Pregnancy-related lumbopelvic pain – treatment modalities

Pregnancy-related lumbopelvic pain (LPP) can be categorized into lumbar pain (LP), pelvic girdle pain (PGP) or mixed pain, i.e. these two types of pain felt simultaneously [1].

These ailments affect many pregnant women, thus exerting a negative influence on their professional life, everyday activities and sleep [2]. The clinical evidence may be diversified – it may be different for different patients and it may change for the same patient with time [3].

Health care professionals often lack the knowledge on how to successfully treat pain in pregnant women. The conviction that LPP is a temporary and self-eliminating problem results in the fact that few women receive appropriate help [4]. Still, 25% of them suffer from post-birth LPP [3]. LPP may negatively affect their quality of life for months or even years [5]. The complexity of the ailment as well as socio-economic consequences of chronic pain require adequate treatment introduced as early as possible.

The aim of the article is to present the latest findings on the possible LPP treatment strategies.

Paracetamol is the only painkiller safe for pregnant women. Still, its effect in LPP relief is low [4,6,7]. Nonsteroidal anti-inflammatory drugs are more efficient in pain relief, yet they are not recommended after 30 weeks of pregnancy. The literature mentions small doses of opioids particularly helpful in night pain and sleep disorders. However, scientific evidence on their application to treat LPP is limited, especially in pregnant women. Tests on animals have shown that they may, though do not have to, result in risk for the foetus [4].

Pain may be categorized into pain triggered in the joint (peripheral pain) and pain triggered in the brain (central sensitization) [8]. The recommended treatment strategy is not to allow receptor-generated peripheral pain to become generated centrally, thus leading to chronic pain. In such cases, it seems advisable to introduce small doses of anti-depressant drugs [9].

Research has shown that numerous forms of physiotherapy can benefit LPP therapy. Even though we lack strong and unambiguous evidence for the effectiveness of any particular method of physiotherapy, it is indisputable that physiotherapy leads to better results in pain relief, disability control and limiting the number of sick leaves than the standard obstetric medical care [10]. As LPP is a complex disorder, a multidisciplinary approach is advised – a combination of procedures such as manual therapy, Mc-Kenzie method, exercise and patient education.

Patient education. In the case of LPP, patient education should include the following issues: basic information on anatomy, information on the disorder, risk factors, ergonomics, healthy posture, pain relieving techniques, relaxation techniques [6,11,12,13]. Pregnant women suffering from LP should avoid excessive exhaustion or rotating movements when lifting objects. They should maintain healthy posture and make frequent pauses in their activities [11]. In addition, women who suffer from PGP should refrain from jumping, uneven loading of lower limbs (e.g. when putting on a pair of trousers), excessive abduction in the hip joint or activities requiring end range movements [14]. When turning in bed, the patient should keep her knees bent and joined together [15].

Kinesiotherapy and exercise. Women who exercise regularly find it easier to bear LPP related ailments. Exercise therapy brings positive effect on pain relief, improves fitness and/or professional activity in patients with LP. The effect is weaker in patients who suffer from PGP. For PGP patients, authors of European guidelines recommend an individualized exercise programme focused on practising healthy behaviour in everyday activities as well as refraining from activities that result in pain [6]. According to these recommendations, there is adequate scientific evidence to support the effectiveness of stabilizing exercises done after birth. A specially designed exercise programme reduces pain intensity and disability and improves quality of life better than conventional physiotherapy (massages, relaxation, joint mobilization, electrotherapy, warm compresses, mobilizing and strengthening exercises) without stabilizing exercises. The beneficial effect can be still visible as long as two years later [17,18]. Some authors reported a positive effect of stabilizing exercises as early as in the pregnancy period [16,19,20]. There is limited evidence, however, on the specificity of the training and exercises that should be done, since only a few studies investigated the impact of a particular type of movement activity [21]. Water gymnastics is a similar case. The available studies [22] reported a significant reduction in pain intensity and a reduced number of sick leaves among women suffering from LP, yet these effects were not observed in women with PGP. As the number of randomized controlled tests was limited, the evidence is not strong enough to explicitly prove the effect of such treatment [21]. Exercise therapy has better effects than standard obstetrics (pharmacotherapy, informing a patient on the disorder, recommending aerobics, warm compresses and an appropriate amount of rest) [23]. It is safer for both the mother and the foetus. The recommended activity is aerobics and strengthening exercises of medium intensity (a minimum of 30 minutes three times a week) [24]. It is advisable to complement this therapy with individually designed and specialized training conducted once or twice a week aimed at improving balance as well as strengthening muscles of the back, pelvic girdle and pelvic floor and co-contracting the transverse abdominal muscle and pelvic floor muscles with other muscle groups [10].

Manual therapy. There are few studies on the effects of manual therapy in LPP treatment. There are no randomized control studies on the effect of mobilization of spinal joints and sacroiliac joints [21]. Although in the study by George et al. [23] manual therapy seemed to have contributed to the achieved effects, the complex character of the treatment used prevents us from reaching any conclusions on manual therapy effects in isolation. Still, there are several studies which may serve as a starting point for future research and as instructions for physiotherapists who use manual therapy with pregnant patients with LPP. Peterson et al. [25] managed to achieve an improvement in the functioning and reduction of pain when using manipulation techniques of High Velocity Low Amplitude (HVLA) on hypomobile spinal joints. There are also some positive reports on the passive and active effects of lumbar spine and sacroiliac joints mobilization [21]. Murphy et al. [26] observed positive effects of manual therapy applied within diagnosis-based clinical assessment schedule.

Physical Agents. Transcutaneous electrical nerve stimulation (TENS) can be used in pregnant women, as there is no risk of side effects provided that contraindications are excluded and that acupuncture points that might induce premature labour are avoided [27]. In their study on TENS treatment in third trimester pregnant women with LP, Keskin et al [28] found that the TENS treatment resulted in a considerable reduction of pain intensity and in a substantial increase in function. The effect was larger than in the case of a group who did a set of exercises at home and a group who received pharmacotherapy. Still, scientific evidence on TENS effectiveness as a single therapeutic method is insufficient. However, as the number of methods of pain relief in pregnant women is limited, an attempt to use TENS is fully recommended. It is a low-cost, easily accessible method, with lower risk levels than pharmacotherapy and acupuncture. TENS treatment should be used as “second line” in the case of LP and PGP, following patient education and kinesiotherapy in the form of individually designed exercise plan [27].

Orthosis. It is mainly because of a limited number of studies on the effect of orthosis as a single treatment method that not enough evidence has been found for it to be recommended [10]. This is in line with the European guidelines on PGP treatment. European guidelines suggest using orthosis when it relieves pain although it is pointed out that it should be used over a limited period of time [6]. The pelvic belt may prove helpful in the case of insufficient force closure mechanism [6,8,13,29]. In their study, Kordi et al [30] found that the pelvic belts they used significantly decreased pain intensity and disability in comparison to exercise and to general educational information. It seems that using pelvic belts is most advisable in the case of symphysis pain. There are two versions of pelvic belts available, the “soft” one and the “stiff” one, of which the former seems to be more effective and more comfortable for the patient [31]. The belt worn in the “high” position (just below the upper spinae iliaca) improves the stabilization of the sacroiliac joints [14], while the “low” position (worn just above the symphysis) is used in the case of symphysis dysfunctions [31]. It is recommended that the patient should decide whether to use crutches or a pelvic belt. If she reports diminishing PGP pain, their use is justified.

Prevention. Although it is difficult to prevent LPP, appropriate patient information and care about physical fitness (e.g. proper physical activity, body posture, ergonomics) may reduce pain and/or make it less traumatizing [13]. Pelvic floor muscle exercise, as an element of specially designed 12-week training, may be helpful in preventing LPP in advanced pregnancy periods and result in the pregnant patient functioning better [33]. It has been proved that there is a correlation between muscle dysfunction and PGP [34]. Hence the hypothesis that appropriate treatment targeted at muscle disbalance could prevent or reduce PGP-related ailments. Physical activity in early and medium-term pregnancy results in a lower risk of PGP, as this risk decreases with an increase in time devoted to exercise. Physical activity in water resulted in lower PGP risk than in women who did not do physical activity. However, this effect was not observed with any other physical activity. Interestingly, it was noted that while physical activity has a beneficial effect on PGP, resistance exercise and fitness training result in increased risk of PGP [35].

Acupuncture. Acupuncture techniques are believed to be safe for pregnant women. Still, therapists need to avoid points related to the cervix and the uterus, as they may prompt premature birth [37]. Acupuncture is more efficient than exercise in relieving evening LPP and disability, and it improves the functioning of the patient. These effects can be achieved if the pain develops in the 26th week of pregnancy. The effects were not observed when pain developed earlier, i.e. in the 20th week of pregnancy [2]. Acupuncture, stabilizing exercises, massage and stretching are equally efficient in reducing pain syndromes that continue post birth [21].

Yoga. It has been proved that yoga, in comparison to posture correction, may lead to pain reduction [20]. However, scientific evidence for yoga effectiveness in LPP treatment is limited, as there have only been a few randomized control studies [21].

Reflexology may be helpful in LPP therapy in reducing pain intensity, pain frequency and disability. It consists in manipulating reflex areas that refer to the pelvis and the back. More reliable randomized control studies are necessary to unquestionably confirm the effectiveness of the method [38].

Osteopathy and chiropractic. It has been proved that patients who received osteopathic treatment along the standard obstetric treatment had less spinal pain than patients who had standard treatment and additional placebo treatment. The procedures included manipulations of soft tissues, myofascial release, movement range improvement techniques, and muscle energy techniques in the cervical, thoracic and lumbar spine, the sacrum and the pelvis, the upper thoracic outlet and the clavicle, the thorax and the diaphragm. There are theoretical premises that High Voltage Low Amplitude thrust techniques as well as the fourth ventricle compression techniques may be risky for the pregnant patient and for the foetus or may lead to premature birth. Therefore, the effectiveness of these procedures in LPP treatment has not been studied [39]. There have been reports on positive effects of chiropractic treatment on pain and disability. However, the same effects were achieved with stabilization exercises [40]. Craniosacral therapy is used in LPP treatment, too. Elden et al. noted lower morning intensity of pain and less diminished function when standard therapy was paired with craniosacral therapy, as opposed to using standard treatment only (patient education, stabilizing belt, instructions for doing strengthening and stretching exercises). Still, in this case scientific evidence is not sufficient enough [21].

Kinesiotaping. The method is simple to use and safe and it does not involve pharmacotherapy. It helps in numerous ailments of the locomotor system and also proves helpful in ailments suffered by pregnant women, especially as a supplementary method. Kaya and Yosunkaya [42] reported higher effectiveness of kinesiotaping in reducing LPP than of group exercise for pregnant women. Kaplan et al. [43] studied patients whose pain was relieved with paracetamol along with kinesiotaping, and their pain reduction was significantly better both at rest and in activity. In their review of the literature, Reyhan et al. [44] concluded, however, that there is not enough scientific evidence to prove the effectiveness of kinesiotaping in LPP treatment.

LPP requires an individualized and complex treatment. There is no single and most effective treatment strategy. A combination of evidence-based methods produces the best treatment outcomes. Healthcare professionals should not refrain from treating pregnant women. Current knowledge gives us a variety of effective tools which help reduce pain and functional limitations with no harm to either a mother or foetus. Appropriate and early interventions will make it possible to reduce the number of patients suffering from this long-term dysfunction.