------------------------------------------------------------ PREGNANCY AND BACK PAIN ------------------------------------------------------------ Pregnancy and childbirth is a special time for all women. In the short space of nine months a variety of hormonal and physical changes take place leading to the eventual birth of a child. Physicians wisely suggest a series of exams, tests and counseling for all pregnant women. Adjustments to diet, exercise and work habits are usually suggested. For most women it would seem that back pain is one of those inevitable side effects of pregnancy. Something that is simply to be endured as a necessary consequence of the process. Surprisingly, however, there is much more to the situation. Not only can back pain be managed with an active exercise regimen, but also it is wise to consider that ignoring back pain as inevitable may lead to chronic back strain, disc damage or other permanent injury after pregnancy has passed. The possibility of back pain and even spinal damage should make a woman spend some time with her physician and ask questions about her backaches as well as her diet before, during and after pregnancy. In the early stages of pregnancy strong hormonal adjustments begin within the body of the now expectant mother. Fatigue, the need for additional sleep, and nausea or classic morning sickness may become apparent. The spine and lower back posture begins to change and become more relaxed. The muscles of the abdomen and back relax under the forces of hormonal control, gravity and for some women the effects of previous poor posture. The lumbar curve begins to accentuate slightly and the pelvis begins to tilt backwards. This new posture begins to play on the weakened and now fatigued lower back muscles which may display mild painful spasm - the first sign of a nagging backache in early pregnancy. As the baby grows and the abdomen protrudes, the forces of both gravity and hormonal changes continue to relax the muscles of the back and abdomen and a pronounced "swayback" appearance begins to appear. The stresses on the lower back muscles and spine increase and backache frequency may dramatically rise. Muscle spasm and pain may rise accordingly if no correctional action is taken. As the delivery date approaches, dramatic changes take place as new hormones are produced which loosen the ligaments of the pelvis so that it may expand and allow passage of the baby through the birth canal. A side effect of this late hormonal burst is that not only the ligaments of the pelvis are relaxed, but also ligaments in the nearby lower spine are allowed to become more flexible. This hormonally-driven joint relaxation is non-selective and affects joints other than those in the pelvis. The lower spine loses additional support and the lumbar curve becomes even more distorted which can further increase backache and muscle spasm. A direct cause of back and lower leg pain during pregnancy can also derive from the increased size of the baby itself. The large fetus can place pressure directly on the nerves of the lumbar area causing direct pressure and immediate pain. The nerves passing though the area of the psoas muscle which serve the lumbar region are especially subject to this source of pain. Vein congestion from the added pressure of a large fetus can also be a source of lower leg pain. Finally, the possibility of a ruptured disc is present in women who are overweight or have poor muscle tone or other pre-existing spinal disorders prior to pregnancy. Sometimes the structural weaknesses induced by pregnancy do not completely return to normal after the birth of the baby. If poor posture, excessive weight and poor exercise habits are allowed to continue, the back problems brought on by pregnancy can become chronic, organic and permanent. Some women who have had minor backaches prior to pregnancy or borderline spinal instability and muscle weaknesses may find that after pregnancy back pain may become a way of life. In most of these cases the pregnancy did not cause the back pain, it simply aggravated pre- existing poor posture and muscle tone thus providing the "straw that broke the camel's back." It is especially important that a woman clearly inform her physician of ANY prior back pain as early as possible during pregnancy. Special exercises, posture adjustments and even back braces are available. Diet and adjustments for rest are usually the first things on a woman's mind during pregnancy, but chronic back pain may be the most painful symptom of pregnancy which is neglected by a woman in discussion with her physician. For most healthy women simple exercises and posture adjustments are all that is required to further strengthen the back and abdominal muscles for the return to normal posture after the baby is born. The coccyx, the small vestigial tailbone at the end of the spine, can create unique problems and special pains during pregnancy. By function, the ligaments of the coccyx are directly attached to the bones of the pelvis. The additional weight of the fetus and other hormonal changes produce an unusually high amount of pressure and stress to the ligaments of the coccyx during pregnancy. During labor in the hospital delivery room the pressure on the ligaments of the coccyx increases further. Immediately after delivery this normally silent area of the spine may present severe pain for many women. The pain quickly disappears as the stretched ligaments and joints mend and reposition themselves into normal alignment. However, it may become difficult for a post-delivery mother to lie directly on her back if any pressure is placed on the area of the coccyx. Treatment depends on the severity of pain. Most hospitals and physicians suggest a small pillow, warm water bottle or donut shaped pad for relief of pressure on the coccyx if a woman must lie on her back. In cases of severe pain, injections of pain relieving medications are prescribed. Cortisone injections have also been used to alleviate pain in this area. In most cases the pain subsides and the damage is not permanent. In rare cases, systemic disorders have been found in pregnant women who complain of lower back pain. Osteomalacia is vaguely related to osteoporosis which was discussed in an earlier chapter. In simplest forms it is a vitamin deficiency. The normal treatment is to administer additional amounts of both calcium and vitamin D. In a sense, this disease is an obscure form of adult rickets. It affects primarily the bones of the pelvis and lumbar area. In severe cases the weakened bones of the pelvis may indicate Caesarian section delivery of the baby since the malformed or twisted bones of the pelvis do not permit easy passage of the fetus during birth. This disease, largely a dietary deficiency, is rare among American women whose diets are reasonably balanced. Osteitis condensans is another unusual disease which can sometimes affect pregnant women. It is unusual since its primary manifestations may be aggravated by pregnancy. The changes brought about by this disease are seen in the sides of the pelvis within the two bones of the ilia which become hard and thickened with calcium buildup. The normal porus matrix structure of the ilia is dramatically altered and the bones become firm and dense. Cause and cure are largely unknown at this time. Pain medications are at present the only relief. The excessive buildup of calcium seems to accelerate with each pregnancy and in some cases of this condition, caesarian section may be the preferred method of delivery. Back pain can be a manifestation of this condition which is relatively rare for most pregnant women. ------------------------------------------------------------ BIRTH DEFECTS ------------------------------------------------------------ A variety of other conditions can also give rise to back pain. Congenital and developmental problems, while rare, can occur before or after a child is born and in specific instances can increase the risk of backache and back pain for the child. Spondylolysis is a unique developmental defect of the back which involves the upper and lower articular facets of the vertebrae. In simplest terms this junction between two vertebrae must precisely match for smooth motion and good structural stability. In this condition a section of the articular facets may be missing and thus poorly aligned. Gradually a gap forms and the empty space is filled with a type of soft cartilage. The site of the defect is frequently in the area of the sacrum and fifth lumbar vertebra - a classic candidate for backache. Since the tissue which fills this missing gap is softer than bone, the misalignment can be significant enough to give rise to a secondary condition termed spondylolyisthesis which refers to the actual movement or slippage of the vertebrae out of proper alignment. The fifth lumbar vertebrae is most frequently affected by this condition which is not purely congenital (present at birth) but probably begins after a child is born. The condition usually deteriorates during the teenage and adult years as the fifth lumbar vertebra slips out from the support of the sacrum below. The disc between these two bones becomes stretched and in time the sciatic nerve may also become involved leading to a sharp pain radiating into the legs. Surgical correction via fusion of the fifth vertebra and sacrum is sometimes attempted in severe cases of this condition. Fortunately this condition, like many congenital and developmental conditions is relatively rare. Spina bifida describes a congenital defect in the development of the fetus growing within the mother's womb. You will recall that the bones of the vertebrae enclose the spinal cord like a protective shell. During embryonic development the rear or posterior portion of the vertebral bones are the last to form and surround the spinal cord. If closure is incomplete during the final stages of spinal development, sections of the delicate spinal cord may remain outside the protective vertebrae along with its covering membrane shroud known as the meninges. A protrusion or sac may form around this nerve tissue and extend directly through the skin of the back and be visible at birth. The exposed portion may be relatively short or long. When extensive portions are exposed, nerve function may be lost in the lower limbs, bowel or bladder. Obviously surgery and substantial medical care is required in cases of spina bifida involving substantial spinal cord damage or exposure. Spina bifida can also be present as smaller defects which do not cause exterior swelling and are relatively minor. In many cases an individual may go through life not realizing that a portion of vertebrae does not completely enclose the spinal cord. The structural integrity of the spine is nonetheless compromised and potential instability is present which may lead to eventual backaches and pain. Typically the lumbar and sacral portions of the spine are most commonly affected in cases of spina bifida. A minor defect may not be apparent even upon X ray examination of a child under the age of six or seven years old. After this age, the defect is more easily diagnosed by X ray or NMR (nuclear magnetic resonance) examination. Occasionally a small pimple or darkened hairy wart may appear at the base of the spine on the skin to mark to defect. Eventually, as the child grows, the structural instability of the spine in this area may lead to backache or pain. Surgery to fuse or repair the defect may be attempted to restore function and reduce pain in cases where spina bifida leads to chronic back pain or potential nerve damage. Some medical journals report that the undetected occurrence of small spina bifida defects in the general population may be as high as 14%. Congenital defects can occur in other ways as well. Normally the lumbar area of the spine consists of five vertebrae. Sometimes the vertebrae develop but do not properly separate, thus leading to congenital vertebral fusion. In other instances only four vertebra develop. Medical literature has also reported six and even seven lumbar vertebrae developing. Finally the articular facets, the bony "projections" or "arms" which extend from the sides of the oval vertebrae may develop poorly and protrude from the vertebrae at unusual angles. Back pain and backaches may thus arise and in some cases surgical intervention may be required. This tutorial is merely a starting point! For further information on back care and back pain, be sure to register this software ($25.00) which brings by prompt postal delivery a printed, illustrated guide to back pain written by a physician plus two software disks. From the main menu select "Print Registration Form." Or from the DOS prompt type the command ORDER. Mail to Seattle Scientific Photography (Dept. BRN), PO Box 1506, Mercer Island, WA 98040. If you cannot print the order form, send $25.00 to the above address and a short letter requesting these materials. End of chapter.