Back and Pelvic Pain in an Underserved
United States Pregnant Population:
A Preliminary Descriptive Survey

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:     Frankp@chiro.org

FROM:   J Manipulative Physiol Ther. 2007 (Feb);   30 (2):   130–134 ~ FULL TEXT

Clayton D. Skaggs, DC, Heidi Prather, DO, Gilad Gross, MD,
James W. George, DC, Paul A. Thompson, PhD, D. Michael Nelson, MD, PhD

Department of Obstetrics and Gynecology,
Washington University School of Medicine,
St Louis, MO, USA.
skaggsdc@swbell.net

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OBJECTIVE:   The objective of this study was to identify the prevalence of back pain and treatment satisfaction in a population of low-socioeconomic pregnant women.

METHODS:   This study used a cross-sectional design to determine the prevalence of self-reported musculoskeletal pain in pregnancy for 599 women. Women completed an author-generated musculoskeletal survey in the second trimester of their pregnancy that addressed pain history, duration, location, and intensity, as well as activities of daily living, treatment frequency, and satisfaction with treatment.

RESULTS:   Sixty-seven percent of the total population reported musculoskeletal pain, and nearly half presented with a multi-focal pattern of pain that involved 2 or more sites. Twenty-one percent reported severe pain intensity rated on a numerical rating scale. Eighty percent of women experiencing pain slept less than 4 hours per night and 75% of these women took pain medications. Importantly, 85% of the women surveyed perceived that they had not been offered treatment for their musculoskeletal disorders.

CONCLUSION:   Multi-focal musculoskeletal pain in pregnancy was prevalent in this underserved patient population. The pain in this population negatively affected sleep and treatment appeared inadequate.

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From the FULL TEXT Article:

Introduction

Low back pain (LBP) in the general population is recognized as a major health concern, and left untreated, this malady can lead to chronic, disabling morbidity. [1, 2] Accordingly, chronic pain is a major health care expense in the United States, and LBP is responsible for the majority of chronic musculoskeletal pain. [3] Low back pain and pelvic pain (PP) in pregnancy, however, are frequently viewed as transient conditions that are anticipated to subside after childbirth. In fact, recent studies have identified that women who do have LBP/PP during pregnancy receive little recommendations and/or treatment for their complaints. [4, 5] Although the prevalence of LBP/PP during pregnancy in the United States is unclear, reports from populations in other countries imply that the condition is prevalent and has a negative effect on quality of life. [6–8] Importantly, women who have been pregnant have the highest incidence of chronic LBP after pregnancy, and up to 40% of pregnant women continue to experience pain 18 months postpartum. [9, 10] Therefore, LBP/PP in pregnancy, although largely ignored, may contribute to a substantial level of morbidity and cost in pregnant women and, particularly, women postpartum.

Studies from Scandinavia suggest that morbidity associated with pregnancy is a major expense for society. [7] For example, 1 in 5 pregnant women in Scandinavia is on sick leave for back pain during or after pregnancy. The average sick leave for these women is 7 weeks, a duration added to the normal pregnancy leave. Surprisingly, sick leave for LBP/PP surrounding pregnancy is the single largest social health care expense in Scandinavia. [7] Certainly, complicating factors during pregnancy and child rearing could have extensive and vital effects on women at important time points in their life.

We aim to identify and classify back pain surrounding pregnancy in an underserved patient population and hypothesize that back pain during pregnancy has negative effects on quality of life. We performed an analysis of collected data on a population of pregnant women attending a multidisciplinary clinic at Barnes-Jewish Hospital in the Washington University Medical Center in St Louis, Mo. The objectives of this study were to

(1)   identify the prevalence of back pain,

(2)   classify the locations of the pain, and

(3)   evaluate patient perception of care and satisfaction with treatment.

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Discussion

The data show a high proportion of patients in an underserved population of pregnant women experience back pain. Although LBP is the most common source of pain, pelvic pain (PP) and mid-back pain (MBP) frequently contributed as symptoms. Multi-focal pain related to reports of severe pain. The pain experienced predisposed those patients to sleep disturbances, 1 measure of quality of life. Pain reports were correlated with frequent use of analgesic medications. The data also indicate that pain in a previous pregnancy predicts a high risk for back complaints in future pregnancies. Despite the high prevalence of musculoskeletal symptoms, few patients had received treatment during standard obstetrical care and even less were satisfied with the treatment received.

This study examined pregnant women using an author-generated survey to gather patient perception on their back pain and treatment. Because this survey has not been studied in previous populations of pregnant women, it cannot be assumed as reliable. In addition, the women did not clearly indicate whether they had expressed their pain to their obstetric practitioners before completing their back pain survey. This could be seen as a limitation; however, they were questioned on average after their third obstetric visit. The survey did not include other areas of musculoskeletal pain such as neck pain or wrist pain either. These other areas of musculoskeletal pain could have individual significance in this population and/or could have overlapping influence on back pain reports. Lastly, the type of medication was not identified as over-the-counter or prescription; therefore, the use of medication is not clear. Nevertheless, such a high percentage of medication use in a pregnant population is somewhat alarming.

Previous studies suggest that LBP/PP may be frequently encountered in pregnancy, although these studies have largely involved populations outside the United States. [6, 8, 13] These studies involved populations of women from mixed socioeconomic backgrounds and older age groups than in our study, yet the prevalence rates for LBP are similar. Ostgaard et al [6] and Kristiannson et al [13] determined that previous pregnancy (regardless of pain history) predisposed women to experience back pain in the current pregnancy. Our results indicate that previous pregnancy does not increase risk of experiencing pain during the current pregnancy overall. However, patients who had pain in a previous pregnancy had a high rate of pain in the current pregnancy. Fully, 85% of women who experienced pain in a previous pregnancy reported pain in our survey. This is in agreement with the distinction made on risk factors related to pain in pregnancy by Orvieto et al [14]and Wu et al. [15]

Previous studies have identified that the most frequent locations for pain in a population of women with PP in pregnancy were at bilateral sacro-iliac joints, pubic symphysis, coccyx, and groin, whereas the highest intensity of pain was in the lower back and sacro-iliac joints. [6, 16] Consistent with our findings, these populations with multi-focal pain have more severe pain and, thus, more disability. [13, 17] Taken together, our results are consistent with a model where the low back is a primary site of pain generation, and where the pelvis and mid back increase the pain severity.

Poor sleep has been shown to be associated with back pain and to negatively impact quality of life. [11, 12, 18] As pregnant women experience changes in shape and size of the body, it is a common notion that the pregnancy experience involves pain and difficulty with sleeping. However, structural changes with weight gain and spine posture during pregnancy do not parallel pain occurrence or intensity. [14, 19, 20] Accordingly, few of the women in the study reported sleep problems in the absence of back pain. With women who experienced back pain, sleep disturbance was commonplace. Therefore, in our population of gravid women, we saw a direct association between sleep deficiency and back pain. We speculate that such disruption in life quality, left untreated, may become a chronic pain issue.

Altered pain medication use is recognized as a clinical outcome measure for nonpregnant patients with chronic LBP. [21] There are implicit concerns on the use and overuse of pain medications, and particularly in pregnant populations. [22–24] Thus, although the type of medication was not identified in this study, the fact that three fourths of the women who reported pain also described use of pain medication suggests increased risk of morbidity for these women. These results raise the question of whether or not the high incidence of pain medication use reflects a lack of education about potential risks of medications or more an inability for the pregnant woman to cope with the pain.

What can be done to effectively treat back pain in pregnancy and, thereby, to enhance the coping skills in pregnant women who experience pain? We suggest that substantial improvements in the well being of pregnant patients might result from programs that proactively address back problems experienced by these women. Accordingly, obstetrical care might include early back pain screening to identify risk factors, such as previous pain in pregnancy, multi-focal pain, or severe pain. Such self-reporting of risk factors for back pain would be a proactive step to allow early education and/or treatment to reduce the risk for pain in the current pregnancy.

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Conclusion

Our findings highlight the prevalence and complexity of back pain in pregnancy, and, notably, in a population in the United States. Importantly, we have identified that pregnancy-related pain is related to sleep disturbance and this may influence the patient's quality of life. In addition, at least within this population, little care was offered, and the care provided was not satisfactory. Taken together with the current understanding of chronic musculoskeletal pain and that no other population has more chronic LBP than women who have been pregnant, back pain in pregnancy can no longer be considered normal. We feel this study raises serious consideration for determining strategies and treatments to alter back pain in pregnancy.

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Practical Applications

• There appears to be a high prevalence of musculoskeletal pain in pregnancy.

• Multi-focal pain in pregnancy leads to greater pain severity.

• Previous pain in pregnancy is a high-risk factor for future pain in pregnancy.

• The care that is offered for musculoskeletal pain in pregnancy needs to be expanded.

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