What are the recommended treatments for back pain in pregnancy?

Management of Back Pain in Pregnancy

For pregnant women with back pain, start with exercise therapy (particularly lumbar stabilization or stretching exercises) combined with superficial heat application, as these are the safest and most effective first-line treatments with proven benefits for pain reduction and functional improvement. 1, 2

First-Line Non-Pharmacological Treatments

Exercise Therapy (Primary Recommendation)

• Lumbar stabilization exercises and stretching protocols are equally effective for reducing pregnancy-related low back pain, with significant pain reduction demonstrated after 6 weeks of twice-weekly sessions 2
• Both modalities improve postural stability and increase trunk muscle activation, particularly the external abdominal oblique muscle 2
• Exercise therapy improves disability scores and quality of life in pregnant women, though pain reduction may take several weeks 3
• Transcutaneous electrical nerve stimulation (TENS) combined with progressive muscle relaxation exercises accompanied by music represents the most effective intervention for pregnancy-related low back pain 3

Physical Modalities

• Superficial heat application provides moderate benefits for acute low back pain and is safe during pregnancy 1
• Massage therapy demonstrates moderate effectiveness and can be used as an adjunctive treatment 1

Manual Therapy

• Spinal manipulation (manipulative therapy) is recommended as a treatment option with moderate evidence for effectiveness in low back pain 1
• Osteopathic manual treatment affects lumbar pain intensity, though differences compared to standard care may not reach statistical significance 3

Pharmacological Options (Use Cautiously)

Acetaminophen

• Acetaminophen (up to 3000 mg/day) may be considered for acute pain, though effectiveness is limited 1, 4
• The FDA label advises pregnant women to "ask a health professional before use" 4
• This represents the safest pharmacological option when non-pharmacological measures are insufficient 1

Medications to Avoid

• Systemic corticosteroids should be avoided as they have not demonstrated superiority over placebo 1
• Opioids should be avoided due to limited evidence of long-term effectiveness and significant risks 1
• NSAIDs require careful consideration, particularly after 20 weeks gestation 1

Essential Patient Education and Activity Modification

• Maintain physical activity and avoid prolonged bed rest, as bed rest is contraindicated and may worsen outcomes 1
• Provide education on proper posture and pain self-management techniques 1
• Reassure patients that pregnancy-related back pain typically improves with activity rather than rest 1

Interventions Lacking Evidence

Ineffective Modalities

• Lumbar supports have not demonstrated clear benefits for chronic low back pain 1
• Continuous or intermittent traction has not shown effectiveness 1
• Yoga did not improve pregnancy-related low back pain in available studies 3
• Kinesio tape and ear acupuncture affected pain intensity but differences were not statistically significant compared to standard care 3

Treatment Algorithm

1. Start immediately with exercise therapy (lumbar stabilization or stretching, twice weekly for 50 minutes) combined with superficial heat application 2, 1
2. Add TENS with progressive muscle relaxation if initial measures provide inadequate relief 3
3. Consider spinal manipulation or massage therapy as adjunctive treatments 1
4. Reserve acetaminophen (up to 3000 mg/day) for breakthrough pain only after consulting with obstetric provider 1, 4
5. Provide ongoing education about posture, activity modification, and self-management strategies 1

Critical Pitfalls to Avoid

• Never prescribe bed rest - it is contraindicated and worsens outcomes 1
• Avoid routine use of NSAIDs, especially after 20 weeks gestation 1
• Do not use systemic corticosteroids - they lack efficacy 1
• Avoid passive physical therapies (ultrasound, TENS alone without exercise, traction) that lack evidence of effectiveness 1
• Do not delay exercise therapy - it should begin immediately as the cornerstone of treatment 2, 3

Expected Outcomes

• Pain reduction typically occurs within 6 weeks of consistent exercise therapy 2
• Improvements in postural stability and trunk muscle activation occur concurrently with pain reduction 2
• Effects are sustained when exercise programs are maintained throughout pregnancy 3