We spoke to Marco Gallotti, physiotherapist and lecturer at UniCamillus University.
Pregnancy is a nine-month journey, and what a journey it is! It causes major changes in the mother-to-be’s body, and it is a challenge most of the time. The spine and musculoskeletal system are particularly affected by the notorious problem of back pain.
The dreaded lower back pain, also known as lumbago, is one of the most common and troublesome complaints during pregnancy; it is not just a consequence of weight gain or postural changes: it is the result of a complex combination of physical, hormonal and mechanical adaptations that the body undergoes to accommodate the baby.
Often underestimated, this condition can have a profound effect on a woman’s daily quality of life, making even the simplest activities a challenge. However, despite the difficulties, back pain is not a punishment that cannot be escaped: thanks to prevention, exercise and the support of specialists such as physiotherapists, it is possible to alleviate the pain and face pregnancy in the best possible way.
But what are the signs to look out for? And how can physiotherapy help improve the well-being of pregnant women? We spoke to Marco Gallotti, a physiotherapist and lecturer in Nursing Sciences and Neuropsychiatric and Rehabilitation Techniques at UniCamillus University.
What are the muscular and joint imbalances that occur during pregnancy?
“It is not correct to speak of muscular or joint imbalances. When a woman is pregnant, her body has to carry more weight at the level of the spine. This increase in load, especially if it is sudden and uncontrolled, overloads the structures of the spine itself, especially at the level of the pelvis and lumbar spine, the intervertebral discs and the ligaments, structures that help the bones to support our weight.
In addition, the presence of hormonal changes—which are typical of pregnancy—can lead to tendinosis: indeed, one of the areas most affected during pregnancy, in addition to the back, is the wrist, where these compressions, which can lead to carpal tunnel syndrome, are more likely to occur”.
What causes back pain in pregnancy?
“There are three main causes of back pain during pregnancy:
- Uncontrolled weight gain: if the patient has a non-progressive weight gain, the spine is the first structure to suffer as it is the structure that has to adapt the most in a very short time.
- Postural changes: as pregnancy progresses and the baby grows, the woman’s centre of gravity shifts forward. This leads to a change in the normal curves of the back and consequently to more work being done by the muscles and joints to support the spine, which can cause pain, especially in people who have certain risk factors prior to pregnancy.
- Hormonal variations that may favour ligamentous hyperlaxity and, consequently, the onset of back pain”.
Is it a temporary and reversible condition, or is it likely to become permanent?
“Back pain in pregnancy is definitely not a permanent condition; it is reversible. However, 20% of women may still have persistent symptoms four weeks after giving birth”.
Are there any risk factors for developing back pain?
“The main risk factors for developing back pain are:
– A history of previous low back pain, even if not related to pregnancy
– A history of trauma to the rachis
– Early disability during pregnancy as a result of back pain itself
– Multiple pregnancy
– Pre-pregnancy BMI > 25
– Physically demanding work”.
What are the typical symptoms of back pain in pregnancy?
“Low back pain usually starts between the 13th and 30th week of pregnancy. It is characterised by pain in the lumbar spine, but can also be felt further down into the pelvis and gluteal region. The pain may radiate to the postero-lateral part of the thigh (also bilaterally) or anteriorly at the level of the inguinal region and pubic symphysis.
The patient usually reports pain with prolonged walking, standing or sitting. They also report difficulty and/or pain with activities of daily living, such as turning in bed, getting dressed while balancing on one leg (e.g. putting on trousers), sitting cross-legged or very low (e.g. during genital hygiene), and getting up from a sitting position”.
Can physiotherapy help?
“The most useful tool we have to reduce the incidence of musculoskeletal disorders is physical activity: the main advice is to keep moving, doing a sport you enjoy: a pregnant woman is NOT a disabled woman, but a woman going through a period of physical adaptation who needs to stay active to avoid potentially painful consequences.
The World Health Organisation (WHO) recommends a programme of 150 minutes per week (e.g. 30 minutes 5 times a week) of moderate-intensity physical activity for pregnant women. Of course, if the pregnant woman has always been sedentary, it is not necessary to start at this level, but she should start exercising gradually to avoid overtraining. It is important to be active, even if it is just 5 minutes a day, and to gradually increase this to the recommended levels.
Obviously, not all women can do physical activity. The following conditions are strictly contraindicated for exercise during pregnancy:
- Severe cardiorespiratory disease
- Placental abruption
- Vasa previa
- Uncontrolled type 1 diabetes (risk of severe hypoglycaemic episodes and fainting)
- Intrauterine growth restriction
- Active preterm labour
Severe pre-eclampsia and cervical insufficiency are associated with a high potential for maternal/fetal harm and are therefore absolute contraindications to exercise during pregnancy. However, pregnant women with these conditions should continue with their daily activities if possible, as recent studies have shown the negative effects of complete bed rest. These categories of pregnant women should always seek medical advice before starting an exercise programme”.
The first trimester is the most delicate: what do you recommend during this time? Could lower back pain have already appeared?
“The first trimester is not a contraindication to physical activity, as there are no time-related contraindications to exercise during pregnancy. Therefore, pregnant women can exercise during the first trimester. As mentioned above, the onset of back pain usually occurs from the 13th week of pregnancy, but this is not the rule: some women may experience back pain as early as the first trimester. If this happens, it is advisable to see a physiotherapist specialising in musculoskeletal disorders as soon as possible, who can help the woman manage her symptoms.
However, prevention is essential: a beneficial exercise programme could include cardiovascular exercise (such as swimming or walking), which counteracts weight gain in pregnancy and the risk of gestational diabetes. This can be combined with a programme of comprehensive mobility exercises and specific exercises for the axial and pelvic floor muscles. This group of muscles is under great strain during pregnancy and childbirth, so keeping them toned helps to prevent various causes of musculoskeletal pain.
In addition to the above-mentioned contraindications, it is also advisable to avoid contact sports (such as martial arts or football) or any form of sport with a high risk of injury and/or falling (such as horse riding, tennis or skating), and to prefer activities you like!”.
Are there any exercises that can help pregnant women in the second and third trimesters?
“It is certainly advisable to continue the aerobic activity started in the first trimester. In addition, it is possible to combine strengthening and stretching exercises, focusing mainly on the hips (especially the gluteus muscles, the abductors, and adductors), the abdominal muscles and the upper limbs: working on the stabilising muscles is essential to reduce pain and disability, even a year after childbirth. In addition, these muscles will be heavily strained at the time of delivery, especially in the case of natural childbirth, so a strong muscle tone will help the pregnant woman to perform all the actions necessary to give birth.
However, it will be necessary to avoid exercises with excessive loads, especially if untrained, and activities that are too painful because they do not allow the tissues to adapt effectively to the load”.
Are there any simple tips or tools for correcting posture with a baby bump?
“Actually, posture should not be corrected: it has been studied and proved that posture is not the cause of pain in pregnant women. Therefore, the use of ‘tools’ such as back braces is absolutely not advisable. In addition to physical activity, we suggest pregnant women should avoid:
– prolonged postures: both at work and at home, it is important to avoid staying in the same position for too long. It would be a good idea to take a 5- to 10-minute break every hour to get up, walk around and move around;
– an overly protective and sedentary lifestyle;
– excessive bed rest”.
Does the physiotherapist offer specific exercises? Manual therapies?
“Yes, the physiotherapist has some tools in their toolbox that can be useful in the management of low back pain or pelvic pain during pregnancy. However, it is important to stress that the physiotherapist is not a ‘fixer’, as the patient must play a leading role in her change. As mentioned above, physical activity appropriate to the pregnancy, supported by specific exercises in the case of pain, are all elements that favour the reduction of symptoms, the disappearance of pain and the prevention of persistent problems.
The physiotherapist can accompany the patient on this journey: indeed, after taking the patient’s medical history and performing physical examination, the physiotherapist can identify and propose the most appropriate exercise programme for the patient, combining it with manual therapy techniques, such as mobilisations and soft tissue techniques, which are appropriate and specific to the patient”.
We would like to thank not only Marco Gallotti, but also Benedetta Campagnola, physiotherapist and specialist in musculoskeletal rehabilitation at the Campus Bio-Medico University in Rome, for writing this text.