenge to clinicians across the various
specialties in medicine globally. The most
important challenges stem from initial denial by
the medical community of its importance and the
relevance of its active management (Perkin et al.,
1998; Vermaniet al., 2010). There are whole lots
of erroneous opinions questioning the desirability
of its management. This could be traced to
apathy among the health care professionals to
develop a basic understanding of the issues
involved in its pathophysiology and hence the
desirability of its management (Vermaniet al.,
2010). However, the issue of management of
pregnancy-related back pain has not been
implemented across board by all medical
disciplines particularly when compared with the
management of back pain in the general
population.
_____________________________________
Corresponding Author: Olushola Ayanniyi (Ph.D)
Senior Lecturer and Specialist Adviser,
Department of Physiotherapy,
College of Medicine / University College Hospital,
University of Ibadan, Nigeria
Email: drayanniyi@gmail.com.

According to Vermaniet al., (2010) there are

several
management
options
that
are
underutilized because of lack of comprehensive
knowledge by health-care professionals and fear
of harmful effects of treatment on the developing
foetus. In order to effectively address the
management of low back pain (LBP) in
pregnancy, health care professionals must be
equipped with the correct knowledge of the
factors predisposing pregnant women to develop
low back pain during pregnancy or after delivery.
This article will focus on the desirability of health
care professionals across board (inclusive of
physiotherapists) to have an informed knowledge
about issues involved in the management of
pregnancy-related LBP. This may encourage the
clinicians to utilize the treatment methods already
developed or possibly develop other set of
treatment to manage pregnancy-related LBP in
their own practice as it is being done in
Scandinavian countries.
Low back pain and pregnancy: Low back pain
(LBP) is one of the most common problems
associated with pregnancy (Ostgaardet al., 1996;
Mogren and Pohjanen, 2005). Many women
experience their first episode of LBP during
pregnancy while at least half of all pregnant

Ghana Journal of Physiotherapy / Volume 4 Number 1 / November, 2013 pp 27-39

women experienced back pain at some time

during pregnancy (De Joseph and Cragin, 1998;
Sabino and Grauer, 2008). Invariably because
this type of pain is a common complaint during
pregnancy, it has led health care professionals
who treat pregnant women to consider LBP as
another pregnancy-related discomfort (Rodrigues
et al.,2011). Consequently, it has been accepted
as almost inevitable (MacEvilly and Buggy, 1994;
Rodrigues et al., 2011). The possible implication
of accepting LBP as one of the pregnancy related
discomfort is to deny it of proper attention and
care it deserves.
According to Novaeset al.,
(2006), lower back pain can cause symptoms
that prevent pregnant women from leading a
normal life, such as motor impairment, insomnia,
and depression. In view of the multitude of
suffering LBP can inflict on pregnant women
Novaeset al., (2006) advocated that preventive
measures and proper treatment are required.
Health care professionals advocacy must
therefore emphasise the need to pay proper
attention to prevention and treatment of
pregnancy-related low back pain.
Back pain affects the area between the first
thoracic vertebra and gluteal folds, and its also
characterized as axial or para-sagittal discomfort
in the lower lumbar region (Sabino and Grauer,
2008). A number of researchers (Ostgaardet
al.,1991; Norenet al.,1997; Ayanniyi et al., 2006)
described three types of back pain (i.e. lumbar
pain, thoracic pain, sacroiliac joint pain) during
pregnancy depending on the site of the problem
and
not
necessarily
based
on
any
pathophysiology considerations. However, over
the years a number of different terms have been
suggested and used to describe LBP in
pregnancy. Such name includes: lumbar back
(LP) and posterior pelvic pain (PPP) (Norenet al.,
1997) pregnancy-related pelvic girdle pain
(PPGP) and pregnancy-related low back pain
(PLBP) (Wu et al., 2004). These terms essentially
describes the same problems. However, there
are on-going arguments supporting the need to
find an all-embracing terminology to describe
comprehensively as much as possible the
perceived nature of the problem of LBP in women
during pregnancy or post-delivery (Wu et al.,
2004; Vermaniet al., 2010).
Wu et al., (2004) coined the terms pregnancyrelated pelvic girdle pain (PPGP), pregnancyrelated low back pain (PLBP) and lumbopelvic
pain to describe various components of LBP. The
introduction of the word pregnancy- related as

used by these authors take into account the fact

that complaints can also start after delivery. This
also has an added advantage of eliminating
alternate words such as in pregnancy and after
pregnancy whiles the term pelvic girdle pain
rather than pelvic pain points to pain being of
musculoskeletal rather than gynaecological origin
(Wu et al., 2004). The term pelvic girdle pain
also includes PPGP, PLBP, and their
combination.
Problem of low back pain among pregnant
women is usually attributed to a combination of
mechanical,
hormonal,
circulatory,
and
psychosocial factors (Sabino and Grauer, 2008;
Rodrigues et al., 2011). According to Wilder et
al., (1996) the risk of experiencing spinal pain is
associated with mechanical factors while
anatomical
factors,
such
as
advancing
pregnancy, can also place extra mechanical
stress on the lower back. It is well established
that during the nine months of pregnancy, the
female body undergoes a number of hormonal
and anatomical changes (Heckman and Sassard,
1994; Beckmann et al., 1998). These changes
are noted to affect a wide range of structures and
organ systems and these are all regarded as
normal pregnancy related adaptation (Beckmann
et al., 1998). In addition to musculo-skeletal
symptoms that are characteristics of pregnancy,
some pre-existing musculo-skeletal conditions,
such as rheumatoid arthritis may experience
remission of symptoms during pregnancy
whereas ankylosing spondylitis have been found
to be activated and even aggravated by
pregnancy (Heckman and Sassard, 1994).
Epidemiology of low back pain in pregnancy:
Studies to date indicated that problem of back
pain in pregnancy is universal, however the bulk
of work on it was carried out in the Scandinavian
countries over the years. Various studies have
sought to establish the prevalence of back pain
among pregnant women (Wang et al., 2004;
Ayanniyi et al., 2006; Rodrigues et al., 2011).
These studies gave prevalence of 50% - 80%
among their studied population and an average
prevalence of 57%. According to May (2000), to
get a true picture of the size of the problem,
groups of women would need to be monitored
throughout pregnancy and questioned at regular
intervals about back pain. It has also been found
out in various studies that prevalence of back
pain varies over time and onset of back pain
occurs mostly during the third to seventh month
(Ostgaardet al., 1991; Wang et al., 2004;

Ghana Journal of Physiotherapy / Volume 4 Number 1 / November, 2013 pp 27-39

Ayanniyi et al., 2006). Thus as pregnancies

proceed the number of women reporting back
pain increases (Ostgaardet al., 1997). It is also
noted that the severity of pain experienced by
women increases as the pregnancy progresses
and declines after child birth (Ostgaardet al.,
1996;Ostgaardet al.,1997). LBP in pregnancy has
also been reported as a leading cause of
morbidity and lost productivity due to absence
from work (Robinson et al., 2006).
Possiblecauses of low back pain in
pregnancy: There are unresolved and on-going
debates on the possible causes of back pain in
pregnancy. However, there are clear indications
that possible causes include both hormonal and
bio-mechanical
factors
associated
with
pregnancy itself (Ostergaardet al., 1992; 1993;
Kristianssonet al., 1999; Brynchildsenet al.,
1998). According to some authors (Heckman and
Sassard, 1994; MacEvilly and Buggy, 1996;
Beckmann et al., 1998) the normal physiological
changes of pregnancy may induce mechanical
and structural changes in the lumbopelvic region
and thereby contributing to gestational and
possibly postpartum back pain. These include
posture, changes in total body water content,
endocrine changes and engorgement of epidural
veins. Findings from studies have also
corroborated a strong link between pregnancy
and onset of first episode of LBP in some women
of child bearing age (Orvitoet al., 1994; Wang et
al., 2004).
A number of studies categorically implicated
reproductive hormones especially serum-relaxin
as being responsible for the development of back
pain in pregnancy (Kristianssonet al., 1999).
Studies by Petersen et al., (1994) and Albert et
al., (1997) however disputed any relationship
between serum relaxin secretions and incidence
of pelvic girdle pain in pregnancy. A systematic
review conducted by Aldabeet al., (2012)
assessing the level of evidence for the
association between PPGP and relaxin levels
during pregnancy, found the association to be
low due to a number confounding factors.
There is consensus of opinion among health care
professionals that pregnancy produces altered
mechanical stresses on the lumbar spine (Dumas
et al., 1995; Okanishiet al., 2012). Other studies
(Ostgaardet al., 1993; Franklin, 1998), however,
reported that there is no significant relationship
between increase lordosis during pregnancy and
development of LBP in pregnancy. According to
the finding by Moore et al., (1990) it is the

tendency of the lordotic curve to increase with the

progression of the pregnancy that was
associated with a greater likelihood of back pain.
McKenzie (1981) held the view that exaggerated
lordosis on its own may predispose some
pregnant women to develop low back pain due to
anterior migration of nucleus pulposus while Rath
(1997) was of the opinion that back pain in
pregnancy
are
predominantly
due
to
derangement syndrome which result from the
lesion of intervertebral disc. Cyriax (1978) on the
other hand was of the opinion that it is the
kyphotic posture maintained by some pregnant
women that provoked their low back pain and not
the lordotic posture of pregnancy. However,
according to some other researchers (Mantle et
al., 1981; Bullock et al., 1987; Franklin, 1998) the
frequently hypothesized postural alterations of
anterior tilt of the pelvis and increased lumbar
lordosis have not been consistently observed and
have not been shown to correlate with back pain
in pregnancy. Therefore, postural alterations
characterised by an increase in lumbar lordosis
during pregnancy may not always contribute to
the development of low back pain.
Engorgement of epidural veins has also been
implicated as a possible cause of nocturnal back
pain in pregnancy (Fast et al., 1979). It has been
suggested that hypervolaemia, combined with
obstruction of the inferior vena cava by enlarging
uterus could result in engorgement of the venous
system, especially the extradural veins distal to
the occluded zone. The back pain is thought to
be provoked by hypoxia and metabolic
disturbance of unmyelinated nerves (Fast et al.,
1979). In a later study, the same author
suggested that the explanation for the cause of
nocturnal LBP lay in the inability of pregnant
women to turn in bed as frequently as non-gravid
individuals (Fast et al., 1987). Studies have also
implicated some specific clinical entities as
causes of back pain in pregnancy; these
includes: pelvic insufficiency (Ostergaardet al.,
1992), sacroiliac joint subluxation (Daly et al.,
1991); sciatica, postural back pain, thoracic back
pain (Bookhout and Boissonault (1988);
lumbosacral disc pathology (LaBanet al., 1993
and Garmelet al., 1997) spondylisthesis (Kelsey
et al., 1975); and coccydynia (Whitehead, 1986).
Common risk factors associated with back
pain in pregnancy: A number of researchers
have looked at various risk factors and their
possible associations with problem of back pain
among pregnant women. Common ground of
agreement was established for some of these

Ghana Journal of Physiotherapy / Volume 4 Number 1 / November, 2013 pp 27-39

risk factors and their associations with

pregnancy-related LBP. However, for some other
risk factors there were conflicting findings with
respect to their associations to pregnancy-related
LBP. Studies have shown that a prior history of
back pain is consistently associated with back
pain in pregnancy (Wang et al., 2004; Ansari et
al., 2010). History of low back pain during
menstruation is also identified as a risk factor for
LBP during pregnancy (Ansari et al., 2010) and
findings have also revealed that most women
experienced their first episode of LBP during
pregnancy period (Orvitoet al., 1994; Ayanniyi et
al., 2006).Studies are however, inconclusive on
the role of parity and problem of LBP among
pregnant women.

Some other studies also implicated factors such

as low socioeconomic status with problem of
back pain in pregnancy (Orvieto, 1994; Worku,
2000). Life styles that promote lack of physical
activity are also associated with incidence of
back pain during pregnancy (Mogren, 2005;
Rodrigues et al., 2011). A sedentary lifestyle was
found to increase the risk of back pain while
women with more active lifestyle were less prone
to developing back pain during pregnancy.
Nonetheless, women who have occupations
described as mostly active and physically
demanding were found to have a higher risk of
developing LBP during pregnancy thus
suggesting that extremes of activity are not ideal
(Sabino and Grauer, 2008).

Some studies identified multiparity as a risk

factors for the development of LBP among
pregnant womem (Ostgaard and Andersson,
1991; Mogren and Pohjanen, 2005) while others
denied any association between the two
(Orvietoet al., 1994). Occupational factors such
as heavy work, bending, twisting and lifting are
consistently associated with back painin
pregnancy (Heiberg, 1997; Wu et al., 2004).
Other occupational related factors such as static
work postures, monotonous work and job
satisfaction were also identified as possible
causative factor of back pain in pregnancy
(Ostgaardet al., 1991). Maternal weight gain was
found to have no association with problem of
back pain in pregnancy (Wang et al., 2004;
Rodrigues et al., 2011). A number of studies also
disputed relationship between babys weight and
problem of back pain in pregnancy (Fast et al.,
1987; Melzack and Belanger, 1989). Menset al.,
(1996) however, found a positive association
between babys weight and problem of backache
in pregnancy. Increasing age of mothers at
delivery was found to be associated with less risk
of back pain in pregnancy (Ostgaardet al., 1991;
Heiberg and Aarseth, 1997), Mantle et al., (1977)
however believed the factor to be associated with
increased prevalence of back pain in pregnancy.
Vleeminget al., (2008) found that the individual
factors of height, weight, use of contraceptive
pills, time interval since last pregnancy, smoking,
and age do not constitute risk factors for back
pain in pregnancy. Ostgaardet al., (1993) found a
positive association between biomechanical
factors of abdominal sagittal and transverse
diameter as well as depth of lumbar lordosis and
problem of backache in pregnancy.

Diagnosis:
One
challenge
facing
the
management of LBP in the general population is
the lack of universally acceptable uniform
diagnosis parameters. Similar problem plagues
the diagnosis of LBP in pregnancy. However, two
broad categories of back pain in pregnancy are
well recognised. These are pregnancy-related
low back pain (PLBP) and pregnancy related
pelvic girdle pain (PPGP) respectively. History
and physical examination are relied upon to
distinguish PPGP from PLBP.To this end, certain
diagnosis criteria have been set up to facilitate
differentiation between the two major types of
low-back pain encountered in pregnancy i.e.
PPGP and PLBP. The clinical profile for PLBP
includes the following: pain site above the
sacrum; pain around the lumbar spine; back pain
experienced in flexion; decrease range of
movement in lumbar spine and pain on palpation
of erector spinal muscle (Ostgaard et al, 1996;
Lileet al., 2003). The pain essentially resembles
the back pain that occurs in the non-pregnant
state (Lileet al., 2003). The clinical profile for
PPGP is defined by Vleeminget al., (2008) as
pain experienced in-between the posterior iliac
crest and the gluteal fold, particularly in the
vicinity of the sacroiliac joints. The pain may
radiate into the posterior thigh and can also occur
in conjunction with /or separately in the
symphysis pubis. The pain has been described
as stabbing, shooting, dull, or burning (Hasenet
al., 1999; Rostet al., 2004). The pain is
intermittent and can be precipitated by prolonged
sustained postures and simple activities of daily
living such as walking, sitting, or standing
(generally starting within 30 minutes of an
activity) activities involving weight bearing also
aggravates subjects pain (such as standing,
carrying shopping bag, standing on one leg,

Ghana Journal of Physiotherapy / Volume 4 Number 1 / November, 2013 pp 27-39

walking, stair climbing. Other activities which

frequently provoke pain are turning over in bed,
sexual intercourse, riding a bicycle, bending
forward and getting in or out of bed (Menset al.,
1996; Rostet al., 2004).Some patients describe
an occasional catching sensation in the leg
while walking (Sturessonet al., 1997). To
diagnose PPGP, Albert et al., (2000) advocated
using a combination of provocative sacroiliac joint
tests of which research has indicated three tests
with superior sensitivity and efficacy: Patrick`s
Fabere test, Menell`s test, and Posterior pelvic
pain provocation test.
Management approaches: There are many and
varied treatment approaches documented in the
literature over the years. The highlights of some
of the published non-pharmacological treatment
approaches are shown in Table 1.Many of these
treatment features physiotherapy approaches
and emphasized patient education consisting of
knowledge of posture, activity modifications, and
using of various physical restraints/supports.It
must be stated in affirmative, that one of the
major challenges confronting the management of
pregnancy-related LBP is not that of lack of any
proven treatment approach to use. According to
Veramaniet al., (2010) the issue at stake is that
of reluctance of the clinicians outside the
Scandinavian countries to embrace and
maximize the use of treatment options already
developed for the management of PLBP and
PPGP respectively.
One of the challenges facing the management of
pregnancy-related LBP may be viewed as an
attitudinal problem on the part of many clinicians
to embrace paradigm shift favoring active
management of pregnancy-related LBP as being
currently advocated for and practiced in the

Scandinavian countries in particular (Vleeminget

al., 2008). Some researchers were of the opinion
that clinicians involved in the care of pregnant
women need to first acknowledge that
pregnancy-related back pain is not a trivial matter
for many women (Perkins et al., 1998; Sabino
and Grauer, 2008). To this end, health care
professional as well as the pregnant women
should be educated on the need to address the
issue of managing LBP in pregnancy as it should.
In essence education for the health care
professionals as well as for the pregnant women
should form the bed rock of any meaningful
intervention.
Which therapy really works? A Cochrane
review by Pennick and Young (2008) of the
available
research
publications
on
the
management of low back pain in pregnancy
found eight of the published work evaluated to
merit some consideration even though the quality
of the studies was not the best. Specifically
tailored strengthening exercise, sitting pelvic tilt
exercise programmes, water gymnastics and a
specially designed pillow (the Ozzlo pillow) were
found to be effective, however Ozllo pillow is no
longer commercially available. In addition,
acupuncture seemed more effective than
physiotherapy and adverse effects, when
reported, appeared minor and transient. With
respect to physiotherapy intervention in the
management of pregnancy-related low back pain,
Young and Jewell (2002) were of the opinion that
physiotherapy may be more effective when given
individually rather than in group sessions. The
highlights of some of the published non
pharmacological treatment approaches are
shown in Table 1.

Table 1: Non-pharmacological Approaches to the Management of Back Pain in Pregnancy

S/No

Reference

Treatment

Conclusion and Comment

1.

Cyriax (1978)

Patient education,
manipulation, traction,
epidural local anaesthesia
(Cyriax personal
management approach)

Postural education, manipulation or traction

during the first four months of pregnancy for disc
lesion is safe; side-lying and supine lying rotation
manipulation practicable till eight month.
Epidural local anaesthesia for back pain quite
safe during last month of pregnancy.

Ghana Journal of Physiotherapy / Volume 4 Number 1 / November, 2013 pp 27-39

2.

Mantle et al.,
(1981)

Back care advice based

on Low back pain
schools concept.

A group of primiparous women experienced

significantly less troublesome and severe back
ache than their control group counterpart for
whom such advice was not made available. The
advice was given as early as possible in the
pregnancy.

3.

Bundsen et
al., (1981)

TENS

Useful for pain of labour, middle and third

trimester pain.

4.

Maring-Klug
(1982)

Early prenatal health

teaching. (A Suggestion)

Early introduction of prenatal health teaching in

pregnancy. Focusing on principles of good
posture, proper body mechanics, exercise and
proper foot wear (suggestion to medical
practitioners for implementation.

5.

Golighty,
(1982)

Manipulation of sacroiliac
joints

Institutionalized treatment approach given by

physiotherapists with special interest in
obstetrics. Treatment found to be effective
among the studied population.

6.

Nwuga (1982)

Ante-natal Physiotherapy
and education

Subjects who attended antenatal physiotherapy

fared significantly better than the control group
as regards the prevalence of back pain. Antenatal physiotherapy was given routinely during
the sixth to eight month of pregnancy. Instruction
on principles of good posture and education on
physiological changes of pregnancy, and selfpain relief exercises.

S/No

Reference

Treatment

Conclusion and Comment

7a.

Bookhout and
Boissonault
(1988)

Patient education (Practice

Suggestion)

Early childbirth training classes (even in first

trimester), given by physiotherapist with
special interest in obstetrics. Emphasis on
informing patients on physiological changes
of pregnancy and self-pain relief exercises.

Physiotherapy (Practice
Suggestion)

Physiotherapy management of sacroiliac joint

subluxation, pelvic insufficiency: using
mobilization and maternity support, modality
for relief of pain

Controlled study of Ozzlo

Study found Ozzlo pillow more beneficial than

b.

8.

Thomas et al,

Ghana Journal of Physiotherapy / Volume 4 Number 1 / November, 2013 pp 27-39

(1989)

pillow versus ordinary pillow.

Ozzlo pillow; a wedge-shaped
pillow used for supporting the
abdomen when in lateral
recumbent position

ordinary pillow. Third trimester night back

pain was reduced and quality of sleep was
perceived to be improved.

9.

Ostergaard et
al. (1992)

Trochanteric belt: a Pelvic

girdle support

Empirical evidence that pelvic insufficiency is

relieved.

10.

Ostgaard et
al., (1994)

Sacroiliac belt; exercise and

patient education

Weekly physical exercise before pregnancy

reduces the risk for back pain problems in
pregnancy. A non-elastic sacroiliac belt
offered some pain relief to significant number
of subjects. The treated groups show
significant reduction in pain relief and enjoy
more comfort in activities of daily living.

11.

McIntyre and
Broadhurst
(1996)

Mobilization of lumbar
spine/sacroiliac joint and home
exercise.

Empirical evidence that back pain of

sacroiliac joint origin is significantly relieved
with mobilization.

12.

Sandler
(1996)

Manual techniques

Manual techniques of management are better

than mechanical ones.

13.

Noren et al.,
(1997)

Patient education and physical

exercise programme.

Sick leave for lumbar back and posterior

pelvic pain in the intervention group was
significantly reduced with the programme,
and the programme was cost effective.

S/No

Reference

Treatment

Conclusion and Comment

14.

Kihlstrand et
al., (1999)

Water-gymnastics

Water gymnastics during the second half of

pregnancy significantly reduced the intensity of back
pain. The treatment programme decreased the
number of women on sick-leave because of back
pain. The women participating in water-gymnastics
recorded a lower intensity of back pain than those in
the control group.

15.

Beaty et al.,
(1999)

Elastic/Velcro lumbar
and abdominal support

Improvement in back discomfort while sitting and

standing was achieved. The support is effective and
safe for the mother and the fetus.

Ghana Journal of Physiotherapy / Volume 4 Number 1 / November, 2013 pp 27-39

16.

Wedenberg et
al., (2000)

Acupuncture versus
physiotherapy

Acupuncture relieved pain and diminished disability in

low back pain (lumbar and Posteriors pelvic pain)
during pregnancy better than physiotherapy. Overall
satisfaction was good in both groups. There were no
serious adverse events in any of the patients.

17.

Requejo et al.,
(2002)

Manual joint
mobilization

Manual techniques in the treatment of low back pain

in pregnancy are effective and safe.

18.

Skriabin et al.,
(2002)

Combination treatment:
Orthopaedic aids,
relaxing massage;
muscular relaxation,
mobilization of
functional blocks of
intervertebral joints and
pelvic junctions and
therapeutic exercises.

The above non-pharmacological system relieved

vertebral pain syndrome partially or completely in
82% of the treated pregnant women.

19.

Suputtitada
(2002)

Sitting pelvic exercise

The Sitting pelvic tilt exercise during the third

trimester in primigravidas decreased back pain
intensity without incidence of preterm labour, low birth
weight or neonatal complication.

20.

Ayanniyi
(2003)

McKenzie Protocol

21

22

Carr (2003)

Shim et al
(2007)

23

Kalus et al
(2008)

24

Kluge et
al.(2011)

Use of a maternity
support Binder for relief
of pregnancy-related
back pain.
Use of a back-painreducing program
during pregnancy.

Use of a support
garment-BellyBra and
Tubigrip to treat low
back pain and posterior
pelvic pain
Use of specific
exercises to treat
pregnancy-related low
back pain( specific
stabilizing exercises)

McKenzie protocol produce significant relief from

back pain and disability in the treatment group at the
end of six weeks of the study irrespective of back pain
types.
The use of a support binder produced significant relief
from back pain, pain on daily activities, exercise
activities, and sleep.
The use of a back-pain reducing program produced
significant relief from back pain, but no significant
effect on functional limitations and anxiety 12 weeks
after intervention.

BellyBra and tubigrip produced reduction in the

severity of pregnancy-related low back pain; BellyBra
was more effective in alleviating the impact of pain on
a number of physical activities of daily living.
A specific exercise program decreased back pain
intensity and increased functional ability during
pregnancy among the participants. with lumbar and
pelvic girdle pain.

Ghana Journal of Physiotherapy / Volume 4 Number 1 / November, 2013 pp 27-39

25
Ernst (1993)

Advice on cigarette
smoking Cessation/
tobacco use

RECOMMENDED MANAGEMENT OPTIONS

Based on review from different bodies with
interest in the management of pregnancy related
low back pain there is consensus of opinion that
conservative management is the gold standard.
Such management includes patient education,
supervised physiotherapy, stabilization belts,
transcutaneous electrical nerve stimulation,
acupuncture, massage, relaxation and yoga
(Young and Jewell, 2002; Pennick and Young,
2008; Vleeminget al., 2008; Vermaniet al., 2010).
Patient education: It has been noticed that back
pain in pregnancy is under-emphasized
(MacEvilly and Buggy, 1996) therefore, education
about the emergence of back pain in pregnancy
should be made an integral part of early child
training courses and also part of pre-pregnancy
counselling (Collition, 1996). Individualized
treatment programmes have been found to be
more effective in reducing absenteeism from
work in women with PLBP and not in women with
PPGP (Ostgaardet al., 1994). Norenet al., (1997)
also demonstrated that individualized treatment
programme consisting of patient education and
physical exercise programmes decreased pain
intensity and sick leave in women with PLBP and
PPGP respectively. Unfortunately, the specifics
on

which muscle groups were targeted in the

treatment groups were not stated in either study.
The study by Stugeet al., (2004) revealed
improvement of symptoms in the therapy group
performing stabilizing exercises for the hip
abductors, hip adductors, gluteus maximus,
transverse and oblique abdominals, erector
spinae, lumbar multifidus, quadratuslumborum,
and latissimusdorsi. According to Perkins et al.,
(1998), while prevention of all pregnancy related
back pain is unlikely to be possible, advice on
back care should be made available to all

Causal relationship between smoking and low back

pain in non-pregnant patients
pregnant women and their active participation in
daily back care activities should be encouraged.
Physiotherapy:Physiotherapy has been found
useful in the third trimester of pregnancy for the
management of sacroiliac joint subluxation and
many other back pain conditions such as pelvic
insufficiency,
postural
back
pain
and
spondylolisthesis (Bookhout and Boissonault,
1988). The use of various mechanical supports
has been found useful in the management of
pregnancy-related LBP. The study by Thomas et
al., (1989) compared the use of normal pillow
with a wedge shaped pillow called Ozzlo pillow.
This pillow is used to support the abdomen of a
pregnant woman lying on her side. The pillow
was found to alleviate pain and aid sleep. This
pillow is no more commercially available
however; women should be encouraged to
experiment with cushions and pillows of various
sizes and shapes to support different parts of
their body, such as their back, abdomen, and
knees for pain relief (Lileet al., 2003).
Trochanteric belt, a pelvic girdle support worn
around the lower back was also found to be
helpful in cases of pelvic insufficiency associated
with pregnancy (Ostergaardet al., 1992;
Ostgaardet al., 1994). Pelvic belts decrease the
mobility of the SIJs and work most effectively
when they are applied just below the anterior
superior iliac spines rather than at the level of the
symphysis pubis (Menset al., 2006). There is no
good quality evidence to support the use of nonelastic pelvic belts. Some women are
apprehensive that the pressure from various
abdomino-lumbar supports will have deleterious
effects on the foetus, but such fears are
unfounded, and the use of an abdomino-lumbar
support is safe (Beatyet al., 1999). A pelvic belt
may be fitted to test for symptomatic relief, but it
should only be applied for short periods (Beatyet
al., 1999). There is no good quality evidence to
support the use of pelvic manipulation,
mobilization, or sacroiliac fusion; therefore, such
extreme interventions cannot be recommended
(Vleeminget al., 2008).
Transcutaneous
Electrical
Nerve
Stimulation:The use of transcutaneous electrical
nerve stimulation (TENS), a modality in physical
therapy, is recognized as a useful adjunct
therapy in the management of PLBP and PPGP.
Nonetheless, there have been theoretical

Ghana Journal of Physiotherapy / Volume 4 Number 1 / November, 2013 pp 27-39

concerns
about
stimulation
of
certain
acupuncture points (which have been used to
induce labour). However, no negative effects
have been reported from the use of TENS during
any stage of pregnancy (Vermaniet al., 2010).
Exercises:Exercises appear to be beneficial
mainly in patients with PLBP (Suputtitadaet al.,
2002) but their role in diminishing PPGP during
pregnancy remains uncertain. The exercises
recommended for PLBP are similar to those used
in non-pregnant backache patients, with minor
modifications for pregnancy (Hammer et al.,
2000). Once the acute pain is settled, individually
tailored back strengthening and stretching
exercises can be started. Ostgaardet al., (1994)
found that an individualized training programme
based on information, ergonomic advice, and
exercises resulted in reduction of sick leave in
pregnant women with back pain, but not in those
with PPGP (Ostgaardet al., 1994). Water
gymnastics have also been found to be useful in
diminishing back pain and sick leave in pregnant
women (Kihlstrandet al., 1999). Exercise may
however offer some benefit to women with PPGP
following delivery. Stugeet al., (2004) found
specific pelvic girdle stabilizing exercises to be
useful in this respect.
Acupuncture: The use of acupuncture, a form of
physical modality was found beneficial in
relieving back pain and diminished disability in
low back pain (PLBP and PPGP) during
pregnancy (Wedenberget al., 2000). The
acupuncturist must avoid certain acupuncture
points in pregnancy that supply the cervix and
uterus (which have been used to induce labour),
but the technique in general is considered to be
safe (Vermaniet al., 2010).
Conclusions: The problem of low back pain in
pregnancy is highly prevalent and it is of
multifactorial origin. Low back pain among
pregnant women should not be considered as a
trivial matter and hence health care professionals
need to develop a positive attitude to its
management due to its negative impact on the
quality of life of the sufferers.Several methods
have been described for the management of
pregnancy-related low back pain; no single
method seems to address all types of back pain.
This suggests that physical methods of
management must take into consideration the
type of back pain in question. There is also the
need to pay attention to its prevention with all
seriousness it deserves.
Its recommended that health care professionals
in Nigeria and indeed in Africa should play

advocacy role in ensuring that pregnancy-related

back pain is given its due recognition as an entity
that should not be ignored but deserves to be
managed in order to ameliorate its negative
impacts on the sufferers.

References
Albert HB, Godskesen M, Westergaard JG,
Chard T, Gunn L (1997). Circulating levels of
relaxin are normal in pregnant women with pelvic
pain.
European
Journal
of
Obstetrics,
Gynecology, and Reproductive Biology. 74(1): 19
- 22.
Albert HB, Godskesen M, Westergaard J (2000).
Evaluation of Clinical tests used in classification
procedures in pregnancy-related pelvic joint pain.
European Spine Journal. 9: 161 - 166.
Albert HB, Godskesen M, Westergaard J (2002).
Incidence of four syndromes of pregnancyrelated pelvic joint pain.Spine. 27 (24) 2831 2834.
Aldabe D, Ribeiro DC, Milosavljevic S, Bussey
MD (2012). Pregnancy-related pelvic girdle pain
and its relationship withrelaxin levels during
pregnancy: A Systematic review. European Spine
Journal.21(9):1769-76. doi 10.1007
/s00586012-2162-x
Ansari NN, Hasson S, Naghdi S,Keyhani S,
Jalaie S (2010). Low back pain during
pregnancy in Iranian women: Prevalence and risk
factors. Physiotherapy Theory and Practice.
26(1): 40-48.
Ayanniyi O, Sanya AO, Ogunlade SO, Oni-Orisan
MO(2006). Prevalence and pattern of back pain
among pregnant
women attending Ante-natal
clinics in selected health care facilities. African
Journal of Biomedical Research.9, 149-156.
Ayanniyi O (2011). Effects of the McKenzie
protocol on the treatment of back pain in
pregnant subjects.VDM .VerLag Dr. Muller
GmbH & Co KG, Deutschland.
Beaty CM, Bhaktaram VJ, Rayburn WF, Parker
MJ,
Christensen HD,
Chandrase-Karan K
(1999). Low backaches during pregnancy.Acute
hemodynamic effects of a lumbar support.Journal
of Reproductive Medicine. 44(12): 1007 - 1011.

Ghana Journal of Physiotherapy / Volume 4 Number 1 / November, 2013 pp 27-39

Bookhout MM, and Boissonault WG (1988).

Physical therapy mangement of Musculoskeletal
Disorders during Pregnancy. In: E. Wilder (Ed.).
Obstetrics and Gynaecology Physical Therapy,
Churchill-Livingstone, New York, 17 - 62.

Brynhildsen JO, Bjors E, Skarspgard C, Hammar

ML (1998). Is hormone replacement therapy a
risk factor for low back pain among
postmonopausal women? Spine. 23(7): 809 813.
Bullock JF, Jull GA, Bullock ML (1987).The
relationship of low back pain to postural changes
during
pregnancy.Australia
Journal
of
Physiotherapy. 33: 10 - 17.
Carr AC (2003). Use of a Maternity support
binder for relief of pregnancy-related back
pain.Journal of Obstetrics, Gynecologic, and
Neonatal Nursing. 32(4): 495-502.
Cyriax J (1978). Textbook of Orthopaedic
Medicine. Volume 1: Diagnosis of Soft Tissue
Lesions. 7th Edition.
London, England,
BaillieraTendal 348 - 573.
Colliton J (1996). Back pain and Pregnancy:
Active management strategies. The Physician
and Sports Medicine.24(7): 89 - 93.
Daly JM, Frams PS, Rapoza PA (1991).
Sacroiliac subluxation: a common, treatable
cause of low back pain in pregnancy. Family
practice Research Journal. 11: 149 - 159.
DeJoseph JF, Cragin L (1998). Biomedical and
feminist perspectives on low back pain during
pregnancy. Nursing Clinic North America.
33:713-724.
Dumas GA, Reid JG, Wolfe LA, Griffin MP,
McGrath MJ (1995). Exercise, posture, and back
pain during pregnancy, Part 1. Exercise and back
pain. Clinical Biomechanics. 10(2): 104-109.
Fast A, Shapiro D, Ducommun EJ (1987). Low
back pain in pregnancy.Spine. 12 - 368 - 371.
Fast AM, Weiss L, Parikh S, Hertz G (1979).
Night backache in pregnancy: hypothetical
physiological mechanisms. AmericanJournal of
Physical Medicine and Rehabilitation.68: 227 229.

Franklin ME, Conner-Kerr T (1998): An analysis

of posture and back pain in the first and third
trimesters of pregnancy. Journal of Orthopedic
Sports Physical Therapy. 28(3):133-138.
Garmel SH, Guzelian GA, DAlton JG, DAlton
ME
(1997).Lumbar
disk
disease
in
pregnancy.Obstetrics and Gynacology. 89(5
pt.2): 821-822.
Heckman JD, Sassard R (1994). Musculoskeletal
Consideration in Pregnancy.Journal of Bone and
Joint Surgery.76A 11: 1720 - 1730.
Heiberg E, Aersath SP (1997). Epidemiology of
Pelvic pain and low-back pain in pregnant
woman.In: Movement stability and low back pain.
The essential Role of the PelvisEsd.Vleeming A.
Mooney V, Dorman T, Snijders C, Stoeckert R.
Churchill Livingstone, New York.
Kalus SM, Kornman LH, Quinlivan JA (2008).
Managing back pain in pregnancy using a
support garment: a randomized trial. BJOG: An
International
Journal
of
Obstetrics
and
Gynaecology. 115(1):68-75.
Kelsey JL, Hardy RJ (1975). Driving motor
vehicles as risk factors for acute herniated disc.
International Journal of Epidemiology. 102: 63 73.
Kihlstrand M, Stenman B, Nilsson S, Axelsson O
(1999). Water-gymnastics reduced the intensity
of back/low back pain in pregnant women.
ActaObstetriciaetGynecologicaScandinavica.7:18
0185.
Kluge J, Hall D, Louw Q, Theron G, Grove D
(2010). Specific exercises to treat pregnancyrelated low back pain in a South African
population. International Journal of Gynecology
and Obstetrics.113:3, 187-191.
Kristiansson P, Svardsudd K, Von Schoultz B
(1999).
Reproductive
Hormones
and
AminoterminalPropeptide of type III procollagen
in Serum as early markers of pelvic pain during
late pregnancy. American Journal of Obstetrics
and Gynecology.180: 128 - 134.
LaBan M, Perrin J, Latimer F (1983). Pregnancy
and herniated lumbar disc.Archives of Physical
Medicine and Rehabilitation. 64: 319 - 321.

Ghana Journal of Physiotherapy / Volume 4 Number 1 / November, 2013 pp 27-39

Leboeuf-Yde C (2000). Body weight and low

back pain: a systematic literature review of 56
journal articles reporting on 65 epidemiologic
studies. Spine 25:226-237.
Lile J, Perkins J, Hammer RL, Loubert PV (2003).
Diagnostic and management strategies for
pregnant women with back pain. JAAPA. 16:3144.

Mogren IM, Pohjanen AI (2005). Low back pain

and pelvic pain during pregnancy: prevalence
and risk factors. Spine. 30(8): 983-91.
Noren L, Ostgaard S, Nielsen TF, Ostgaard NC
(1997). Reduction of Sickleave for Lumber back
and posterior pelvic pain in pregnancy.Spine.22:
2157 - 2160.

MacEvilly M, Buggy D (1996). Back pain and

Pregnancy: A review. Pain.64, 405 - 414.

Novaes FS, Shimo AKK, Lopes MHBM (2006):

Lombalgianagestao.
Rev
LatinoamEnferm.14(4):620-4.(Abstract).

Mantle MJ, Greewood RM, Currey HLF (1977).

Backache
in
pregnancy.Rheumatism
and
Rehabilitation.16: 95 - 101.

Nwuga VC (1982). Pregnancy and back pain

among upper class Nigerian women. Australia
Journal of Physiotherapy. 28: 8- 11.

Mantle MJ, Holmes J,Currey HL (1981).

Backache in pregnancy II Prophylactic influence
of back care classes.Rhuematology and
Rehabilitation. 20(4): 227 - 32.

Okanishi N, Kita N, Akiyanoi M, Yamamoto M

(2012). Spinal curvature and characteristics of
postural
change
in
pregnant
women.ActaObstetriciaetGynecologicaScandinav
ica, 91(7): 856-861.

May S (2000). Back Pain and Pregnancy - A

Review. McKenzie (U.K.) Newsletter. 8: 3-14.
McKenzie RA (1981). The Lumbar Spine:
Mechanical Diagnosis and Therapy. 1st Edition
Waikanae, New Zeland. Spinal Publication 81 120.
McIntyre IN, Broadhurst NA. (1996). Effective
treatment
of
low
back
pain
in
pregnancy.Australian Family Physician. 25 (9
Suppl. 2): S65 - 7.
Melzack R, Belanger E (1989). Labour Pain:
Correlation with Menstrual pain before and during
pregnancy. Pain. 36(2): 225 -9.
Mens JMA, Vleeming A, Stoeckart R, Stan HJ,
Snijders CJ (1996). Understanding Peripartum
Pain. Implication of a patient Survey.Spine. 21:
1363 - 1370.
Mens JM, Damen L, Snijders CJ, Stam HJ(2006).
The mechanical effect of a pelvic belt in patients
with
pregnancyrelated
pelvic
pain.Clinical
Biomechanics. 21:122127.
Mogren IM (2005). Previous physical activity
decreases the risk of low back pain and pelvic
pain during pregnancy. Scandinavian Journal
Public Health. 33(4): 300-306.

Orvieto R, Achiron A, Ben-Rafael Z, Gelernter I,

Achiron R (1994). Low Back Pain of
Pregnancy.ActaObstetriciaetGynecologicaScandi
navica. 73(3): 209 - 14.
Ostgaard HC (1996). Assessment and Treatment
of Low Back Pain in Working Pregnant
Women.Seminar in perinatology. 21: 61 - 69.
Ostgaard HC (1997). Lumbar Back and Posterior
Pelvic Pain in Pregnancy. In: Movement, Stability
and Low Back Pain. The Essential Role of the
Pelvis.(Eds.) Vleeming A.; Mooney V, Dorman T,
Snijders C, Stoeckart, R. Churchill Livingstone,
New York. Pp. 52 - 61
Ostgaard, HC, Andersson GBJ, Karlsson K
(1991). Prevalence of Back Pain during
Pregnancy.Spine.16: 549 - 552.
Ostgaard HC, Andersson GB, Schultz AB, Miller
JA (1993). Influence of some biomechanical
factors on Low-Back Pain in pregnancy. Spine.
18(1): 61 - 65.
Ostgaard HC, Anderson G B, Wennergren M
(1991). The impact of low back and pelvic pain in
Pregnancy
on
the
pregnancy
outcome.ActaObstetriciaetGynecologicaScandina
vica. 70(1): 21 - 4.

Ghana Journal of Physiotherapy / Volume 4 Number 1 / November, 2013 pp 27-39

Ostergaard M, Bonde B, Thomsen, BS (1992).

Pelvic insufficiency during pregnancy: Is girdle
relaxation
an
unambiguous
concept?
UgestkriftLaeger.154: 3568 - 3572.

Rost CC, Jacqueline J, Kaiser A, Verhagen AP,

Koes BW (2004). Pelvic pain during pregnancy: a
descriptive study of signs and symptoms of 870
patients in primary care. Spine. 29: 2567-2572.

Ostgaard HC, Roos-Hansson E, Zetherstrom G

(1996). Regression of back and posterior pelvic
pain after pregnancy.Spine.21(23): 2777 - 2780.

Sabino J, Gruer JN (2008). Pregnancy and low

back pain.Current Review of Musculoskeletal
Medicine. 1:137-141.

Ostgaard HC, Zetherstrom G, Roos Hansson E,

Svanberg B (1994). Reduction of Back and
Posterior Pelvic Pain in Pregnancy.Spine. 19:
894 - 900.

Sandler SE (1996). The management of Low

back pain in pregnancy. Manual Therapy. (14):
178 - 185.

Ostgaard HC,Zetherstrom G, Roos-Hansson E

(1997). Back Pain in Relation to Pregnancy. A 6year follow-up.Spine.22: 2945 - 2950.
Pennick V, Young G ( 2008).Interventions for
preventing and treating pelvic and back pain in
pregnancy.Cochrane Database of Systematic
Reviews.
Issue
2.
Art.
No.:
CD001139.DOI:10.1002/14651858.
CD001139.pub2.
Perkins J, Hammer RL, Loubert PV (1998).
Identification and mangement of pregnancyrelated low back pain.Journal of Nurse-Midwifery.
43(5): 331 - 40.
Petersen LK, Hvidman L, Uldbjerg N(1994).
Normal serum relaxin in women with disabling
pelvic pain during pregnancy.Gynecology and
Obstetrics Investigations.38: 21 - 23.
Rath JD (1997). Mechanical low back pain in
pregnancy: Preliminary findings in a consecutive
case
series
investigation.
Abstract
of
proceedings. 5th McKenzie Institute International
Conference Philadelphia Pennsylvania 12 - 14,
September 1997. Journal of McKenzie Institute
USA. 5(3): 6-30.
Robinson HS, Eskild A, Heiberg E, EberhardGran M (2006). Pelvic girdle pain in pregnancy:
the
impact
on
function.ActaObstetriciaetGynecologicaScandina
vica. 85: 160-164.
Rodrigues WFG, Silva LR, Nascimento MAL,
Pemambuco CS, Giani TS, Dantas EHM (2011).
Prevalence of lower back pain and physical
inactivity: the impact of psychosocial factors in
pregnant women served by the family health
strategy. Einstein 9(4 Pt 1):489-93.

Shim MJ, Lee YS, Oh HE, Kim JS (2007). Effects

of a back-pain-reducing program during
pregnancy for Korean women: A non- equivalent
controlgroup
pretest-posttest
study.
International Journal of Nursing Studies. 44(1):
19-28.
Skriabin EG, Brynza NS, Ivanov NV, Gaisin AG
(2002). Complex treatment of vertebrogenic pain
syndrome in women during pregnancy.(Abstract)
VoprKurortolFizieter Lech FizKult. (2): 29 - 31.
Stuge B, Laerum E, Kirkesola G, Vollestad N
(2004). The efficacy of a treatment program
focusing on specific stabilizing exercises for
pelvic girdle pain after pregnancy: a randomized
controlled trial. Spine. 29:351-9.
Sturesson B, Uden G, Uden A (1997). Pain
pattern in Pregnancy and catching of leg in
pregnant women with posterior pelvic pain.Spine.
22(16): 1880 - 3, 4.
Thomas IL, Nicklin J, Pollock H, Faulkner K
(1989). Evaluation of a maternity cushion (Ozzlo
pillow) for backache and insomnia in late
pregnancy.Australian New Zealand Journal of
Obstetrics and Gynaecology. 29(2): 133 -138.
Turgut F, Turgut M, Cetinsahim M (1998). A
prospective study of persistent back pain after
pregancy.European Journal of Obstetrics,
Gynecology and Reproductive Biology. 80(1): 45
- 48.
Vermani E, Mittal R, Weeks A (2010). Pelvic
girdle pain and low back pain in pregnancy: a
review. Pain Practice. 10(1):60-71.
Vleeming A, Stoeckart R, Volkers AC, Snijders
CJ (1990). Relation between form and function in
the sacroiliac joint. Part 1. Clinical anatomical
aspects.Spine. 15: 130-132.

Ghana Journal of Physiotherapy / Volume 4 Number 1 / November, 2013 pp 27-39

Vleeming A, Albert HB, Ostgaard HC, Sturesson

B, Stuge B (2008). European guidelines for the
diagnosis and treatment of pelvic girdle
pain.Europe Spine Journal. 17: 794-819.
Wang SM, Dezinno P, Maranets I, Beman MR,
Caldwell-Andrews AA, Kain ZK (2004). Low back
pain during pregnancy: Prevalence, risk factors,
and outcomes. Obstetrics and Gynecology.
104(1): 65-70.
Weldenberg K, Moen B, Norling A (2000). A
Prospective Randomized Study Comparing
acupunture with Physiotherapy for Low back and
Pelvic
Pain
in
Pregnancy.
ActaObstetriciaetGynecologicaScandinavica.
72(5): 331 - 5

Worku L (2000). Prevalence of low-back pain in

Lesotho mothers.Journal of Manipulative and
Physiological Therapeutics. 23(3):147-154.
Wu WH, Meijer OG, Uegaki K, Mens JMA, van
Dieen JH, Wuisman PIJM, Ostgaard HC
(2004).Pregnancy-related pelvic girdle pain,
(PPP)1:terminology, clinical presentation, and
prevalence. Eur Spine Journal. 13:575-589.
Young G, Jewell D (2002).Interventions for
preventing and treating pelvic and back pain in
pregnancy.Cochrane
Database
Systemic
Review.2002;
CD001139.
DOI:10.1002/14651858.CD001139.

Whitehead CR (1986). Dewhursts Textbook of

Obstetrics and Gynaecology for Postgraduates.
4th Edition, Blackwell, Oxford. pp. 602 - 621.

Ghana Journal of Physiotherapy / Volume 4 Number 1 / November, 2013 pp 27-39