Back Pain During Pregnancy
How to Find Relief
When Amy developed back pain during her 27th week of pregnancy, she thought maybe she had just strained a muscle and that it would be better in a few days after some rest. Unfortunately, the pain worsened and she developed trouble sleeping, was unable to pick up her 18 month old son, and started having a sharp pain when she put weight onto her right leg, especially with stairs and standing to put on her pants. When she sought medical care, she was told that many women have back pain during pregnancy and that it would resolve after she had the baby – in 13 weeks!
In our culture, information abounds for women about the physiological changes during pregnancy, such as increased blood volume and changes in breath rate. Women can easily find out the size of their growing baby and uterus – usually as compared to the size of various produce items. And there is a wealth of information about crafting a birth plan, how to care for babies once they arrive, and what products we will need to accomplish all of this. Yet somehow, knowledge about the physical changes during pregnancy and postpartum, often predictable and easily managed, is less accessible and its importance minimized, as if mom’s physical condition and function is an acceptable casualty of the magical journey of motherhood. While many factors can contribute to the onset of musculoskeletal problems during pregnancy, there are a few that affect all women and understanding these can change a women’s perception of her body during pregnancy and her expectations for postpartum recovery.
It is well known that women experience hormonal changes during pregnancy, one of the effects of this is due to the increase laxity in the joints. This means that the level of support provided to joints pre-pregnancy is decreased and the joints are allowed more movement during the course of daily activities. The evolutionary reasons behind this are to allow the woman’s bony pelvis to spread, thus facilitating passage of the baby through the birth canal. However, the distribution of the hormones is not isolated to the pelvis, which means that all of the joints in the body now have increased movement and can be more vulnerable to injury. Further, the effect in the pelvic joints can make it more difficult for the woman’s body to be stable when forces pass through the pelvis, particularly with activities that load the pelvis (carrying a laundry basket) or unilateral activities (stair-climbing, standing on one leg).
In all individuals, certain muscles in the trunk turn on prior to movement to help stabilize the pelvic joints as we load them with the activities of daily life. When we consider that the pelvis of the pregnant woman is already more mobile due to hormonal changes, we would expect that the role of these stabilizing muscles becomes even more important, however pregnancy may actually decrease the ability of these muscles to function optimally. One muscle, called the transversus abdominus (TA), runs horizontally around the lower trunk deep to all of the other abdominal muscles, and it works with the deep muscles of the lower back to provide stability at the top of the pelvic joints. These muscles can be inhibited, i.e. they do not function properly, as a result of episodes of back pain and they do not start working the right way again just because the back pain is resolved. These factors suggest that awareness of the TA and intentionally recruiting it would be advantageous for pregnant women to prevent or resolve back and pelvic girdle pain.
Additionally, the physical stretch on the TA during pregnancy (note your growing abdomen) can cause its function to decline, since no muscle in the body functions best when it is stretched to its limit. There are also common structural changes to the TA and other abdominal muscles, a finding called diastases recti abdominus (DRA). Envision a vertical line from the bottom of your breastbone to the top of your pubic bones – there is a thick band of connective tissue running along this line that is the attachment site of the abdominals. During pregnancy this tissue is placed under increased strain, which can cause the tissue to separate leaving a space between the right and left abdominal muscles in that vertical orientation. It is thought that this separation is a normal occurrence and will resolve on its own in the postpartum year, however clinical experience and an increasing amount of peer-reviewed literature suggests that the presence of this separation is linked long-term to urinary incontinence, pelvic pain, and pelvic organ prolapse and should be monitored and treated.
So considering even this limited amount of information, what is someone in Amy’s position to do? Should she just “tough it out” for the remaining three months of her pregnancy and hope for the best? Hardly! Starting the TA exercise and using it for functional activities – such as getting up from a chair and lifting her son – making minor changes in body mechanics, and monitoring for DRA are all likely to start alleviating her pain and will also decrease the likelihood of postpartum musculoskeletal problems. If this does not take away her pain, if DRA develops, or if she needs additional guidance, a physical therapist skilled in women’s health issues can be of enormous benefit. Consult with your obstetrician or midwife to be sure that any precautions are identified.
By taking an active role in one’s physical experience of pregnancy and delivery, women can experience less pain, minimize long-term problems, and recover the physical function and form necessary to navigate the new and exciting demands of motherhood!
Performing the exercise for the TA: Lie on your back (if early enough in pregnancy that you are still able to do so) or your side. Place your fingers just inside the front of your pelvic bones (this will usually be 6-8 inches below and to the side of your navel). Take a normal breath in and exhale gently, making a “shhhhhh” sound. As you exhale, try to engage your deep abdominal muscles as if you are trying to bring your pelvic bones together in the front. You may feel a small squeeze in your pelvic floor muscles. DO NOT hold your breath or bear down (as if having a bowel movement). This is a very subtle exercise and should never feel strenuous or forced.
Checking for DRA: Lie on your back with both knees bent and place your fingers horizontally at the navel. As you lift just the head from the pillow, you should feel your abdominal muscles engage under your fingers. If you have a DRA, you will either feel that your fingers are over soft tissue and you will feel the abdominals engage on either side of your fingers or you may actually see the skin “pooch” up along the midline. If you suspect either of these things, consult with your healthcare providers to confirm and they may refer you to a physical therapist to learn how to address it during and after pregnancy.
Body mechanics: Avoid breath holding whenever lifting or doing a physical task – try to exhale as you do the task. Never sit straight up from a reclined position – always roll to your side first, then press up with your arms and drop your legs.
