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Information for Physiotherapists and Registered Massage Therapists

A primer on low back pain and pelvic girdle pain in pregnancy in the context of sleep in the third trimester.

A brief update for busy physiotherapists and registered massage therapists.

 
Short answer: It is likely a result of the way your body is adapting to your pregnancy.
Long answer:
During pregnancy, a series of hormonal and biomechanical changes are likely causative of new-onset or exacerbation of previous low back pain (LBP) and pelvic girdle pain (PGP).[1,2] 
  • These changes include a weight gain of 25-35 pounds;[3] the progressive antero-superior rise of the gravid uterus out of the pelvis and into the abdomen with occasional diastasis recti; a forward shift in the center of gravity and center of pressure; increased loading at and mobility of joints [4] (including the “fixed” symphysis pubis and sacroiliac joints), but reduced trunk and hip range of motion;[1] exaggerated lumbar lordosis, anterior pelvic tilt, and widened stance affecting gait, balance, and posture control;[1,5–7] forward neck flexion; slumping of the shoulders; and increased tension on the paraspinal muscles.
    Short answer: Quite common - in 5 pregnancies, about 3 or 4 will experience it.
    Long answer
    Prevalence of LBP and PGP in pregnancy
    • Between 56-80% of pregnant patients report LBP and about 65% report PGP.[8–11]
      Short answer: Sometimes - in about 45% of patients, it can spread to the legs.
      Long answer
      Characterization of LBP and PGP in pregnancy
      • Pain can stay in the area of the low back and pelvis but radiates to the lower extremities in about 45% of patients.[11]
        Short answer: For most patients, it starts between 5 and 7 months.
        Long answer
        Onset of LBP and PGP in pregnancy
        • While LBP and PGP can begin at any point in pregnancy, it begins for most patients between the fifth and seventh months.[11]
          Short answer: For some, it gets worse as the day goes on. For others, it gets worse during the night.
          Long answer
          Timing of LBP and PGP in pregnancy
          • In 1 in 3 patients, the pain increases as the day wears on. 
          • In 33-67% of patients (1-2 in 3 patients), the pain gets worse during the night and disturbs sleep.[11–13]
            Short answer: Yes, there are lots of things, for example, having pre-existing back pain.
            Long answer
            Risk factors for LBP and PGP in pregnancy 
            • Pre-existing back pain, back pain during menses, back pain in a previous pregnancy,[14previous back surgery, high pre-pregnancy BMI, low and high gestational weight gain, higher postpartum weight retention, younger age, grand multiparity, lower physical activity level, anxiety, and depression.[8,10,15,16]
              Short answer: Yes. It affects the day-to-day activities of 1 in 3 pregnancies, and 1 in 2 experience sleep disturbances due to the pain.
              Long answer
              Effect of LBP and PGP on quality of life
              • Average pain is “moderate” in severity.
              • As a result of LBP and PGP, 30-60% experience sleep disturbances [8,11] and nearly 60% experience impaired daily living.
              • 1 in 3 stop performing at least one daily activity due to the pain and report that the pain also impaired the performance of other routine tasks.
                  Short answer: Yes. As pregnancy advances, the movements that trigger the pain can change, but these two movements seem to be consistent triggers throughout the entire pregnancy.
                  Long answer
                  Activities that provoke LBP and PGP
                  • At least 16 kinds of movement that induce LBP and PGP have been identified. All of these movements are regular daily activities rather than specific movements requiring special skill or additional effort.[11,17]
                  • As pregnancy progresses, pain provocation becomes less attributed as a result of these 16 movements; however, throughout the entire pregnancy, standing up from a chair and turning over in bed at night seem to consistently provoke a significant amount of LBP and PGP.[17] Indeed, LBP and PGP are commonly reported to occur when lying, sleeping, and sitting.[11,16]
                    Short answer: It could be related to unknowingly sleeping on the back, which can result in congestion of small blood vessels that drain important structures in the lower back causing pain.
                    Long answer
                    Pathophysiology of nocturnal LBP
                    • In polysomnographic sleep studies, nocturnal LBP in late pregnancy has been associated with spending more time sleeping supine and having a lower blood-oxygen saturation.[13] The LBP likely causes the disturbed sleep rather than the disturbed sleep causing the LBP.
                    • MRI studies have shown that compression of the inferior vena cava (IVC) in pregnancy while in the supine position can result in epidural venous plexus engorgement and LBP, including radicular pain.[18]
                    • It is thought that the occlusion of the IVC by the gravid uterus in late pregnancy in the supine position,[19] combined with inadequate collateral circulation to bypass the occluded IVC in some patients [20,21] and lower blood-oxygen saturation while sleeping supine,[22] increases the pressure and venostasis in the vessels draining the neural structures, and this may lead to hypoxemia, compromised metabolic supply, and pain.[12,13] 
                    • Note that between 9.5% and 47% of sleeping time is spent supine in the third trimester.[22–28]
                      Short answer: Wearing supportive clothing and shoes. Use chairs with good back support. Sleeping on the side, with knees bent and pillow between them, and a pillow under the belly. Exercise. Massage therapy and physiotherapy. Maternity belts like the PrenaBelt™.
                      Long answer
                      Treatment of LBP and PGP in pregnancy
                      • Only 1 in 3 people with LBP and/or PGP during pregnancy alert their prenatal care providers about their symptoms, and only 1 in 4 prenatal care providers recommend treatment.[8]
                      • After serious causes are ruled out, a multimodal approach is recommended.[29]
                      • Wear supportive clothing [30] and shoes. Shoes should be low-heeled, but not flat. Avoid high heels. Use a maternity support belt.[30,31]
                      • Pay attention to posture:[32]
                        • Use chairs with good back support including lumbar support.
                        • If standing for long periods, alternate resting one foot on a small box.
                        • Sleep on the side. Keep one or both knees bent. Place one pillow between the knees and one pillow under the belly.[33]
                        • Get help for lifting heavy objects. Lift with the back straight, squatting, with knees bent. Do not bend at the waist.
                      • Alternate using a heat or cool pack on the lower back for a limited time.[32]
                        • Warning: Do NOT use a heat pack on or near the abdomen during pregnancy. This could be dangerous and could result in a stillbirth.
                      • Exercise (on land or in water [34,35]) has been shown to reduce LBP, improve functional disability, and reduce sick leave;[32,36–38] however, evidence for benefit for PGP is lacking.[37]
                      • Massage therapy and physical therapy.[31,38]
                      • Complementary and alternative medicine approaches.[39]
                      • The PrenaBelt™ is the first and only internationally-published and clinically-tested positional therapy device for use during sleep in pregnancy and has been shown to significantly reduce the amount of time spent sleeping supine during the third trimester without affecting sleep architecture.[23,24,40] The PrenaBelt™ is also a maternity support belt and includes a knee pillow, side pillow, and thermal pack to ensure comfortable sleep and relieve LBP and PGP in pregnancy.
                        Short answer: Yes. In 80-95% of patients, the pain goes away after the pregnancy is completed.
                        Long answer
                        Prognosis of LBP and PGP in pregnancy
                        • Resolves in 80-95% of patients.[14,41,42]
                        • Elevated pre-pregnancy or postpartum BMI increases the risk of persistent LBP.[15]
                          Short answer: Yes (see long answer).
                          Long answer
                          Practical points for physiotherapists and registered massage therapists
                          • Since routine movements (especially rising from a chair) can provoke LBP and PGP in pregnancy, teaching these patients modified movements to reduce loading and stresses on the body may be helpful.[17]
                          • Supine? When positioning a pregnant patient for treatment, if the supine position is needed, always keep her pelvis tilted 15 degrees or more to the left.[43] Further, to put her in this position, always start out with her lying on her left side and then roll her toward this position. There is evidence that moving to this left pelvic tilt position from the supine position is not as effective in relieving aortocaval compression as moving to this position from the left lateral position.[44] If tilting the pelvis to the right, more than 30 degrees of tilt may be required.[45,46]
                          • Prone? For over two decades, it has been known that maternal prone position in late pregnancy can be adopted using a special bed, stretcher, or pillow (e.g., Belly Pillow® [47]) with a large hole that accommodates the gravid uterus and ensures that there is no pressure being applied to the abdominal region. Under these conditions, this position has been demonstrated to be safe for at least 5-6 minutes,[48] comfortable,[47,48] and can completely relieve uterine compression of the IVC and aorta. This, in turn, can improve maternal respiration rate,[48] blood-oxygen saturation,[48] and blood pressure [47,48] and can improve umbilical artery flow in the fetus.[49]
                          References:
                          1. Conder R, Zamani R, Akrami M. The Biomechanics of Pregnancy: A Systematic Review. J Funct Morphol Kinesiol, 2019.
                          2. MacEvilly M, Buggy D. Back pain and pregnancy: a review. Pain, 1996.
                          3. American Academy of Obstetricians and Gynecologists. Committee Opinion No. 548: Weight Gain During Pregnancy. Published online 2020:3.
                          4. Chu SR, et al. Pregnancy Results in Lasting Changes in Knee Joint Laxity. PM R, 2019.
                          5. Foti T, Davids JR, Bagley A. A biomechanical analysis of gait during pregnancy. J Bone Joint Surg Am, 2000.
                          6. Forczek W, et al. Progressive changes in walking kinematics throughout pregnancy-A follow up study. Gait Posture, 2019.
                          7. Gilleard W, Crosbie J, Smith R. Effect of pregnancy on trunk range of motion when sitting and standing. Acta Obstet Gynecol Scand, 2002.
                          8. Wang SM, et al. Low back pain during pregnancy: prevalence, risk factors, and outcomes. Obstet Gynecol, 2004.
                          9. Thorell E, Kristiansson P. Pregnancy related back pain, is it related to aerobic fitness? A longitudinal cohort study. BMC Pregnancy Childbirth, 2012.
                          10. Kovacs FM, et al. Spanish Back Pain Research Network. Prevalence and factors associated with low back pain and pelvic girdle pain during pregnancy: a multicenter study conducted in the Spanish National Health Service. Spine, 2012.
                          11. Fast A, et al. Low-back pain in pregnancy. Spine, 1987.
                          12. Fast A, et al. Night backache in pregnancy. Hypothetical pathophysiological mechanisms. Am J Phys Med Rehabil, 1989.
                          13. Fast A, Hertz G. Nocturnal low back pain in pregnancy: polysomnographic correlates. Am J Reprod Immunol N Y N, 1992.
                          14. Brynhildsen J, et al. Follow-up of patients with low back pain during pregnancy. Obstet Gynecol, 1998.
                          15. Bliddal M, et al. Association of Pre-Pregnancy Body Mass Index, Pregnancy-Related Weight Changes, and Parity With the Risk of Developing Degenerative Musculoskeletal Conditions. Arthritis Rheumatol Hoboken NJ, 2016.
                          16. Bryndal A, et al. Risk Factors Associated with Low Back Pain among A Group of 1510 Pregnant Women. J Pers Med, 2020.
                          17. Morino S, et al. Low back pain and causative movements in pregnancy: a prospective cohort study. BMC Musculoskelet Disord, 2017.
                          18. Paksoy Y, Gormus N. Epidural venous plexus enlargements presenting with radiculopathy and back pain in patients with inferior vena cava obstruction or occlusion. Spine, 2004.
                          19. Humphries A, et al. The effect of supine positioning on maternal hemodynamics during late pregnancy. J Matern-Fetal Neonatal Med, 2019.
                          20. Humphries A, Stone P, Mirjalili SA. The collateral venous system in late pregnancy: A systematic review of the literature. Clin Anat N Y N, 2017.
                          21. Humphries A, et al. Hemodynamic changes in women with symptoms of supine hypotensive syndrome. Acta Obstet Gynecol Scand, 2020.
                          22. Dunietz GL, et al. Sleep position and breathing in late pregnancy and perinatal outcomes. J Clin Sleep Med, 2020.
                          23. Kember AJ, et al. Modifying maternal sleep position in the third trimester of pregnancy with positional therapy: a randomised pilot trial. BMJ Open, 2018.
                          24. Warland J, et al. Modifying Maternal Sleep Position in Late Pregnancy Through Positional Therapy: A Feasibility Study. J Clin Sleep Med, 2018.
                          25. McIntyre JPR, et al. A description of sleep behaviour in healthy late pregnancy, and the accuracy of self-reports. BMC Pregnancy Childbirth, 2016.
                          26. Warland J, Dorrian J. Accuracy of Self-Reported Sleep Position in Late Pregnancy. PLOS ONE, 2014.
                          27. O’Brien LM, Warland J. Typical sleep positions in pregnant women. Early Hum Dev, 2014.
                          28. Wilson DL, et al. Decreased sleep efficiency, increased wake after sleep onset and increased cortical arousals in late pregnancy. Aust N Z J Obstet Gynaecol, 2011.
                          29. George JW, et al. A randomized controlled trial comparing a multimodal intervention and standard obstetrics care for low back and pelvic pain in pregnancy. Am J Obstet Gynecol, 2013.
                          30. Quintero Rodriguez C, Troynikov O. The Effect of Maternity Support Garments on Alleviation of Pains and Discomforts during Pregnancy: A Systematic Review. J Pregnancy, 2019.
                          31. Richards E, et al. Does antenatal physical therapy for pregnant women with low back pain or pelvic pain improve functional outcomes? A systematic review. Acta Obstet Gynecol Scand, 2012.
                          32. American College of Obstetricians and Gynecologists. Back Pain During Pregnancy. Accessed February 5, 2022. https://www.acog.org/en/womens-health/faqs/back-pain-during-pregnancy
                          33. Thomas IL, et al. Evaluation of a maternity cushion (Ozzlo pillow) for backache and insomnia in late pregnancy. Aust N Z J Obstet Gynaecol, 1989.
                          34. Kihlstrand M, et al. Water-gymnastics reduced the intensity of back/low back pain in pregnant women. Acta Obstet Gynecol Scand, 1999.
                          35. Granath AB, Hellgren MSE, Gunnarsson RK. Water aerobics reduces sick leave due to low back pain during pregnancy. J Obstet Gynecol Neonatal Nurs, 2006.
                          36. Liddle SD, Pennick V. Interventions for preventing and treating low-back and pelvic pain during pregnancy. Cochrane Database Syst Rev, 2015.
                          37. Shiri R, Coggon D, Falah-Hassani K. Exercise for the prevention of low back and pelvic girdle pain in pregnancy: A meta-analysis of randomized controlled trials. Eur J Pain Lond Engl, 2018.
                          38. van Benten E, et al. Recommendations for physical therapists on the treatment of lumbopelvic pain during pregnancy: a systematic review. J Orthop Sports Phys Ther, 2014.
                          39. Close C, et al. A systematic review investigating the effectiveness of Complementary and Alternative Medicine (CAM) for the management of low back and/or pelvic pain (LBPP) in pregnancy. J Adv Nurs, 2014.
                          40. Coleman J, et al. The Ghana PrenaBelt trial: a double-blind, sham-controlled, randomised clinical trial to evaluate the effect of maternal positional therapy during third-trimester sleep on birth weight. BMJ Open, 2019.
                          41. Ostgaard HC, Zetherström G, Roos-Hansson E. Back pain in relation to pregnancy: a 6-year follow-up. Spine, 1997.
                          42. Norén L, et al. Lumbar back and posterior pelvic pain during pregnancy: a 3-year follow-up. Eur Spine J, 2002.
                          43. Lee SWY, et al. Haemodynamic effects from aortocaval compression at different angles of lateral tilt in non-labouring term pregnant women. Br J Anaesth, 2012.
                          44. Kundra P, et al. Effect of positioning from supine and left lateral positions to left lateral tilt on maternal blood flow velocities and waveforms in full-term parturients. Anaesthesia, 2012.
                          45. Fujita N, et al. Effect of Right-Lateral Versus Left-Lateral Tilt Position on Compression of the Inferior Vena Cava in Pregnant Women Determined by Magnetic Resonance Imaging. Anesth Analg, 2019.
                          46. Higuchi H, et al. Effect of lateral tilt angle on the volume of the abdominal aorta and inferior vena cava in pregnant and nonpregnant women determined by magnetic resonance imaging. Anesthesiology, 2015.
                          47. Dennis AT, Hardy L, Leeton L. The prone position in healthy pregnant women and in women with preeclampsia - a pilot study. BMC Pregnancy Childbirth, 2018.
                          48. Oliveira C, et al. Influence of the prone position on a stretcher for pregnant women on maternal and fetal hemodynamic parameters and comfort in pregnancy. Clin Sao Paulo Braz, 2017.
                          49. Nakai Y, et al. Effects of maternal prone position on the umbilical arterial flow. Acta Obstet Gynecol Scand, 1998.
                          Disclaimer: The information provided on this page is for informational purposes only and is not professional medical advice, diagnosis, treatment, or care, nor is it intended to be a substitute therefore.
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                            Long answer:
                            • Practical points for physiotherapists and registered massage therapist
                              • Since routine movements (especially rising from a chair) can provoke LBP and PGP in pregnancy, teaching these patients modified movements to reduce loading and stresses on the body may be helpful.[17]
                              • Supine? When positioning a pregnant patient for treatment, if the supine position is needed, always keep her pelvis tilted 15 degrees or more to the left.[43] Further, to put her in this position, always start out with her lying on her left side and then roll her toward this position. There is evidence that moving to this left pelvic tilt position from the supine position is not as effective in relieving aortocaval compression as moving to this position from the left lateral position.[44] If tilting the pelvis to the right, more than 30 degrees of tilt may be required.[45,46]
                              • Prone? For over two decades, it has been known that maternal prone position in late pregnancy can be adopted using a special bed, stretcher, or pillow (e.g., Belly Pillow®47) with a large hole that accommodates the gravid uterus and ensures that there is no pressure being applied to the abdominal region. Under these conditions, this position has been demonstrated to be safe for at least 5-6 minutes,[48] comfortable,[47,48] and can completely relieve uterine compression of the IVC and aorta. This, in turn, can improve maternal respiration rate,[48] blood-oxygen saturation,[48] and blood pressure [47,48] and can improve umbilical artery flow in the fetus.[49]