What is the recommended management for back pain in pregnancy?

Management of Back Pain in Pregnancy

Nonpharmacologic therapies should be the first-line treatment for back pain during pregnancy, including pregnancy-specific exercises, physical therapy, and acupuncture, as these approaches effectively reduce pain intensity while avoiding medication risks. 1, 2

Understanding Back Pain in Pregnancy

Back pain is extremely common during pregnancy, affecting:

• Up to two-thirds of pregnant women experience low back pain (LBP) 1
• Nearly 20% experience pelvic girdle pain (PGP) 1
• Pain typically peaks during months 6 and 7 of pregnancy 1
• Severe symptoms affect 15-20% of pregnant women 1

Risk Factors and Mechanisms

• Joint laxity due to hormonal changes reduces ligament rigidity and weakens joint stability 1
• Increased abdominal mass and shift in center of gravity 1
• Occupational factors, particularly heavy lifting 1

Treatment Algorithm

First-Line: Nonpharmacologic Interventions

1. Exercise-Based Therapies:

   • Strengthening exercises targeting core and back muscles 2
   • Water gymnastics (reduces pain intensity and back pain-related sick leave) 2
   • Sitting pelvic tilt exercises 2
   • Stretching exercises (shown to provide 60% total pain relief compared to 11% with usual care) 2

2. Physical Modalities:

   • Application of ice or heat to affected areas 3
   • Elevation of the head while sleeping 3
   • Supportive pillows (specially designed for pregnancy) 2
   • Pelvic support belts for pelvic girdle pain 2, 4

3. Manual and Alternative Therapies:

   • Acupuncture (particularly effective for evening pain and shown to be more effective than physiotherapy in some studies) 2
   • Physiotherapy with specific pregnancy-adapted techniques 2

Second-Line: Pharmacologic Management (if necessary)

1. Acetaminophen:

   • First-line medication when nonpharmacologic approaches are insufficient 3
   • Recommended dose: 650 mg every 6 hours or 975 mg every 8 hours 3
   • Maximum daily dose: 3000-4000 mg, though lower doses are preferable in pregnancy 3
   • Use at lowest effective dose for shortest duration due to potential associations with neurodevelopmental effects 3

2. NSAIDs:

   • Use only in second trimester if absolutely necessary 3
   • Contraindicated in first trimester (risk of congenital malformations) and third trimester (risk of premature closure of ductus arteriosus) 3
   • Use lowest effective dose for shortest duration possible 3

3. Opioids:

   • Reserve for severe, debilitating pain unresponsive to other treatments 3
   • Significant risks include respiratory depression, dependence, and neonatal withdrawal syndrome 3
   • Not recommended as first-line therapy 3

Special Considerations

Occupational Recommendations

• American Medical Association guidelines for lifting during pregnancy 1:
  • Before 24 weeks: No specific restrictions for repetitive lifting
  • 24-30 weeks: Limit repetitive lifting to under 51 pounds
  • After 30 weeks: Limit repetitive lifting to under 24 pounds and intermittent lifting to under 31 pounds
  • Final week: Further reduction in weight limits

When to Refer for Specialist Care

• Severe, debilitating pain unresponsive to conservative measures 3
• Neurological symptoms suggesting nerve root compression
• Pain accompanied by fever or other concerning systemic symptoms
• History of trauma

Long-Term Implications

• Back pain spontaneously resolves postpartum for most women 1, 5
• Risk factors for persistent postpartum pain include 1:
  • Pre-existing back pain before pregnancy
  • Early onset of symptoms during pregnancy
  • Higher pain severity during pregnancy
  • Presence of both LBP and PGP (greatest risk)

Pitfalls and Caveats

• Back pain is often underreported to prenatal providers, leading to insufficient clinical attention 1
• Severe cases can trigger or exacerbate comorbid conditions including sleep disturbance, impaired daily living, and depression 1
• Persistent pain can interfere with postpartum weight loss and resumption of physical activity 1
• Avoid sodium valproate, topiramate, and candesartan during pregnancy due to teratogenic risks 3

By implementing this comprehensive approach to managing back pain in pregnancy, clinicians can effectively reduce pain intensity and improve quality of life while minimizing risks to both mother and fetus.