REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
PublicaçãoOficialdaSociedadeBrasileiradeAnestesiologiawww.sba.com.br
SCIENTIFIC
ARTICLE
Low
back
pain
during
pregnancy
Maria
Emília
Coelho
Costa
Carvalho
a,
Luciana
Cavalcanti
Lima
a,b,
Cristovam
Alves
de
Lira
Terceiro
a,
Deyvid
Ravy
Lacerda
Pinto
a,
Marcelo
Neves
Silva
a,
Gustavo
Araújo
Cozer
a,
Tania
Cursino
de
Menezes
Couceiro
a,c,d,e,f,∗aInstitutodeMedicinaIntegralProfessorFernandoFigueira(IMIP),Recife,PE,Brazil bUniversidadeEstadualPaulista‘‘JúliodeMesquitaFilho’’(Unesp),Botucatu,SP,Brazil
cNeuropsiquiatriaeCiênciadoComportamento,UniversidadeFederaldaPernambuco(UFPE),Recife,PE,Brazil dSociedadeMédicaBrasileiradeAcupuntura,SãoPaulo,SP,Brazil
eSociedadeBrasileiradeAnestesiologista,RiodeJaneiro,RJ,Brazil fHospitalBarãodeLucena,Recife,PE,Brazil
Received11June2015;accepted25August2015
Availableonline25November2016
KEYWORDS
Lowbackpain; Frequencyand characteristicsoflow backpain;
Pregnantwomen
Abstract
Objective:Lowbackpainisacommoncomplaintamongpregnantwomen.Itisestimatedthat about50%ofpregnantwomencomplainofsomeformofbackpainatsomepointinpregnancy orduringthepostpartumperiod.Theaimofthisstudywastoevaluatethefrequencyoflow backpainduringpregnancyanditscharacteristics.
Methods:Cross-sectionalstudy withlow-riskpregnantwomen.AfterapprovalbytheHuman Research EthicsCommittee and receiving written informedconsent, we includedpregnant womenover18 yearsofageandexcluded thosewithpsychiatricdisorders,previouslumbar pathologies,andreceivingtreatmentforlowbackpain.
Results:Weinterviewed97pregnantwomen.Thefrequencyoflowback painwas68%.The meanagewas26.2yearsandthemediangestationalagewas30weeks.Fifty-eightpregnant womendeclaredthemselvesasbrown(58%).Most(88.6%)weremarriedorlivingin common-lawmarriage,56(57.7%)workedoutsidethehome,and71(73.2%)hadcompletedhighschool. Lowbackpainwasmorefrequentduringthesecondtrimesterofpregnancy(43.9%),referred toasa‘‘burning’’sensationin37.8%ofpatients,withintermittentfrequencyin96.9%ofthe women.Thesymptomsgotworseatnight(71.2%).Restingreducedlowbackpainin43.9%of pregnantwomen,whilethestandingpositionforalongtimeworseneditin27.2%ofpatients. Conclusion:Lowbackpainiscommoninpregnantwomen,hasspecificcharacteristics,andis morefrequent inthesecond trimesterofpregnancy.Thisindicatestheneedfor prevention strategiesthatenablebetterqualityoflifeforpregnantwomen.
©2016SociedadeBrasileiradeAnestesiologia.PublishedbyElsevierEditoraLtda.Thisisan openaccessarticleundertheCCBY-NC-NDlicense( http://creativecommons.org/licenses/by-nc-nd/4.0/).
∗Correspondingauthor.
E-mail:taniacouceiro@yahoo.com.br(T.C.Couceiro).
http://dx.doi.org/10.1016/j.bjane.2015.08.014
PALAVRAS-CHAVE
Lombalgia; Frequênciae característicasda lombalgia; Gestantes
Lombalgianagestac¸ão
Resumo
Objetivo: Alombalgiaéumaqueixacomumentregrávidas. Estima-sequecercade50%das gestantesqueixam-sedealgumtipodedorlombaremalgummomentodagravidezoudurante opuerpério.Oobjetivodesteestudofoiavaliarafrequênciadalombalgianagestac¸ãoesuas características.
Método: Estudo de corte transversal com gestantes de baixorisco. Apósa aprovac¸ão pelo ComitêdeÉtica em Pesquisaem SeresHumanos eaassinaturadotermodeconsentimento livreeesclarecido,foramincluídasmaioresde18anosealfabetizadaseexcluídasgestantes comdistúrbiospsiquiátricos,compatologiaslombarespréviaseemtratamentoparadorlombar. Resultados: Foramentrevistadas97gestantes.Afrequênciadedorlombarfoi68%.Amédiade idadefoi26,2anoseamedianadaidadegestacionalde30semanas;58consideraram-separdas (58%).Amaioria(88,6%)eracasadaouviviaemuniãoestável,56(57,7%)trabalhavamforae 71(73,2%)tinhamoensinomédiocompleto.Alombalgiafoimaisfrequenteduranteosegundo trimestregestacional(43,9%),referidacomo‘‘emqueimac¸ão’’por37,8%daspacientesecom frequênciaintermitenteem96,9%.Ossintomaspioravamnoperíodonoturno(71,2%).Orepouso reduziaadorlombarem43,9%,enquantoaposic¸ãoortostáticaporlongotempoagravavaem 27,2%.
Conclusão:Alombalgiaécomumemgestantes,apresentacaracterísticasespecíficaseémais frequentenosegundotrimestre.Issoalertaparaanecessidadedesereminstituídasestratégias deprevenc¸ãoquepossibilitemmelhorqualidadedevidaparaagestante.
©2016SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Este ´eum artigo OpenAccess sobumalicenc¸aCCBY-NC-ND( http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Lowbackpainisusuallydefinedastheaxialorparasagittal
discomfortinthelowerbackregion.Itisessentially
muscu-loskeletalandmaybeduetoacombinationofmechanical,
circulatory,hormonal,andpsychosocialfactors.1
Itisacommoncomplaintamongpregnantwomen.1Itis
estimatedthatabout 50%of pregnantwomen complainof
somesortofbackpainatsomepointinpregnancyorduring
thepostpartumperiod.2
The etiologyof pregnancy-specificlowbackpainis not
well defined.3 From abiomechanical standpoint,the
cen-ter of gravity moves forward due to the increase in the
abdomenandbreasts,whichleadstoposturechanges,such
as reduction in plantar arch, knee hyperextension, and
pelvic anteversion. These changes generate stress in the
lumbar lordosis and consequent tension in the paraspinal
muscles. The compression of great vessels by the gravid
uterusdecreasesspinalbloodflowandmaycauselowback
pain,particularlyinthelasthalfofpregnancy.4Significant
water retention determined by progesterone stimulation5
andligamentouslaxitybyrelaxinsecretedfromthecorpus
luteummayalsobeseen,leavingthelumbarspineandhip
jointsless stableandtherefore moresusceptibletostress
andpain.4
Somerisk factorsrelatedtolow backpainduring
preg-nancyhavebeenreported,6includinglowbackpainduring
themenstrualperiodandprevioushistoryoflowbackpain.
Regarding age, it is known that the younger the patient,
thegreaterthechanceofdevelopingpregnancy-relatedlow
backpain.6,7Anotherfactorrelatedtolowbackpainisthe
increasedweight,which resultsinsacroiliacjoint
instabil-ity,inadditiontoincreasedspinalflexibilityandconsequent
onsetorworseningoflowbackpain.7,8
Mostprevalencestudiesconfirmthatlowbackpainduring
pregnancyis amajorcomplaintduetothehighfrequency
ofaffectedwomenandtheseverityanddiscomfortcaused
bypain.5Besidesinfluencingnegativelythequalityofsleep,
physicalcondition,performanceatwork,sociallife,
house-holdactivities,andleisure,5itcauseseconomiclossesdue
toabsenteeism.9,10Basedontheabove,theobjectiveofthis
studywastoevaluatethefrequencyoflowbackpainduring
pregnancyanditsfeatures.
Method
A cross-sectional cohort study was performed involving
pregnantwomen,fromthefirsttothirdtrimesterof
preg-nancy,attendingtheprenatallow-riskprogramattheCenter
forWomenCare(CWC)oftheInstitutodeMedicinaIntegral
Professor Fernando Figueira (IMIP) whoagreed to
partici-pateinthestudy.
TheprojectwasapprovedbytheIMIPEthicsCommittee,
No.23173313800005201.Datawerecollectedfrom
Decem-ber2013toJanuary2014.Alistofquestionsdeterminedby
theresearchersand thedatabase filled bythem withthe
responseswereusedastools.The questionnairewas
com-posedofsimpleanddirectquestions,includingthepregnant
womanpersonaldata,suchasage,weight,occupation,and
informationrelatedtopregnancyandpresenceor absence
Thepregnantwomenwereinformedabouttheresearch,
itsobjectivesandproceduresandconsultedonthe
partici-pationinthestudy.Afterexplanations,thosewhoagreedto
voluntarilyparticipatein thestudy gavewritten informed
consent(WIC).
Pregnant women aged over 18 years and literate who
wereattendedattheIMIPHospitalComplexwereincluded
inthesample.Patientswithpsychiatricdisorders,previous
spinalpathologies,thoseintreatmentforlowbackpainand
taken analgesics or nonsteroidal anti-inflammatory drugs
(NSAIDs)wereexcludedfromthestudy.
Fordataanalysis,theEPI-INFOTMsoftwareversion3.5.1
forWindowsTM wasused;data weredescribedasabsolute
andrelativefrequencydistributionandpresentedintables.
Numericalvariableswererepresentedbycentraltendency
anddispersionmeasures.Chi-squaretestandFisher’sexact
testwereusedtocheckforassociationbetweencategorical
variables.
Results
Ninety-seven patients completed the questionnaire. The
meanagewas26.2years;themediangestationalagewas30
weeks;and58%consideredtheirskincolorasbrown,88.6%
weremarried or living in common-lawmarriage,50% and
57.7%worked out, and73.2% had completedhigh school.
Regardingthenumberofpregnancies,51.5%wereintheir
first pregnancy. Regarding the number of live births, 28
women(28.8%)hadlivebirth.Thefrequencyofpatientswho
hadhadabortionswas13.3%.
Ofthe 97patientsinterviewed,68% reportedlowback
pain and of these 43.9% reported that low back pain
began in the second trimester. Pain was characterized as
severe (median=7), and more than half (71.2%) patients
reportedthat it was more painful at night;37% reported
painasa ‘‘burning’’sensation, and mostof the surveyed
patients (72.7%) denied urinary tract infection (Table 1).
Dataregardingpainfrequency,irradiation,andmostpainful
timeare in Table 2. Regarding pain aggravating and
mit-igatingfactors, lessthan half of pregnant women(43.9%)
claimedthatrestingwasarelieffactorandonly27.2%
iden-tifiedthe fact of standingfor long periods of timeas an
aggravatingfactor(Table3).
History of low back pain in previous pregnancies,
advancedpregnancyasacauseofpainworsening,andthe
factthatthispainlimitsdailyphysicalactivitiesareshown
inTable3.
Discussion
The human pregnancy period involves physical changes.
Throughout pregnancy, the woman undergoes
physiologi-cal changes caused by anatomical and functional needs.
Physiologicalchangesaffectthemusculoskeletalsystemand
usuallygeneratepain,includinglowerbackpain.10---12
The frequency of low back pain was found to be 68%
among the pregnant women interviewed. This finding is
in agreement with those found in the literature, whose
prevalencerangesfrom68.5%to80%.5,6,13 Thisprevalence
isconsidered high, asthis isa group oflow-risk pregnant
women, that is, patients without significant pathological
Table1 Low-backpainfrequency,onsettime,relationship withUTI,andfeature.
Variable n %
Lowbackpain
No 31/97 31.9
Yes 66/97 68
Onsettime
Firsttrimester 23/66 34.8 Secondtrimester 29/66 43.9 Thirdtrimester 14/66 21.2
UTIduringpregnancy
No 48/66 72.7
Yes 18/66 27.2
RelationshipwithUTI/painonset
No 15/18 22.7
Yes 3/18 4.5
Paintype
Griping 8/66 12.1
Griping/burning 1/66 1.5
Stinging 5/66 7.5
Twinging 5/66 7.5
Throbbing 2/66 3
Stabbing 14/66 21.2
Stabbing/burning 5/66 7.5
Burning 25/66 37.8
Burning/twinging 1/66 1.5
conditions that often worsen back pain, such as obesity, advancedage,andtwinpregnancy.
Lowbackpainisusuallydefinedasaxialorparasagittal discomfortinthelowerbackregion.Itisessentially muscu-loskeletalandmaybeduetoacombinationofmechanical, circulatory,hormonal,andpsychosocialfactors.1
Riskfactorsrelatedtolow backpain duringpregnancy
have alreadybeen reported, whichinclude low backpain
during the menstrual period and previous history of low
backpain.3Regardingage,itisknownthattheyoungerthe
patient,the greater thechance of developing
pregnancy-relatedlowbackpain.3,5Increasedweightisalsoidentified
asariskfactorbecausethegreaterweightgainduring
preg-nancy,thegreaterthechanceofsacroiliacjointinstability
andincreasedlumbarlordosis,whichresultsinpain.7
In this study assessing pregnant women in the three
trimesters of pregnancy, it was found that the low back
painreportedbythewomenstartsmoreofteninthesecond
trimesterofpregnancy(43.24%).Thesedatawerealsofound
by other authors8,11 and may be justifiedby the changes
in the spinal flexibility aforementioned. Our study
sam-pleincludedthethreetrimestersofpregnancyinorderto
identifyiflowbackpainoccurredpreferablyinanyofthe
trimesters.Butsomeprospectivestudies14,15foundthatthe
prevalenceoflowbackpainwashigherinpregnantwomen
from thethird trimester, theseresults are differentfrom
thosefoundinourstudy.
In a study with pregnant women attending a prenatal
Table2 Characteristicsoflowbackpainregardingweekly frequency, onset time, more severe time, duration, and irradiation.
Variable n %
Weeklyfrequency
>3times/week 13/66 19.9
once/week 2/66 3
twice/week 12/66 18.1
Everyday 39/66 59
Onsettime
Morning 10/66 15.1
Night 17/66 25.7
Norelationship 30/66 45.4
Afternoon 9/66 13.6
Moreseveretime
Morning 7/66 10.6
Night 47/66 71.2
Norelationship 3/66 4.5
Afternoon 9/66 13.6
Duration
Continuous 2/66 3
Intermittent 64/66 96.9
Irradiation
Abdomen 4/66 6
Thigh 9/66 13.6
Thighandabdomen 1/66 1.5 Thighandlowerleg 4/66 6
Buttocks 6/66 9
Buttocksandthigh 1/66 1.5
No 37/66 56
Legs 4/66 6
glutealregion.13Inthepresentstudy,mostpregnantwomen
reportednolowbackpainirradiation.
By studying the characteristics of low back pain, the
following characteristics were observed: severe intensity,
‘‘burning’’sensation,withoutirradiation,intermittentand
daily occurrence, starting at any time of day and more
severeatnight----datadifferingfromthosefoundbyAssisand
Tibúrcio16whoidentifieditas‘‘stabbingpain’’and‘‘griping
pain’’.Thus,themultifactorialgenesisofpainisjustified.
Regardingpainseverity,thereisdisagreementbetween
our data and those found by a US study5 that evaluated
the severity of gestational low back pain in 645 women
whoquantified painasmoderate. This differencemay be
explainedbythedifferentethnicityofthestudied
popula-tions.
Thestandingpositionhaslongbeen identifiedasapain
aggravating factor and resting as the main relief factor.
Thisdataspeaksinfavorofmuscleinvolvementinthe
lum-bar painreported by pregnantwomen. More than half of
pregnantwomen interviewedsaidthat lowback painwas
notanobstacletotheirdailyactivities.Thisfindingdiffers
fromthoseoftheliterature,aspreviousstudieshaveshown
that lowback paincanbe sosevere thataffect the daily
activitiesofpregnantwomen.8,11,16However,itisimportant
Table3 Aggravatingandmitigatingfactorsand interfer-enceindailyactivitiesrelatedtolowbackpain.
Variable n %
Mitigatingfactors
Physicalexercise 2/66 3
Massage 9/66 13.6
Massage/medicines 1/66 1.5
Medicines 3/66 4.5
Medicines/physicalexercise 1/66 1.5 Medicines/massage 2/66 3
Position 7/66 10.6
Resting 29/66 43.9
Restingandposition 2/66 3
Resting/massage 4/66 6
Resting/medicines 3/66 4.5 Resting/medicines/massage 2/66 3 Resting/position 1/66 1.5
Aggravatingfactors
Householdactivities 14/66 21.2 Householdactivities/remainstanding 2/66 3 Householdactivities/remainseated 1/66 1.5 Householdactivities/remainseated
position
1/66 1.5
Remainstanding 18/66 27.2 Remainseated 13/66 19.7 Remainseatedandstanding 2/66 3 Remainseated/standing 2/66 3
Position 10/66 15
Position/remainstanding 1/66 1.5
toemphasize that notalllow backpainduringpregnancy hasthe pregnancy itself asa triggering factor.17 Much of
thelowbackpainexistedbeforethepregnancyandpersists
orworsensduring thisperiod,whichmeansthat lowback
painduring pregnancy should be analyzed in many ways,
notsimplified.
Gestationalagewasfoundtobeariskfactor;thatis,the
moreadvanced,thegreatertheriskofdevelopinglowback
pain.Otherauthorshaveshownthattheprevalenceoflow
backpainduringpregnancyincreaseswithgestationalage.
AssisandTibúrcio16 alsoreportedthatit happenedin60%
ofcases,although theresults ofWangetal.5 have shown
thattheprevalence oflow backpainwasnotaffectedby
gestationalage.
Thisstudyshowsthateveninpatientswithlow-risk
preg-nancylowbackpainispresent,thereisadirectrelationship
with increasing gestational age and this finding
empha-sizesthebiomechanicaloriginoflowbackpaininpregnant
women.
Based on the results provided by this study regarding
lowbackpainduringpregnancy,newstudiesshouldbe
per-formedassessingpreventivetreatmentforlowbackpain.
Conflicts
of
interest
References
1.SabinoJ,GrauerJN.Pregnancy andlowbackpain.CurrRev MusculoskeletMed.2008;1:137---41.
2.VadiveluR,GreenTP,BhattR.Anuncommoncauseofbackpain inpregnancy.PostgradMedJ.2005;81:65---7.
3.SantosMM,GalloAP.Lombalgiagestacional:prevalênciae car-acterísticasdeum programapré-natal.Arq BrasCiênSaúde. 2010;35:174---9.
4.KatonisP,KampouroglouA,AggelopoulosA,etal. Pregnancy-relatedlowbackpain.Hippokratia.2011;15:205---10.
5.Wang SM,Dezinno P,Maranets I,et al. Low back pain dur-ingpregnancy:prevalence,riskfactors,andoutcomes.Obstet Gynecol.2004;104:65---70.
6.NovaesFS,ShimoAKK, LopesMHBM.Lombalgianagestac¸ão. RevLatino-amEnfermagem.2006;14:620---4.
7.FerreiraCHJ,NakanoAMS.Lombalgianagestac¸ão:etiologia, fatoresderiscoeprevenc¸ão.Femina.2000;28:435---8.
8.GomesMRA,AraújoRCL,PitanguiACR.Lombalgiagestacional: prevalênciaecaracterísticasclinicasemumgrupodegestantes. RevDor.2013;14:114---7.
9.MouraSRV,CamposSR,MarianiSHV,etal.Dorlombar gesta-cional:impactodeumprotocolodefisioterapia.ArqMedABC. 2007;32:S59---63.
10.Ferreira CHJ, Nakano AMS. Reflexões sobre as bases con-ceituais que fundamentam a construc¸ão do conhecimento
acercada lombalgia na gestac¸ão. Rev Lat Am Enfermagem. 2001;9:95---100.
11.De Carvalho YBR, Caromano FA. Alterac¸ões morfofisiológ-icas com lombalgia gestacional. Arq Ciên Saúde Unipar. 2001;5:267---77.
12.StapletonDB, MacLennan AH,Kristiansson P.The prevalence of recalled low back pain during and after pregnancy: a SouthAustralianpopulationsurvey.AustNZJObstetGynaecol. 2002;42:482---5.
13.FastA,WeissL,ParichS,etal.Nightbackacheinpregnancy hypotheticalpathophysiological mechanisms.Am JPhys Med Rehab.1989;68:227---9.
14.Martins RF, Silva JLP. Prevalência de dores nas costas na gestac¸ão.RevAssocMedBras.2005;51:144---7.
15.Sant’anna PF, Freire SS, Alves AT, et al. Caracterizac¸ão da dor lombar em gestantes atendidas no Hospital Univer-sitário de Brasília. Universitas: Ciências da Saúde. 2006;4: 37---48.
16.AssisRG, TibúrcioRES.Prevalênciaecaracterísticasda lom-balgia nagestac¸ão: um estudo entregestantes assistidas no programade pré-nataldamaternidadedonaÍrisemGoiânia. Trabalhodeconclusãodecurso.Goiânia:UniversidadeCatólica deGoiás;2004.p.10---28.
