- 2014 - Pilot Grant
Background, Significance and Aims
Pregnancy-related back pain is a significant health problem affecting over two thirds of women in the
U.S.1 It is poorly and infrequently treated due to a misconception that it is self-limited, resolves with the birth of the baby, and does not have lasting effects. On the contrary, gestational low back pain is associated with considerable morbidity, not only during pregnancy, but extending through childbirth and into motherhood.
Pregnant women with lower back pain have higher rates of insomnia, impaired daily activity, loss of work, pain medication use, increased rates of Caesarean section, post-partum depression, and chronic recurrent back pain.2,3 Up to forty percent of those afflicted will continue to have pain after birth.4
Obstetrical providers in the United States typically ‘normalize’ gestational back pain and do not provide women with skills to manage pain on their own. One U.S. study found that 85% of pregnant underserved women with back pain report that they do not receive any treatment for it.5
Most of the available, evidence supported treatments such as acupuncture, supportive belts, and osteopathic manipulation, place the expecting mother in a passive role. Exercise 6 is one of the few effective self-care treatments for gestational back pain that an expecting mother can actively participate in, which can boost her self-confidence and overall self-efficacy.
While the exact etiology of pregnancy-related low back pain is unclear, possible causes are increases in maternal weight, spinal lordosis, and higher levels of the hormone relaxin in combination with biomechanical factors. Increased joint laxity within the pubic symphysis and sacroiliac joints diminishes the efficiency of load transmission in the pelvis. These changes, in combination with decreased abdominal muscle strength and anterior shift in the body’s center of mass, increase shear forces across the joints of the lower back and pelvis.7,8,9
Compounding the morbidity of pregnancy-related back pain is the increased risk of falling as pregnancy progresses. The 27% rate of falls in pregnancy is similar to the rate in women >70 years old.10
Having a fall during pregnancy can also be a source of back pain for expectant mothers. In pregnant women, falls are the second leading cause of emergency room visits11 and up to thirty percent of all hospital admissions during pregnancy are due to accidental falls.10,12 Still, there are no evidence-based recommendations for fall prevention. Biomechanical factors have been found to influence a pregnant woman’s chance of falling. These include alterations in mobility and gait that arise primarily from increased joint laxity due to relaxin, increased body mass and changes in the body’s center of mass.13 Some of these are the same factors that are suspected to increase the incidence of pregnancy-related back pain.
Finally, psychosocial factors independently impact an expecting mother’s pregnancy, developing fetus,
childbirth, mothering skills and infant wellbeing. Pregnancy-related depression and stress are associated with prematurity,14,15 low birth rate,16,17 and post-partum depression. Pregnancy-specific scales are becoming more readily available, which measure elements of maternal wellbeing such as depression, anxiety, and childbirth self-efficacy. These tools offer an opportunity to more subtly track how these elements influence an expecting mother. Efforts to improve individual psychosocial factors have included exercise,18 mind-body interventions,19 and group visits.20
Literature supports physical activity, as well as cognitive behavioral strategies to help with back pain and wellbeing in the adult population.21,22,23 Yoga is a novel multi-modal intervention that incorporates these components into one gentle, accessible activity that includes elements of stretching, core strengthening, balance training, cultivation of mindfulness, acceptance, and self-compassion. Studies have shown yoga to be an effective intervention for back pain and overall well-being in the non-pregnant patient population.24,25,26,27,28
Practicing yoga also improves gait, postural stability and flexibility for non-pregnant practitioners.29 Yoga could have the potential to reduce pregnancy-related back pain, holistically empower an expectant mother, and improve her overall wellbeing. Small, limited studies done in India, Brazil and the U.S. have suggested promise in this area.30,19,31,32 However, despite the fact that pre-natal yoga is offered widely in metropolitan areas in the U.S., its safety and efficacy during pregnancy has not been thoroughly studied and there have been very few randomized trials for this population within the US.32,33,34 Utilizing a time-matched, randomized controlled design, our overarching goals are to evaluate the potential efficacy of pre-natal yoga in prevention and treatment of pregnancy-related back pain and enhancing overall maternal wellbeing.
1) To explore the potential benefit of prenatal yoga for reducing disability due to back pain during
pregnancy. We hypothesize that 12 or more weeks of prenatal yoga classes will prevent or attenuate
the degree of disability that pregnant women with back pain experience at the end of their pregnancy.
2) To explore the potential benefit of prenatal yoga on stress, quality of life, self-efficacy, and
3) To explore the potential benefit of prenatal yoga on both objective and subjective measures of gait,
balance, and falls.
1 Wang S.‐M, Dezinno P, Maranets I, Berman M.R, Caldwell-Andrews A.A. & Kain Z.N. “Low back pain during pregnancy: prevalence, risk factors and outcomes”. Obstetrics & Gynecology 2004;104(1), 65–70.
2 Gutke A, O€stgaard H.C. & Oberg B. “Pelvic girdle pain and lumbar pain in pregnancy: a cohort study of the consequences in terms of health and functioning”. Spine 2006;31(5), E149–155.
3 Bergström, C, Persson, M. & Mogren, I. “Pregnancy-‐related low back pain and pelvic girdle pain approximately 14 months after pregnancy – pain status, self-rated health and family situation”. BMC Pregnancy and Childbirth, 2014;14:48
4 Mogren IM. “BMI, pain and hyper-‐mobility are determinants of long-‐term outcome for women with low back pain and pelvic pain during pregnancy”. Eur Spine J 2006;15(7):1093–102.
5 Skaggs CD, Prather H, Gross G, George JW, Thompson PA, Nelson DM. “Back and pelvic pain in an underserved United States pregnant population: a preliminary descriptive survey”. J Manipulative Physiol Ther. 2007 Feb;30(2):130‐4.
6 Pennick V, Liddle SD. “Interventions for preventing and treating pelvic and back pain in pregnancy”. Cochrane Database Syst Rev. 2013 Aug 1;8
7 MacLennan AH, Nicolson R, Green RC, Bath M. “Serum relaxin and pelvic pain of pregnancy”. Lancet 1986;ii:243–5.
8 Sabino J, Grauer JN. “Pregnancy and low back pain”. Curr Rev Musculoskelet Med. 2008 Jun;1(2):137-41.
9 Cakmak B, Inanir A, Nacar MC, Filiz B. “The Effect of Maternity Support Belts on Postural Balance in Pregnancy”. PM R. 2014 Jan 8. pii: S1934-‐1482(13)01234-3.
10 Dunning K, Lemasters G, Bhattacharya A. “A major public health issue: the high incidence of falls during pregnancy.” Matern Child Health J. 2010 Sep;14(5):720-5.
11 Weiss, H., Sauber-‐Schatz, E., & Cook, L. “The epidemiology of pregnancy-‐associated emergency department injury visits and their impact on birth outcomes”. Accident Analysis and Prevention. 2007; 40, 1088–1095.
12 Kuo C, Jamieson DJ, McPheeters ML, Meikle SF, Posner SF. “Injury hospitalizations of pregnant women in the United States”. Am J Obstet Gynecol 2007;196(161):e1–6.
13 McCrory JL, Chambers AJ, Daftary A, Redfern MS. “Dynamic postural stability during advancing pregnancy”. J Biomech. 2010;Aug 26;43(12):2434-9
14 Dole, N., Savitz, D. A., Hertz-‐Picciotto, I., Siega-‐Riz, A. M., McMahon, M. J., & Buekens, P. “Maternal stress and preterm birth”. American Journal of Epidemiology, 2003;157, 14-24.
15 Li, D, Liu, L, Odouli, R. “Presence of depressive symptoms during early pregnancy and the risk of preterm delivery: a prospective cohort study”. Human Reproduction 2009;24, 146e153.
16 Grote, N.K, Bridge, J.A, Gavin, A.R, Melville, J.L, Iyengar, S, Katon, W.J. “A meta-‐analysis of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth restriction”. Archives of General Psychiatry 2010;67, 1012e1024.
17 Zhu P, Tao F, Hao J, Sun Y, Jiang X. “Prenatal life events stress: implications for preterm birth and infant birthweight”. Am J Obstet Gynecol. 2010;203(1):34.e1-8
18 Field T. “Prenatal exercise research” Infant Behav Dev. 2012:Jun;35(3):397-407
19 Beddoe AE, Lee KA. “Mind-‐body interventions during pregnancy.” J Obstet Gynecol Neonatal Nurs. 2008 Mar-Apr;37(2):165-75
20 Ickovics JR, Kershaw TS, Westdahl C, et al. “Group prenatal care and perinatal outcomes: A randomized controlled trial.” Obstet Gynecol 2007;110:330–338
21 Kerns, R. D, Sellinger, J. J, & Goodin, B. “Psychological treatment of chronic pain”. Annual Review of Clinical Psychology, 2011;7, 411–434
22 Henchoz Y, Kai-Lik So A. “Exercise and nonspecific low back pain: a literature review”. Jt Bone Spine. 2008;75:533–539
23 Conn, V. S. “Depressive symptom outcomes of physical activity interventions: Meta-‐analysis findings”. Annals of Behavioral Medicine. 2010;39, 128–138.
24 Saper RB, Boah AR, Keosaian J, Cerrada C, Weinberg J, Sherman KJ. “Comparing Once-‐versus Twice-‐Weekly Yoga Classes for Chronic Low Back Pain in Predominantly Low Income Minorities: A Randomized Dosing Trial”. Evid Based Complement Alternat Med. 2013
25 Sharma M. “Yoga as an alternative and complementary approach for stress management: a systematic review”. J Evid Based Complementary Altern Med. 2014 Jan;19(1):59-67
26 Louie L. “The effectiveness of yoga for depression: a critical literature review”. Issues Ment Health Nurs. 2014 Apr;35(4):265-76
27 Posadzki P, Ernst E. “Yoga for low back pain: a systematic review of randomized clinical trials”. Clin Rheumatol. 2011;30:1257–1262
28 Sherman KJ, Cherkin DC, Erro J, Miglioretti DL, Deyo RA. “Comparing yoga, exercise, and a self-‐care book for chronic low back pain: a randomized, controlled trial”. Ann Intern Med. 2005;143:849–856
29 Jeter PE, Nkodo AF, Moonaz SH, Dagnelie G. “A Systematic Review of Yoga for Balance in a Healthy Population”. J Altern Complement Med. 2014 Feb 11
30 Martins RF, Pinto e Silva JL. “Treatment of pregnancy-‐related lumbar and pelvic girdle pain by the yoga method: a randomized controlled study”. J Altern Complement Med. 2014 Jan;20(1):24-31
31 Satyapriya M, Nagarathna R, Padmalatha V, Nagendra HR. “Effect of integrated yoga on anxiety, depression & well being in normal pregnancy.” Complement Ther Clin Pract. 2013 Nov;19(4):230-6.
32 Muzik M, Hamilton SE, Lisa Rosenblum K, Waxler E, Hadi Z. “Mindfulness yoga during pregnancy for psychiatrically at-risk women: preliminary results from a pilot feasibility study”. Complement Ther Clin Pract. 2012 Nov;18(4):235‐40.
33 Curtis K1, Weinrib A, Katz J. “Systematic review of yoga for pregnant women: current status and future directions”. Evid Based Complement Alternat Med. 2012
34 Field T, Diego M, Delgado J, Medina L. “Tai chi/yoga reduces prenatal depression, anxiety and sleep disturbances”. Complement Ther Clin Pract. 2013 Feb;19(1):6-10.