与妊娠有关的腰痛

A long-standing debate in pregnancy care is whether Low Back Pain or LBP is an inevitable process and allowed to resolve spontaneously or perhaps could be prevented. This article reviews the clinical presentation, practical treatment and management strategies for Low Back Pain during pregnancy for patients.

腰背痛（LBP）和后盆腔疼痛（PPP）以前被认为是相同的。过去的研究分为这两个条件的一个分类下的“腰痛。”然而，他们最近已经被离散described-and-measured.It现在很明显，他们需要诊断和管理单独审议。

腰背痛代表怀孕的约为50％，9个月的患病率一个共同的病理生理过程。尽管有丰富的文献资料，在怀孕期间遗骸腰痛知之甚少。目前的治疗方法往往是无效的，留下困惑如何管理病人的症状医生。

一般的想法是,无事可做o alleviate these problems short of the mother completing the pregnancy and to simply allow these symptoms to resolve spontaneously. But with careful diagnosis, appropriate treatment is possible.

Clinical Presentation

孕期腰痛的特点是最大的疼痛强度和疼痛的位置的时间。怀孕有关LBP相比，非孕期LBP的功能会有所不同。相比于普通人群的23.6％，那存严重LBP，所有孕妇的三分之一形容自己在怀孕期间严重LBP一段时间。地幔等所指示的第二和早期第三个三个月是周期时背痛是最普遍的。一些研究还报道说，晚上的时间显然比天的休息更痛苦。孕妇大约有67％来自夜间不适或背痛和36％患有夜间有腰酸很严厉它唤醒他们的睡眠。

疼痛强度或位置的图案在确定的背部疼痛的来源是至关重要的。Ostgaard等分化成LBP疼痛源自后部骨盆区域 - PP（远侧和横向至L5）或下腰部区域（LP）。据报道，发生PPP 2至4倍更频繁然后腰部类型。PPP不像LP已经直接关系到双方的疼痛强度和病假，因此被认为是更致残。虽然妇女与LP疼痛通常全妊娠期保持不变，购买力平价的增加在怀孕中期及后期的流行。

体格检查/标志

Assessments of LBP during pregnancy include the visual analog scale and body charts/pain diagrams but they may be inadequate in distinguishing between lumbar and posterior pelvic pain. The neurological examination usually is unremarkable for both types of pain with negative dural tension signs including the straight leg raise.

腰椎疼痛（LP）在怀孕期间相似，患者的临床表现没有怀孕，是比较容易比盆腔疼痛（PPP）来诊断。LP更趋于慢性和激烈产后。疼痛椎旁肌，hypomobility和弱点在腰椎背部肌肉意味着不足的触诊。有可能还与疼痛腰椎前屈再现被腰椎的运动范围减小，。

PPP典型的LP介绍不同，往往是急性的，妊娠，和不常见的非孕妇人群。没有额外的创伤或色料，轻度PPP通常可解决产后3个月。在临床上，患者目前背痛和“深，枯燥的，边界不清的疼痛是局部的不良”和向下的后外侧大腿至于小牛辐射。Sturesson等人建议，大神经支配的骶髂关节（L4-S1）有助于由孕妇经历的称为疼痛。虽然有用于评估骶髂关节病理学无数次试验，研究表明3次测试的具有优异的灵敏度和功效;“帕特里克Fabere测试，Menell的测试，和后盆腔疼痛激发试验。”

Differential Diagnosis

Pregnancy-related LBP can be defined as any type of idiopathic pain arising between the 12th rib and the gluteal folds during the course of the pregnancy. As such, this does not include any situation in which the pain can be attributed to a specific pathological condition, such as a disk herniation that arises either before or during the pregnancy. It is important to consider other disease pathologies, some of which are listed in Table 1, that mimic the symptoms of “primary” LBP associated with pregnancy.
As previously stated, LBP with radiation into the buttocks and legs is a common problem during pregnancy. However, LBP must be carefully differentiated from radicular and other neurologic symptoms. True sciatica is rarely diagnosed in the pregnant population. Posterior facet syndrome can present with pain radiation down the posterior thigh and mimic radicular pain. Another type of radiculopathy, meralgia paresthetica, follows the distribution of the lateral femoral cutaneous nerve and may be confused with referred pain symptoms experienced with LBP. Meralgia paresthetica is associated with severe pain, numbness, tingling, hypesthesia, or burning sensation down the anterolateral aspect of the thigh.

Management/Treatment

Common treatment interventions for LBP include physiotherapy and exercises. Ostgaard et al studied the relationship between sick leave and prepartum back education and training classes. They found a 12% decrease in sick leave time among pregnant women enrolled in an individualized back education and training program for both PPP and LP pain types. As a precaution, the physiotherapy routine should be designed and monitored by women’s health physiotherapists, or health care providers who specialize in women’s health. This is because improper management of special populations, such as expectant women with PPP, may lead to worsening of the condition. For example, PPP sufferers should refrain from stair climbing, standing on one leg, extreme motion at the hips and back, and other positions that overload the pelvis. Those who present with both lumbar and posterior pelvic pain symptoms should avoid back-strengthening exercises until the posterior pelvic symptoms resolve; these symptoms may worsen if lumbar strengthening exercises are performed.

In addition to physiotherapy, exercises to alleviate mild LBP may include walking, swimming, or bicycling at low to moderate intensities. Deep abdominal toning is recommended which generates less stress on back muscles, but abdominal crunches and straight leg raises are contraindicated. It also should be noted that the goal of exercise during pregnancy is to improve or maintain muscle tone and not to control weight gain or to correct posture. Hypertension, diabetes mellitus, history of premature labor, placenta previa, threatened abortion are all contraindications to exercise during pregnancy.

Other supplemental therapies also are available for women with pelvic pain and may diminish the need for medications. Berg et al reported 71% of patients that suffered from severe LBP experienced some relief with a trochanteric belt, which provides support to the pelvic girdle, but this belt may compress the abdomen and cause discomfort. Sacroiliac belts, in contrast, do not compress the abdomen and 82% of women with posterior pelvic pain reported some pain relief with these belts.

Prevention

Prevention of LBP is often associated to how one manages her pregnancy during this period. Maximum working capacity is expected during pregnancy in some career environments, and ignoring the additional responsibility of pregnancy by employers or the employees themselves only exacerbates the symptoms. Pain intensity during pregnancy has been positively associated with duration of pain postpartum. Women who did not take breaks at work report experiencing back pain symptoms 6 years postpartum. Wergeland and Strand found that women felt more at ease during pregnancy if they controlled their own work pace.

Prepartum physiotherapy management and exercises have also been considered a component of LBP prevention. Women who are more physically fit prepartum appear to have a reduced risk of developing LP and PPP during pregnancy. Exercise regimens as little as 45 total minutes per week have been correlated with reduced lumbar pain symptoms. Expectant women with history of PPP and/or LP felt more positive and less fearful of their pregnancy when they know that help and support is available from qualified physiotherapists in the event that symptoms flare up.

Conclusion

Pregnancy, for good reason, is considered by many a fragile time of a woman’s life. Health care providers use special precautionary measures to ensure the health of the growing fetus and the mother. For this reason, they are often hesitant to address the symptoms of LBP, which are widespread and often debilitating. But if unaddressed, these symptoms can persist during pregnancy and severely affect the lifestyle and health of the patient postpartum. It is therefore vital that health care providers and patients understand the underlying issues of LBP, including appropriate prevention and treatment options, to allow for a pain-free and stress-free pregnancy.

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