Low back pain is amongst the most common reasons for pregnant people to visit a chiropractor. In fact, greater than 50% of pregnant people experience some form of low back or pelvic girdle pain and it appears that as pregnancy progresses these symptoms can worsen. This pain impacts quality of life and can even influence birth outcomes.
As a chiropractor, I’ve cared for hundreds of pregnant people and have found that many birth providers have a poor understanding of how low back pain manifests in pregnancy. To the contrary, in my experience it is not uncommon for obstetricians to diagnose their patients with lumbalgia (low back pain) without identifying the cause and subsequently prescribing pain medication and anti-inflammatories. I’ve even cared for pregnant people who were prescribed narcotics. This is not meant to denigrate obstetricians, but more to indict the state of research and public health policy related to low back pain in pregnancy.
While hormonal, circulatory and psychosocial factors are known to play a role in pregnancy-related back pain one of the most common etiologies is mechanical. Misalignments in the spine called subluxations can be caused by stress to the spine and can contribute to dysfunction. When a subluxation has been in existence for weeks or longer, we believe the body actually starts to adapt around it laying down scar tissue and calluses to prevent further degeneration. The consequence of this process is that the body also releases inflammatory cytokines to help repair the damage and inflammation causes pain. When uncorrected, this process can result in chronic pain, pelvic floor dysfunction, muscle spasms, postural changes and balance control issues.
Pregnancy can accelerate this process. Certain hormones like progesterone and relaxin that increase in certain stages of pregnancy cause lumbar, sacral and uterosacral ligaments to stretch, increasing the likelihood that subluxations will present due to otherwise innocuous movements like bending, lifting, stretching and rolling. This process is further exaggerated by changes in center-of-mass beyond week 28. As baby increases in size, pregnant people carry their weight further in front of their bodies, putting stress on lumbar discs and joints. Ligamentous laxity exacerbates this condition and when subluxations exist, stress to the joints and discs worsen. For every inch forward your center-of-mass moves, an additional 20-30 lbs worth of pressure is added and distributed to the rest of the spine. This means that in a 150 lb person, 1 inch of forward translation in his or her center-of-mass yields 170-180 lbs of strain on the spine. In this very common circumstance, something must give. Subluxations of the lumbar spine and pelvis coupled with soft-tissue imbalances not only cause back and pelvic pain, but can often contribute to fetal malposition as well.
The primary tool in a chiropractor’s toolbox is a chiropractic adjustment. The most effective way to address subluxations is to gently and precisely correct them. In pregnancy, this process is delicate and is often less forceful than a traditional chiropractic adjustment. Chiropractors who are trained in pregnancy employ the use of the Webster technique, a specific, six-pronged approach to leveling the pelvis and lumbar spine. In this technique there is no twisting or “cracking.” To the contrary, much of the work involves leveraging ligaments and soft tissues to gently pull the sacrum, pelvis and lumbar vertebrae into position.
Obviously an ounce of prevention is better than a pound of cure and while subluxations are often unavoidable, there are simple ways to minimize their frequency and severity.
Side Lying Release
of my favorite techniques to assist with low back and pelvic discomfort is Gail
Tully’s side-lying release (SLR). I’ve been using this technique for years to
take stress off of the glutes, piriformis muscles, hamstrings and hip flexors.
To perform this movement, you’ll need another person to stabilize your iliac crest
(the bony protuberance above your hip joint). The trick is to ensure that the pelvis
does not rotate and stays in line with the shoulders and hips, which is why the
stabilizing person must put gentle inferior to superior pressure on the iliac
crest while the leg hangs gently off the table. Hold this position for 30-45
secs then switch sides. Repeat as necessary.
Another simple and favored technique to help relieve pressure on the sacrum and lumbar spine especially in active labor is called sacral pressure. This can be performed both with the patient standing or on his or her hands and knees and requires a helper to stabilize the sacrum. To perform this movement, the helper simply applies gentle superior to inferior pressure on the sacral base or upper part of the sacrum where it inserts into the lumbar spine. Hold for 30-45 seconds or as long as necessary between contractions.
Pelvic Circles and Figure Eights
Yet another simple exercise to perform to alleviate stress on the sacral and lumbar spinal joints are performed on a yoga ball. I prescribe these techniques to every pregnant person that comes through my office, regardless of where they are in their pregnancies. Notice in the picture that the ball is inflated so that the hips, knees and ankles are all at right angles. This is proper ergonomic anatomical position and ensures that the center of mass is as close to L5 (proper position) as possible. You can even perform this exercise by sitting in a solitary position and gently rolling your sacrum forward as though your pelvis is a bowl and you’re gently trying to spill just a little water out of the front. This helps to activate spinal stabilizing musculature which his often weak in pregnancy, especially after week 28.
Daniel Bronstein is a pediatric and family chiropractor certified by the Academy Council of Chiropractic Pediatrics and the director of the Beacon Clinic of Chiropractic in Grover Beach. For the best research and resources available regarding chiropractic and pregnancy, visit the International Chiropractic Pediatrics Association.