From the Guidelines
The most appropriate next step in management for this patient is conservative treatment with reassurance, advice to stay active, and a short course of a simple pain medication, as her symptoms are consistent with pregnancy-related low back pain. This 36-year-old pregnant woman at 32 weeks gestation is experiencing symptoms consistent with pregnancy-related low back pain, likely due to mechanical strain from her growing uterus and the effects of relaxin hormone on her pelvic ligaments. Her symptoms - pain that worsens with activity and improves at rest, bilateral radiation to the buttocks, and absence of neurological deficits - are classic for this condition. According to a systematic review and synthesis of qualitative studies using the theoretical domains framework, the recommended care for managing back pain includes performing a diagnostic triage to rule out rare cases of specific spinal pathology or radicular syndrome, and for non-specific cases, investigations are not recommended and management should include reassurance about good prognosis, advice to stay active and avoid bed rest, a short course of a simple pain medication, and self-care strategies 1. The patient should be advised to avoid prolonged standing, use proper body mechanics when lifting, and consider a maternity support belt to reduce pelvic strain. Physical therapy focusing on gentle stretching and strengthening exercises may also be beneficial. Her ankle edema is likely related to normal physiological changes of pregnancy, and can be managed with leg elevation and avoiding prolonged standing. The urinary frequency is due to pressure from the enlarging uterus on the bladder. Some key points to consider in the management of this patient include:
- Avoiding unnecessary referrals for imaging and surgery
- Avoiding over-prescription of opioid medicines
- Assessing yellow flags to tailor education, reassurance, and advice
- Considering referral to adjunct conservative management if the patient has not improved after 6 weeks 1. The patient's history of post–lumbar puncture headache after epidural anesthesia in her previous pregnancy is noted, but it is not directly relevant to her current symptoms of low back pain.
From the Research
Patient Assessment and Management
The patient presents with dull, low back pain radiating bilaterally to the buttocks and posterior thighs, which increases with activity and at the end of the day. She also experiences ankle edema, numbness in her feet, urinary frequency, and nocturia. Given her symptoms and physical examination findings, the most appropriate next step in management would involve a conservative approach to address her low back pain.
Conservative Management Options
- The patient's symptoms can be managed with conservative approaches, including patient education, therapeutic exercises, and bracing, as suggested by studies on conservative management of low back pain 2, 3, 4.
- Individual strengthening exercises for anterior pelvic tilt muscles may also be beneficial in reducing back pain and improving lumbar range of motion, as seen in a study on the effect of individual strengthening exercises for anterior pelvic tilt muscles on back pain 5.
- A personalized medicine approach, considering evidence-based interventions such as duloxetine, acceptance and commitment therapy, classification-based exercise and manual therapy intervention, and self-management approaches, may also be effective in managing chronic low back pain 6.
Next Steps
- The patient's care should focus on encouraging a rapid return to physical fitness and other activities, including employment, while acknowledging that returning to a normal life may require working through pain.
- Medication may be used to facilitate this process, and the patient should be referred to a specialist service for a physical and psychosocial assessment if her pain persists beyond six weeks.