Treatment of Low Back Pain During Pregnancy

Low back pain is a common complaint among pregnant women, with an estimated prevalence of 60–70% during pregnancy¹. Pain can be localized in the pelvic ring (between the posterior iliac crest and the gluteal fold) or in the lumbar spine². The underlying causes are thought to be hormonal, circulatory, and mechanical changes, which can significantly reduce maternal quality of life³.

Terminology

• Prenatal refers to the period before birth and is crucial for fetal development. Adequate nutrition is essential for normal growth of the embryo or fetus⁴.

• Postpartum (postnatal) describes the first six weeks after delivery, an important time of adaptation to parenthood and establishing a lifelong bond with the child⁵.

Epidemiology

The prevalence of low back pain during pregnancy varies internationally from 25% to 90%, with the highest rates reported in Brazil and Sweden⁶. Onset typically occurs in the second trimester but may persist for up to three years postpartum in about 20% of women². One-third report severe pain affecting quality of life, sleep, and work capacity.

A study of 400 pregnant women found that 75.3% experienced low back pain, with an average VAS score of 4.91 ± 1.88³. These results are limited due to the subjective assessment of pain and localization.

Etiology

The causes are multifactorial and not fully understood. Theories point to biochemical, vascular, and hormonal changes. Risk factors include:

• Young maternal age

• History of pelvic or spinal injury

• Altered posture (kyphotic back)

• Gestational weight gain

• Pre-existing chronic low back pain

• Previous pregnancy-related back pain⁷

Treatment Approaches

General Principles

Management depends on gestational stage, underlying causes, aggravating factors, and comorbidities. Common measures include:

• Postural correction⁸

• Supported side-sleeping

• Use of a lumbar cushion when sitting

• Limiting prolonged standing and walking

• Antenatal exercise: healthy pregnant women should engage in at least 150 minutes of physical activity per week, or 20–30 minutes of moderate to vigorous activity daily⁹

• Aquatic exercise

• Acupuncture¹⁰

• Yoga

• Relaxation-based low-intensity activities

Yoga

Yoga combines mobility training with breathing techniques and mental relaxation, promoting flexibility, strength, and balance⁶. Globally, yoga is practiced by about 300 million people, and approximately 7% of pregnant women participate in yoga¹¹. Yoga is low-intensity, adaptable, and considered safe during pregnancy⁶.

Evidence shows promising but variable results. Some studies demonstrate that yoga can reduce pain intensity and sick leave, while others highlight limited long-term effects due to methodological weaknesses.

• A systematic review found no significant long-term benefits of yoga for pregnancy-related back pain but noted that small sample sizes limited generalizability¹³.

• An RCT with 60 pregnant women showed that 10 weeks of 1-hour Hatha yoga sessions significantly reduced pain (VAS) compared to postural exercises (p<0.0058)¹⁴.

• Yoga was particularly beneficial in women with comorbid symptoms such as anxiety, sleep disturbances, and stress, and it also improved childbirth experiences¹¹.

• A systematic review of 15 studies (2566 participants) found that 8 weeks of yoga (20 minutes twice daily) improved back pain, mental health, and functional capacity, though further research is needed due to heterogeneous study designs¹².

Pilates as a Treatment for Low Back Pain in Pregnancy

Pilates is defined as a holistic exercise method focusing on strength, core stability, flexibility, muscle control, posture, and breathing techniques¹⁵. The method was developed by Joseph Pilates in the 1980s, inspired by spring-based systems for bedridden patients, where he observed that resistance enhanced muscle strength¹⁶.

Core Principles of Pilates

According to Latey¹⁷, the traditional principles of Pilates include:

• Centering: Activation of core muscles (between the rib cage and pelvic floor) during exercises.

• Concentration: Cognitive awareness and presence during each movement.

• Control: Exercises are guided actively from the core.

• Precision: Technical accuracy is more important than the number of repetitions.

• Flow: Seamless transitions between exercises.

• Breathing: Coordinated breathing to optimize oxygen delivery to tissues.

Evidence Base

Although several studies support Pilates for chronic low back pain in general, the evidence is weaker for pregnancy-related back pain.

• A 2015 systematic review concluded that Pilates improves postural control and lumbar stabilization, showing positive effects on chronic low back pain¹⁸. These findings may be applied to pregnant women experiencing persistent back pain (longer than three months)¹⁸.

• Another study found that Pilates reduces back pain, improves lower limb strength, and positively impacts pregnancy-related complaints and birth preparation¹⁹.

• A randomized controlled trial (2021) demonstrated that eight weeks of Pilates twice weekly significantly reduced pain, disability, sleep disturbances, mobility issues, and improved lumbar stability in pregnant women²⁰. The control group reported no significant improvements.

Training Frequency and Duration

There is no universal agreement on optimal frequency and duration, but examples from the literature include:

• 70–80 minutes once per week for eight weeks²¹.

• Two weekly sessions of 40–45 minutes, including warm-up, strengthening, mobility, and relaxation²².

The American College of Obstetricians and Gynecologists (ACOG) recommends at least 30 minutes of daily activity for healthy pregnancies, recognizing Pilates as a suitable option for achieving this through strengthening¹⁹.

Exercises and Positions to Avoid

Mazzarino et al.³⁴ recommend modifications for pregnant women:

• Avoid direct abdominal training, which may cause rectus diastasis. Replace with seated flexion exercises.

• Avoid supine exercises, which may lead to vena cava compression and dizziness. Side-lying, standing, or seated positions are preferable.

Instructor recommendations on exercise type and frequency do not always align with ACOG guidelines from 2015³⁴.

Example of a Pilates Program

Pelvic Obstetric Gynaecological Physiotherapy has developed a tailored Pilates program for pregnant women, created by licensed physiotherapists²⁴.

Safety Considerations

According to ACOG, women with uncomplicated pregnancies can safely participate in physical activity, including Pilates. Nevertheless, it is advised to consult a physician or midwife during the first prenatal visit²⁵.

Manual Treatment Methods

There is growing evidence that manual therapy is a safe and effective treatment option for low back pain during pregnancy, particularly massage and spinal manipulation²⁶.

Massage

Massage therapy can positively influence stress management, well-being, and pain relief in pregnant women, and is frequently used to alleviate low back pain²⁷.

• A small study evaluated deep tissue massage twice weekly for two months, including adapted pressure techniques, longitudinal strokes, treatment of intermuscular grooves, and muscle stretching.

• The study reported significant pain reduction and improved function among pregnant participants²⁸.

Spinal Manipulation

A 2017 systematic review evaluated osteopathic manipulative therapy and spinal manipulation for pregnancy-related and postpartum low back pain.

• The review found moderate evidence for pain reduction and improved function during pregnancy.

• Only low evidence supported effectiveness after delivery²⁹.

• Additional benefits included general physical and psychological health improvements and reduced reliance on pharmacological treatment³⁰.

Hydrotherapy

Hydrotherapy makes use of the physical properties of water and is applied as a treatment for low back pain. Although evidence during pregnancy is limited, the method is widely practiced.

• A small prospective quantitative study in Australia reported pain reduction in 70% of participants following hydrotherapy.

• Exercises emphasized thoracic mobility, strengthening of the transversus abdominis and pelvic floor, as well as general aerobic conditioning³¹.

• A systematic review indicated positive effects, but most included studies were of low methodological quality³².

• An RCT with 129 participants showed reduced low back pain following thrice-weekly aquatic exercise, though pain relief was only a secondary outcome measure³³.

Benefits of Physical Activity During Pregnancy

Maternal Benefits

• Improved cardiac function³⁴

• Reduced risk of gestational diabetes³⁴

• Enhanced mental health³⁴

• Better sleep quality³⁴

• Reduced musculoskeletal pain, including low back pain³⁴

• Weight management: prevents complications such as hypertension, preeclampsia, and gestational diabetes³⁴

Fetal Benefits

• Lower resting heart rate³⁴

• Improved placental function³⁴

• Reduced birth weight³⁴

• Increased gestational age³⁴

• Improved neurological development³⁴

Contraindications to Exercise in Pregnancy

Exercise is contraindicated in the following conditions³⁵:

• Persistent vaginal bleeding in the second or third trimester

• Cardiovascular disease

• Cervical insufficiency

• History of intrauterine growth restriction

• Previous preterm birth

• Multiple pregnancy

• Placenta previa after week 26

• Preeclampsia or gestational hypertension

• Preterm labor

• Premature rupture of membranes

• Severe anemia

• Chronic bronchitis

• Uncontrolled diabetes

• Uncontrolled epileptic seizures

• Uncontrolled thyroid disease

Note: The American College of Obstetricians and Gynecologists (ACOG) does not always clearly distinguish between absolute and relative contraindications³⁵.

References

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