Post-Pregnancy Problems Part III - Low Back and Pelvic Pain, Or, A Pain In The A***

Dr. Edmund Bruce-Gardner

We will be covering past material a bit here, so I will keep it (relatively!) brief, and link to the appropriate posts so you can refresh your memory if needed.

Here we will consider some of the reasons for low back, gluteal (buttock) and pelvic pain during pregnancy, and why it may continue after giving birth.

 (According to an admittedly ancient (1994) study, more than 67% of women experienced back pain just after delivery, while 37% said they had back pain at a follow up examination at least twelve months later (1).
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More recent data indicates that up to 75% of women who suffer from low back pain during pregnancy may continue to have pain after birth, or postpartum​ (2, 3, 4, 5, 6, 7).

the differentiation between low back pain (LBP) and pelvic girdle pain (PGP).

It is worth noting, however, as we consider all these potential causes of low back and pelvic girdle pain (LBP/PGP, for brevity's sake as we continue), that the following were not associated with postpartum LBP/PGP and: mode of delivery, epidural anaesthesia (or number of attempts at placement thereof), duration of second stage of labour, or birth weight (8).

Chimpanzee vs. Australopithecine (an early human) vs H. sapiens (us) comparative pelvic and lower limb anatomy

Evolutionarily-speaking, the shift from moving around on all fours to two legs required a number of compromises, trade-offs, and (to be honest) bodgy quick-fixes that would embarrass the shonkiest unlicensed contractor.
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Shortly put, the pelvis got narrower to accommodate to the changed way of moving, which in turn reduced the amount of space for the baby's head as it, ahem, exits the body.  This occurred at the same time that human brains were getting larger, which poses an obvious problem. 

One of the workarounds the body uses is to release a hormone called relaxin, which (if you couldn't guess), relaxes the ligaments that bind and support the joints in the body, particularly aimed at the joints of the pelvis so it can stretch and shift to allow the huge head of the infant through. 
Note, however that relaxin, as a hormone, affects everywhere in the body (and indeed plays a role in the management of blood pressure and flow, and tissue repair as well as affecting the joints and ligaments). 

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Late postural changes in pregnancy. From Stone (2007)

​Furthermore, high levels of relaxin may  be related to joint laxity and instability, but the relationship is uncertain; with some studies showing a relationship between higher relaxin and progesterone levels in pregnant women with PGP syndrome (9, 10, 11), and others, well, not (12, 13, 14).
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In either case, the joints in the low back and pelvis get a serious work-out during pregnancy and delivery, and combined the biomechanical changes in posture and walking through this period (some of which will continue into the postpartum period), it is perhaps not surprising that around one in five women will experience LBP/PGP either during or after pregnancy (or both), and, again, around twenty percent of these will report continuing pain months or even years later (1, 15).

The pelvic floor

Another complication of the shift to upright posture was the fact that the pelvic floor suddenly had to start bearing load, and never more so is this true than during pregnancy.  The weight and trauma of pregnancy and parturition (the birth process) can directly injure the pelvic floor muscles, or the nerves that control them (as well as other important muscles, like the diaphragm, or abdominal musculature). 

​This reduces the body's ability to support the pelvis and low back, and may contribute significantly to postpartum low back and pelvic pain - in one study, over half of women with pregnancy-related low back and pelvic pain had pelvic floor dysfunction (16).
To add another dimension, there has been some suggestion that high relaxin levels are related to pelvic floor dysfunction (17)!

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 So what are the risk factors for LBP and PGP after giving birth?

According to the study in Anaesthesiology, a history of low back pain (no revelations there!), greater weight, and slightly more surprisingly, younger age are among the associations for postpartum low back pain (8).
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Unluckily for the vertically challenged among us, shorter stature was also associated with new-onset postpartum back pain (ibid).

These risk factors cannot be altered much - you are your current age, height, and weight, no matter how much we might wish otherwise; and having been unlucky enough to have a history of back pain is not something amenable to change!

So how can we help with this?

Once your osteopath or healthcare provider has eliminated other common causes of low back pain such as the intervertebral discs or facet joints, as well as more uncommon but concerning conditions with complicated names such as osteomyelitis or cauda equina syndrome, they will undertake a full assessment of the biomechanics and postural adaptations/mechanisms of the affected and surrounding areas.

Images from:
Stone, C. (2007) Visceral & Obstetric Osteopathy, Churchill LIvingstone
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References

(1) Ostgaard HC, Andersson GB. (1992)
"Postpartum low-back pain"
Spine. 1992;17(1):53-55

(2) Stapleton DB, MacLennan AH, Kristiansson P (2002) The prevalence of recalled low back pain during and after pregnancy: a South Australian population survey. Aust N Z J Obstet Gynaecol 42: 482-485.

(3) Turgut F, Turgut M, CetinÅŸahin M (1998) A prospective study of persistent back pain after pregnancy. Eur J Obstet Gynecol Reprod Biol 80: 45-48.

(4) Líndal E, Hauksson A, Arnardóttir S, Hallgrímsson JP (2000) Low back pain, smoking and employment during pregnancy and after delivery - a 3-month follow-up study. J Obstet Gynaecol 20: 263-266.4. Ansari NN, Hasson S, Naghdi S, Keyhani S, Jalaie S (2010) Low back pain during pregnancy in Iranian women: Prevalence 

(5) Bastiaenen CH, de Bie RA, Vlaeyen JW, Goossens ME, Leffers P, et al. (2008) Long-term effectiveness and costs of a brief self-management intervention in women with pregnancy-related low back pain after delivery. BMC Pregnancy Childbirth 8: 19.

(6) Breen  TW,  Ransil  BJ,  Groves  PA,  Oriol  NE  (1994)  Factors  associated  with  back pain after childbirth. Anesthesiology 81: 29-34.

(7) Gutke  A,  Lundberg  M,  Östgaard  HC,  Öberg  B  (2011)  Impact  of  postpartum  lumbopelvic pain on disability, pain intensity, health-related quality of life, activity level, kinesiophobia, and depressive symptoms. Eur Spine J 20: 440-448.

(8) Breen TW1, Ransil BJ, Groves PA, Oriol NE (1994)
"Factors associated with back pain after childbirth"
Anesthesiology. 1994 Jul;81(1):29-34

​(9) Lubahn J, Ivance D, Konieczko E, Cooney T
"Immunohistochemical detection of relaxin binding to the volar oblique ligament"
J Hand Surg Am. 2006 Jan; 31(1):80-4.

(10) ​Dragoo JL, Castillo TN, Braun HJ, Ridley BA, Kennedy AC, Golish SR (2011)
"Prospective correlation between serum relaxin concentration and anterior cruciate ligament tears among elite collegiate female athletes"
Am J Sports Med. 2011 Oct; 39(10):2175-80.

(11) Dragoo JL, Castillo TN, Korotkova TA, Kennedy AC, Kim HJ, Stewart DR (2011)
"​Trends in serum relaxin concentration among elite collegiate female athletes"
Int J Womens Health. 2011 Jan 19; 3():19-24.

(12) ​Ohtera K, Zobitz ME, Luo ZP, Morrey BF, O'Driscoll SW, Ramin KD, An KN (1985)
"Effect of pregnancy on joint contracture in the rat knee"
J Appl Physiol (1985). 2002 Apr; 92(4):1494-8.

​(13) Arnold C, Van Bell C, Rogers V, Cooney T (2002)
"The relationship between serum relaxin and knee joint laxity in female athletes"
Orthopedics. 2002 Jun; 25(6):669-73.

(14) Wolf JM, Williams AE, Delaronde S, Leger R, Clifton KB, King KB (2013)
"Relationship of serum relaxin to generalized and trapezial-metacarpal joint laxity"
J Hand Surg Am. 2013 Apr; 38(4):721-8.

(15) Norén L, Ostgaard S, Johansson G, Ostgaard HC. (2002)
"Lumbar back and posterior pelvic pain during pregnancy: a 3-year follow-up"
Eur Spine J. 2002;11(3):267-271.​

(16) Pool-Goudzwaard AL, Slieker ten Hove MC, Vierhout ME, Mulder PH, Pool JJ, Snijders CJ, Stoeckart R.  (2005)
"Relations between pregnancy-related low back pain, pelvic floor activity and pelvic floor dysfunction"
Int Urogynecol J Pelvic Floor Dysfunct. 2005;16(6):468-474

(17) ​Harvey MA, Johnston SL, Davies GA (2008)
"Mid-trimester serum relaxin concentrations and post-partum pelvic floor dysfunction"
Acta Obstet Gynecol Scand. 2008; 87(12):1315-21.

Generally, such a program will focus on stretching and mobilising painful bits; and strengthening the muscular support of the affected (and related) areas.

We know that this, along with appropriate and effective manual therapy, is the key to you managing your postpartum low back/pelvic girdle pain.