• conclusion.

Introduction

Low back pain and related pelvic pain, particularly in the region of the symphysis pubis, are significant issues during and after pregnancy, occurring in at least 50 per cent of women (Malmqvist et al. 2012). A Cochrane review by Liddle and Pennick (2015) suggested that as many as 60 per cent of expectant mothers experience generalised lumbosacral back pain, with 20 per cent suffering pelvic pain, either concomitantly or separately, while Mogren and Pohjanen (2005) found an incidence of 72 per cent. Sibbritt, Ladanyi and Adams (2016) revealed that, in a population of over 1800 pregnant Australian women, almost 40 per cent experienced backache, 16 per cent suffered pelvic pain and 12 per cent reported neck pain. Conversely, a Nigerian study found a higher incidence of pelvic, rather than lower back, pain (34.3% and 57.4% respectively), with an incidental finding of urinary incontinence in many of the women (Usman et al. 2017). Lumbar pain is frequently accompanied by sacroiliac joint pain and/or sciatica, as well as groin and buttock discomfort. Back and pelvic pain can be debilitating, often impacting on daily life, work and sleep, with not only physical but also psycho-social effects.

Physiologically, relaxation of the muscles, ligaments and tendons occurs during pregnancy, mainly due to the action of the hormone relaxin, as well as progesterone. Biomechanical factors also play a part, with pre-existing or gestational musculoskeletal misalignment increasingly being acknowledged (Fishburn 2015; Tiran 2010b). Micronutrient deficiencies may contribute to overall compromise to the musculoskeletal system, including loss of bone mass density and an epigenetic effect on the fetal skeleton, suggesting that there is justification for the use of vitamin D supplementation before and during pregnancy (Moon, Harvey and Cooper 2015). Weight increases and postural adaptations to accommodate the changing centre of gravity cause an increased lumbar lordosis (concave curvature) and a correspondingly accentuated thoracic kyphosis (convex curvature).

Back pain tends to be exacerbated by tiredness, poor posture during day-to-day activities, positions adopted whilst sleeping and by inappropriate or inadequate exercise, whereas women who undertake regular pre-pregnancy exercise routines tend to experience fewer problems (Mogren 2005). It has been shown that abdominal muscles become thinner during pregnancy under hormonal influences (Weis et al. 2015), predisposing women who are obese or who have a large fetus, multiple pregnancy or poor pre-conceptional abdominal muscle tone to increased discomfort. However, this theory remains somewhat controversial as a later study found no real variation in abdominal muscle thickness in women who had back pain compared to those who did not (Weis et al. 2017).

Conventional management of back pain

As with many other physiological discomforts, expectant mothers frequently attempt to self-manage their back pain, perhaps because they have no real faith in conventional methods to resolve the problem (Close et al. 2016a). One study found that only 12 per cent of women experiencing symptoms actually sought professional help (Chang, Jensen and Lai 2015). Similarly, Sibbritt et al. (2016) found that around 30 per cent of women do not inform their midwife or consult their doctor or another professional such as a physiotherapist. Of the remaining 70 per cent, only 22 per cent request medical help, whereas 32 per cent opt to consult massage therapists or other complementary practitioners (27%). When there is accompanying sciatica, women may, however, be more likely to seek medical help at an earlier stage (Hall, Lauche et al. 2016). Unfortunately, Hall, Cramer et al.’s meta-analysis (2016) found limited robust evidence for the effectiveness of complementary therapies for back pain, although they acknowledge that the client-therapist relationship and the accessibility of a practitioner over a sustained period of time may play a part in some subjective relief of symptoms.