The document discusses the management of low back pain during pregnancy. It notes that around 45-75% of pregnant women experience low back pain, which is caused by hormonal, circulatory, and mechanical changes. Non-pharmacological treatment options include exercises, yoga, Pilates, aquatic therapy, acupuncture, massage, and spinal manipulation. Studies show that programs including education and physical therapy can reduce pain and disability in pregnant women with low back pain.

1. The Management of Low
Back Pain In Pregnancy

2. Introduction
Around 45% to 75% of pregnant women
are said to experience low back pain
(LBP) at some point during their
pregnancy.
This type of LBP can be present in the
pelvic girdle, between the posterior iliac
crest, gluteal fold and/or in the general
lumbar spine region.
It is thought to occur due to hormonal,
circulatory and mechanical changes and as
a result, the quality of life of the pregnant
woman is affected.

3. Sagittal
Section
of the
Lumbar
Spine

4. Introduction
Prenatal is a term to describe the time frame
prior to birth.
It is a critical phase for fetal development
therefore, it is important that the mother’s
nutritional needs are met to ensure the
healthy growth of the embryo or fetus.

5. The term Postpartum (also
known as postnatal) refers to the
first six weeks immediately after
birth of an infant.
This is a significant phase in the
mothers and babies’ lives, it is the
period of adjustments to
parenthood and the start of a life
long bond within the family and
the wider community.
Introduction

6. Epidemiology
The global prevalence of LBP in pregnancy is high
yet ranges from 25-90% in the United States of
America, Europe and Africa, with the highest rates
recorded in Brazil and Sweden.
This is because there is currently no universally
recognized classification system for the condition.
LBP usually occurs in the second trimester
(gestational 22 week average),
although pain continues for up to three years in
20% of women postpartum.

7. Epidemiology
It is estimated that one third of women will suffer
from severe pain, reporting that 80% impacts their
quality of life, sleep and 10% causing an inability to
work.
A cross-sectional study consisting of 400 pregnant
women found that 75.3% (300 pregnant women)
experienced LBP, reporting a mean Visual Analog
Scale (VAS) score of 4.91 ±1.88. Despite a sufficient
sample size, the generalisability is limited and the
classification of pain, type and localisation were
subjectively assessed.

8. Etiology
The etiology is poorly understood due to the multifactorial nature,
but suggested theories are associated with biochemical, vascular
and hormonal changes during pregnancy.
Although there are no true consensus regarding the risk factors,
those most common include-
 Young Age
 Pelvic Trauma
 Hunchback Posture
 Gestational Weight Gain
 Chronic LBP
 Previous History of LBP in Pregnancy.

9. HUNCHBACK
POSTURE

10. Management Techniques
The management of LBP in pregnancy
includes a number of non-
pharmacological treatment options. It
is treated differently depending on the
stage of pregnancy, the underlying
cause, aggravating factors and the
involvement of other medical
conditions such as diabetes or heart
problems.

11. Medical Management
It is important to encourage the patient to receive regular checkups by her
obstetrician. During the therapy session, continually check on pain levels and any
aches radiating from the low back or stomach. Some patients tolerate pain and
discomfort better than others and will therefore mask their distress – Use a chart
for Rate of Perceived Exertion to determine the patient's true status and take note
of any changes that occur between the begging and end of the session.
Although there are numerous interventions promoted for low back pain during
pregnancy, the most common and widely used is a specific exercise program
designed by a physical/physiotherapist. Another intervention that is getting
tractions and shows prominent research is acupuncture. Recent studies show that a
week of continuous acupuncture at specific auricular points can decrease pain and
increase the capacity for some physical activity which can help diminish the need
for drugs.

12. Restore biomechanics during daily
activities
Improve lumbo-pelvic stabilization
Educate and prevent
Physical Therapy Goals

13. Treatment/management options may include:
o Postural correction
o Supported side-sleeping
o Lumbar roll while sitting
o Limiting standing and walking
o Antenatal exercises. Healthy pregnant women can exercise
for at least 150 minutes per week or 20-30 minutes of
moderate to intense aerobic activity
o Aquatic therapy
o Acupuncture
o Yoga
o Any low intensity, relaxation activity

14. Other Interventions
o Side lying while sleeping or resting using a wedge shaped pillow to support
stomach
o Use of pillow between the legs while side lying (squeeze the pillow/legs together
while rolling)
o Compression socks to promote venous return and decrease edema
o Support belt
o Soft tissue massage
o Acetaminophen as proscribed by physician
o Intra-articular sacroiliac joint injections (under imaging guidance) for ankylosing
spondylitis can be recommended. There are indications that acupuncture during
pregnancy may reduce pain, but high quality studies are required for sacroiliac
joint therapeutic injection therapy.
o Most therapeutic strategies encourage preventive measures among pregnant
women and those who are planning to become pregnant. It has been shown that
women who participate in prophylactic education and strengthening programs
during early pregnancy can avoid problems from low back pain.

15. Physical Therapy Management
Conservative management is the ideal option. Treatment starts
with education and activity adjustments. Educational strategies
focus on back care measures, such as ergonomics, which
teaches women correct posture; pregnant women learn how to
stand, walk, or bend properly, without causing stress on the
spine. Accurate posture is essential to improve low back pain.
Braces that ensure correct body posture are also available if the
instructions are not enough. In regard to activity modifications,
scheduled rest during the day is helpful for relieving muscle
spasms and acute pain. During this time, posture is again
important as both feet should be elevated, which will help
flex the hips and decrease the lumbar lordosis of the spine.

16. Studies have found that pregnant women with low back pain, who
participate in both education and physical therapy, have less pain and
disability, higher quality of life, and improvement on physical tests.
Physical therapy encompasses several factors such as postural
modifications, back strengthening, stretching, and self-mobilization
techniques. Functional stability can be maintained throughout
pregnancy by strengthening the muscles around the lumbar spine
through various back exercises.
Treatment depends on the diagnosis and timing of pregnancy (before
or after childbirth). The patient should understand her own symptoms
and be motivated to remain active.
Physical Therapy Management

17. Patient Instructions
It’s important to communicate with the patient and
provide information about the relevant anatomy,
ergonomics, back education (to prevent unnecessary
mechanical stress on the back), and how to manage
ADL activities (walking, standing, sitting, lying, and
work position, learning how to control pain).
Research shows that when the symptoms are
explained, patients can feel more at ease and their
anxiety may decrease.

18. • Using a small pillow between the legs while sitting and
rolling in order to stabilize the back.
• Postural correction by standing upright with a neutral
posture, avoiding hyper lordosis
• Do not sit or stand for a long time, alternate it with walking
or stretching
• Taking breaks and resting in a comfortable position, with the
back supported to relieve tired muscles
• Sleeping lying on one side with the top leg on a pillow
• “Use of a small foot stool for one foot in sitting or standing,
alternate feet”
• Avoiding spine twisting while lifting
Patient Instructions

19.  Even though most pregnant patients will be advised to exercises within their safe
and pain free range, studies show that less than 50% will actually do so.
 Furthermore it has also been proven that training the rectus abdominus muscles
will be useless due to his weakness during the pregnancy.
 Stability, coordination and functional preservation should be trained with active back
exercises – endurance training for back muscles stabilization. Pelvic tilts, knee pull,
straight leg raising, curl up, lateral straight leg raising and water aerobics are
recommended because these exercises could relieves lumbar pain in pregnancy.
 Relaxation exercises while paying close attention to proper respiration also show to
be beneficial.
 Management includes specific interventions to address pain, weakness, and mobility
in the low back region. The Ottawa Panel also recommends massage therapy in
order to treat subacute and chronic low back pain
Active Back Exercises

20. Manual Therapy Techniques
Posterior/Anterior
mobilizations in side lying
position
 Addresses pain and mobility
(Grades 1-4)

21. Corrects anterior innominate
rotation.
Muscle Energy
Technique by
resisting hip flexion
in side laying while
stabilizing the
sacrum

22. Position the patient in a side lying and
place an elastic around both legs above
the knees.
Ask the patient to perform an external
rotation of her leg in order to strengthen
the Gluteus Medius. Perform this
exercise on both sides.
Feet need to be kept together during
the whole exercise. Also, prevent the
pelvis from externally rotating.
Strengthening
Gluteus Medius

23. Ask the patient to sit on a physio
ball and simulate a walk
movement with the lower
extremities. This will encourage
the back muscle memory to
stabilize back during ADL’s. The
patient will have to keep her
back strait during the whole
exercise.
Abdominal Drawing
in Maneuver with
Physio ball (ADIM)

24. The patient will be positioned on a physio ball,
which will force the pelvic, abdomen and back
muscles to stay active in order to find a
balanced sitting position. This part of the
exercise will provoke a contraction of the
glutei to increase the strength of the posterior
oblique sling muscles which compress the SIJ.
In the meantime the patient will perform a
latissimus dorsi pull-down by bringing the
strait arms with the arms positioned in front
and above the head to a position with flexed
arms with the arms in front of the chest and
bring the arms back to the prior position.
This second part of the exercise will improve
the latissimus dorsi muscle strength. Keep the
back straight during the whole exercise.
Latissimus dorsi
pulldowns

25. Starting from the hands-and knees-
position the patient will move her back
up and down.
During this exercise it is important to
keep the arms stretched out with the
hands positioned right under the
shoulders and to keep the stomach
muscles tight throughout the entire
exercise.
Angry Cat

26. Lay down with flexed knees and
move the pelvic in an anterior
and posterior position.
Pelvic Tilt

27.  Yoga is a form of complementary and alternative
medicine, incorporating fluid transitions of poses to
promote increased joint range of motion, flexibility,
muscular strength and balance.
 This is coupled with deep breathing exercises and
meditation to facilitate mental relaxation,
concentration.
 Yoga is widely recognized having 300 million people
practicing worldwide, encompassing 7% of women
during pregnancy.
Yoga

28. Yoga
A Cochrane Review investigated various interventions for
preventing and treating low back and pelvic pain during
pregnancy.
This included 34 randomised controlled trials (RCTs)
consisting of 5121 pregnant women aged 16-45 years
old.
Primary outcome measures were pain intensity, back or
pelvic related functional disability, sick leave and adverse
effects.

29. Yoga
It revealed that an 8-12 week exercise programme
with yoga reduced the risk of pregnant women
reporting LBP by 44% and sick leave by 24%.
However, a systematic review recently conducted
by Koukoulithras et al. (2021) finding that yoga was
not effective to improve long-term pregnancy
related LBP nor statistically significant. But, the
small population sample size limited conclusions
able to be drawn.

30. A RCT of 60 pregnant women ranging from 14-40 years old
found that 1 hour of Hatha yoga practice per week for 10 weeks
significantly lowered lumbo-pelvic pain on the Visual Analog
Scale (VAS) compared to postural orientation exercises.
Also, lumbar pain provocation tests showed a gradual decreased
response throughout the sessions. Yoga was shown to be of
most benefit in women suffering from LBP coupled with anxiety,
depression, stress and sleep disturbances.
Also, associated with more comfort and shorter duration of first
stage labour. It concluded that yoga is a safe and fetal tolerated
therapeutic intervention for LBP in both first time and higher risk
pregnancies, with no adverse events reported.
YOGA

31. YOGA
 A Systematic Review (SR) of 15 articles including 2566
participants meeting the inclusion criteria to evaluate the
literature about non-pharmacological, easily accessible
management strategies for pregnancy-related LBP.
 The types of Yoga were Iyengear-based, Hatha and modified
yoga based, incorporating progressive muscle relaxation as a
tranquility aspect.
 Findings indicated that 8 weeks of yoga for 20 minutes
twice daily showed statistically significant improvements in
LBP, with additional improvements in mental health, physical
and social function.

32. Pilates
Pilates is defined as “a mind–body exercise that
focuses on -
• Strength
• Core Stability
• Flexibility
• Muscle Control
• Posture And Breathing
Pilates was created in the 1980’s by Joseph Pilates,
a German exercise instructor.

33. In a randomized control study completed
in 2021 by Sonmezer et al, it was found
that not only was low back pain
significantly improved, functional
disability, sleep, mobility and lumbopelvic
stabilization also improved.
The group completed Pilates based
exercises twice a week for eight weeks
and results showed that pain and
disability significantly improved.
Evidence Behind Pilates

34. In a study completed by Mazzarino, Kerr and Morris in 2018, there were a few
Pilates exercises and positions which were recommended to be avoided or
modified by pregnant women. These include:
• Modification of abdominal exercises; this is to avoid significant divarication
of the rectus abdominus muscle which can be split from pressure from the
uterus. Flexion should be performed while seated to avoid this.
• Exercises in the supine position should be avoided as it can prevent and
obstruct venous return due to the growing uterus compressing the vena
cava; this can cause the mother to feel dizzy. Positions can be modified to
include side-lying, seated or standing exercises.
This study also found that opinion of Pilates instructors on the type of exercises
to be included and excluded and the average duration and frequency was
discordant with the advice from the ACOG published in 2015
Positions to be Avoided

35. Manual Therapy Techniques
There is a growing evidence in
support of the use of manual therapy
as a safe treatment to effectively treat
low back pain, especially
massage and spinal manipulation.

36. Massage therapy can be helpful for stress relief, well-
being and pain reduction among women during
pregnancy, and is also used to relieve LBP during
pregnancy.
A small study explored the impact of deep tissue
massage for low back pain in women, the
intervention included twice a week deep tissue
massage for 2-months;
the massage included: appropriate pressure,
lengthening movements, movements in
intermuscular grooves, anchor and stretch technique
and releasing muscle tension and found it decreased
pain and improve functionality of the pregnant
participants.
Massage

37. A systematic review was conducted in 2017,
which explored osteopathic manipulative
treatment/ spinal manipulation therapy for low
back pain during and after pregnancy, and it
was concluded that it had a significant
medium-sized effect on decreasing pain and
increasing functional status in women with low
back pain during pregnancy, but had low
quality evidence that it decreased pain and
functional status postpartum.
Additionally, it was found that there are
physical and mental health benefits and can
minimize pharmacological treatment options
for low back pain.
Spinal Manipulation

38. Aquatic therapy utilizes the
beneficial properties of water
and has been used as a
treatment method for the
management of lower back
pain. There is limited evidence
in its effectiveness in the
management of lower back
pain during pregnancy,
however it is still used as a
treatment method.
Aquatic Therapy

39.  A small scale prospective quantitative study conducted in
Australia found aquatic physiotherapy sessions reduced low back
pain in 70% of participants. Exercises included focused on thoracic
mobility, transverse abdominus and pelvic floor muscle
strengthening, aiming to improve core stability and a
component of aerobic exercise to maintain general fitness.
 A systematic review concluded that there was sufficient evidence to
suggest that aquatic therapy does provide some benefits to patients
suffering from LBP during pregnancy.
A randomized clinical trial containing 129 participants found that
participants who completed 60 minute aquatic therapy classes three
times a week reported reductions in lower back pain.
Aquatic Therapy

40. Maternal Benefits
• Improved cardiovascular function
• Lowers risk of developing gestational
diabetes.
• Improved psychological well-being.
• Improvement in sleep.
• Reduction in musculoskeletal pain associated
with pregnancy e.g., low back pain.
• Helps with weight management: excessive
weight gain during pregnancy can lead to
maternal complications such as
hypertension, preeclampsia, and gestational
diabetes.
Benefits of Exercise During
Pregnancy

41. Fetal Benefits
 Decreased resting fetal heart
rate.
 Increase viability of the
placenta.
 Lower birth weight.
 Increase gestational age.
 Improved neurodevelopment.
Benefits of Exercise During
Pregnancy

42.  Vaginal bleeding
 Dizziness/feeling faint
 Shortness of breath
 Chest pain
 Headache
 Muscles weakness
 Calf pain or swelling
 Uterine contractions
 Decreased fetal movement
 Vaginal fluid leakage
 Neurological symptoms
Red Flags

43. Contraindications to Exercise During Pregnancy
Persistent vaginal bleeding in the
2nd and 3rd trimester.
Preeclampsia or pregnancy
induced hypertension.
Cardiovascular disease.
Cervical Weakness.
History of fetal growth restriction.
History of preterm labour.
Multiple gestation.
Premature contractions or labour.
Premature rupture of membranes.
Severe anemia.
Chronic bronchitis.
Poorly controlled diabetes.
Poorly controlled seizures.
Poorly controlled thyroid disease.
Placenta previa after 26 weeks.
These contraindications are taken from the American College of Obstetricians and
Gynecologists, no distinction was made between absolute and relative contraindications.

44. Clinical Relevance
Pregnancy-related LBP is prevalent, disabling and costly to both the
individual and the society. There is growing evidence in support of
the use of yoga, pilates, aquatic therapy and manual therapy as safe
treatment options to effectively manage pregnancy-related LBP.
Although the evidence base is of low quality, these management
strategies are safe and recommended interventions. However, further
research is required to determine the extent of benefits in clinical
practice. It is the responsibility of clinicians to ensure evidence-based
practice when providing holistic patient centred care. Future
investigations should focus on higher quality research to explore
the effects of LBP in the long term and on quality of life in pregnant
women.

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49. Questions & Answers

50. Thanks for
Attention