WHO recommendation on interventions for the relief of low back and pelvic pain during pregnancy

WHO recommendation on interventions for the relief of low back and pelvic pain during pregnancy

Recommendation

Regular exercise throughout pregnancy is recommended to prevent low back and pelvic pain. There are a number of different treatment options that can be used, such as physiotherapy, support belts and acupuncture, based on a woman’s preferences and available options.

(Recommended)

 

Publication history

First published: November 2016

Updated: No update planned

Assessed as up-to-date: November 2016

 

Remarks

  • Exercise to prevent low back and pelvic pain in pregnancy can take place on land or in water. While exercise may also be helpful to relieve low back pain, it could exacerbate pelvic pain associated with symphysis pubis dysfunction and is not recommended for this condition.
  • Regular exercise is a key component of lifestyle interventions, which are recommended for pregnant women as part of ANC to prevent excessive weight gain in pregnancy.
  • Pregnant women with low back and/or pelvic pain should be informed that symptoms usually improve in the months after birth.
  • Women should be informed that it is unclear whether there are side-effects to alternative treatment options due to a paucity of data.
  • Standardized reporting of outcomes is needed for future research on treatment for low back and/or pelvic pain in pregnancy.

 

Background

Women’s bodies undergo substantial changes during pregnancy, which are brought about by both hormonal and mechanical effects. These changes lead to a variety of common symptoms – including nausea and vomiting, low back and pelvic pain, heartburn, varicose veins, constipation and leg cramps – that in some women cause severe discomfort and negatively affects their pregnancy experience. In general, symptoms associated with mechanical effects, e.g. pelvic pain, heartburn and varicose veins, often worsen as pregnancy progresses. Low back and pelvic pain is estimated to occur in half of pregnant women, 8% of whom experience severe disability (1).

 

Methods

The ANC recommendations are intended to inform the development of relevant health-care policies and clinical protocols. These recommendations were developed in accordance with the methods described in the WHO handbook for guideline development (2). In summary, the process included: identification of priority questions and outcomes, retrieval of evidence, assessment and synthesis of the evidence, formulation of recommendations, and planning for the implementation, dissemination, impact evaluation and updating of the guideline.

The quality of the scientific evidence underpinning the recommendations was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) (3) and Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) (4) approaches, for quantitative and qualitative evidence, respectively. Up-to-date systematic reviews were used to prepare evidence profiles for priority questions. The DECIDE (Developing and Evaluating Communication Strategies to support Informed Decisions and Practice based on Evidence) (5) framework, an evidence-to-decision tool that includes intervention effects, values, resources, equity, acceptability and feasibility criteria, was used to guide the formulation and approval of recommendations by the Guideline Development Group (GDG) – an international group of experts assembled for the purpose of developing this guideline – at three Technical Consultations between October 2015 and March 2016.

To ensure that each recommendation is correctly understood and applied in practice, the context of all context-specific recommendations is clearly stated within each recommendation, and the contributing experts provided additional remarks where needed.

In accordance with WHO guideline development standards, these recommendations will be reviewed and updated following the identification of new evidence, with major reviews and updates at least every five years.

Further information on procedures for developing this recommendation are available here.

 

Recommendation question

For this recommendation, we aimed to answer the following question:

  • For pregnant women (P), what interventions (pharmacological or non-pharmacological) for pelvic and back pain (I) compared with no interventions (C) reduce morbidity and improve outcomes (O)?

 

Evidence summary

The evidence on the effects of various interventions for low back and pelvic pain in pregnancy was derived from a Cochrane review that included 34 trials involving 5121 women (6).

The definitions and terminology of low back and pelvic pain varied such that in 15 trials the interventions were aimed at reducing low back pain, in six trials interventions were for pelvic pain, and in 13 trials the interventions were for low back and pelvic pain. Most trials evaluated treatment; however, six trials evaluated prevention. Few trials contributed data to analyses and several individual study findings were described only in narrative. Main outcomes were relief of symptoms and functional disability, and perinatal outcomes relevant to this guideline were not reported.

Comparisons included:

1. Any exercise (plus standard care) versus standard care

2. Acupuncture (plus standard care) versus sham acupuncture (plus standard care)

3. Acupuncture (plus standard care) versus individualized physiotherapy (plus standard care)

4. Osteopathic manipulation (plus standard care) versus standard care

5. One type of support belt versus another typee

6. Multimodal interventions versus standard care.

 

Any exercise (plus standard care) versus standard care

Seven trials (645 women) contributed data to this comparison for low back pain. Trials were conducted in Brazil, the Islamic Republic of Iran, Norway, South Africa and Thailand. Exercise interventions varied from individually supervised exercise to group exercise, including yoga and aqua-aerobics, and some included education via CDs and booklets. Interventions ran for 8–12 weeks and the presence or intensity of pain was assessed in most trials using visual analogue scales. However, the evidence on symptom relief from a meta-analysis of these seven studies is very uncertain.

Low-certainty evidence suggests that functional disability scores are better with exercise interventions for low back pain (2 trials, 146 women; standardized MD: 0.56 lower, 95% CI: 0.23–0.89 lower). Evidence on pain intensity (symptom scores) for low back pain was assessed as very uncertain. Low-certainty evidence suggests that an 8- to 12-week exercise programme may reduce low back and pelvic pain compared with standard care (4 trials, 1176 women; RR: 0.66, 95% CI: 0.45–0.97) and moderate-certainty evidence shows that healthy pregnant women taking part in an exercise programme are probably less likely to take sick leave related to low back and pelvic pain (2 trials, 1062 women; RR: 0.76; 95% CI: 0.62–0.94).

 

Acupuncture (plus standard care) versus sham acupuncture (plus standard care)

Four small studies conducted in Sweden and the USA evaluated the effects of acupuncture plus standard care versus sham acupuncture plus standard care. However, little data were extracted from these studies and data could not be pooled.

Low-certainty evidence from one study suggests that acupuncture may relieve low back and pelvic pain (72 women; RR: 4.16, 95% CI: 1.77–9.78). Evidence from other studies was variously reported and very uncertain.

 

Acupuncture (plus standard care) versus individualized physiotherapy (plus standard care)

One small study conducted in Sweden involving 46 women with low back and pelvic pain evaluated this comparison. Women’s satisfaction with treatment was the main outcome, but the evidence was assessed as very uncertain.

 

Osteopathic manipulation therapy (OMT) (plus standard care) versus no osteopathic manipulation (standard care)

Three studies evaluated OMT; however, data could not be pooled and the evidence from individual studies is inconsistent. The largest study involving 400 women compared OMT plus standard care with placebo ultrasound plus standard care, or standard care only. Limited data from this study suggests that OMT may relieve low back pain symptoms more than standard care, and may lead to lower functional disability scores, but may not be better than placebo ultrasound for these outcomes.

 

One type of support belt versus another type

One small study conducted in Australia compared two types of support belts in women with low back pain, the BellyBra® and Tubigrip® (N = 94) and the evidence from this study was assessed as very low-certainty evidence.

 

Multimodal interventions versus standard care

One study in the USA reported the effect of a multimodal intervention that included weekly manual therapy by a chiropractic specialist, combined with daily exercise at home, and education versus standard care (rest, exercise, heat pads and analgesics) on low back and pelvic pain. Moderate-certainty evidence suggests that the multimodal intervention is probably associated with better pain scores (1 study, 169 women; MD: 2.70 lower, 95% CI: 1.86–3.54 lower) and better functional disability scores (MD: 1.40 lower; 95% CI: 0.71–2.09 lower) compared with standard care.

 

Additional considerations

It is not clear whether the evidence on exercise interventions applies equally to low back pain and pelvic pain, or equally to prevention and treatment, as data from studies of prevention and treatment were pooled. Evidence from two studies on the effect of exercise plus education suggests that such interventions may have little or no effect on preventing pelvic pain (RR: 0.97; 95% CI: 0.77– 1.23).

Very low-certainty evidence on a number of other interventions, such as transcutaneous electrical nerve stimulation (TENS), progressive muscle relaxation with music, craniosacral therapy, and acetaminophen (paracetamol) – which were evaluated in single small trials with apparent relief of symptoms relative to standard care – was also presented in the review.

Standard care of low back and pelvic pain symptoms usually comprises rest, hot or cold compresses, and paracetamol analgesia. There is a paucity of evidence on potential side effects of alternative therapies, e.g. chiropractic and osteopathic manipulation, and further high-quality research is needed to establish whether these therapies are beneficial for low back and/or pelvic pain and safe during pregnancy. Exercise in pregnancy has been shown to have other benefits for pregnant women, including reducing excessive gestational weight gain.

Resources

Exercise can be administered in a group setting and individually at home; therefore, the cost of exercise interventions varies. Support belts are available commercially from under US$ 10 per item. Physiotherapy and acupuncture require specialist training and are therefore likely to be more resource intensive.

Equity

Improving access to low back and pelvic pain interventions may reduce inequalities by reducing functional disability and sick leave related to low back and pelvic pain among disadvantaged women.  

Acceptability

Qualitative evidence from a diverse range of settings, indicates that while women generally appreciate the interventions and information provided during antenatal visits, they are less likely to engage with services if their beliefs, traditions and socioeconomic circumstances are ignored or overlooked by healthcare providers and/or policy-makers (high confidence in the evidence) (7). This may be particularly pertinent for an intervention like acupuncture, which may be culturally alien and/or poorly understood in certain contexts. In addition, where there are likely to be additional costs associated with treatment or where the treatment may be unavailable (because of resource constraints), women are less likely to engage with health services (high confidence in the evidence).

Feasibility

A lack of resources may limit the offer of treatment for this condition (high confidence in the evidence) (8).

 

Further information and considerations related to this recommendation can be found in the WHO guidelines, available at:

http://apps.who.int/iris/bitstream/10665/250796/8/9789241549912-websupplement-eng.pdf?ua=1

 

Implementation considerations

  • The successful introduction of evidence-based policies related to antenatal care into national programmes and health care services depends on well-planned and participatory consensus-driven processes of adaptation and implementation. These processes may include the development or revision of national guidelines or protocols based on this recommendation.
  • The recommendation should be adapted into locally-appropriate documents and tools that are able to meet the specific needs of each country and health service. Modifications to the recommendation, where necessary, should be justified in an explicit and transparent manner.
  • An enabling environment should be created for the use of this recommendation, including changes in the behaviour of health care practitioners to enable the use of evidence-based practices.
  • Local professional societies may play important roles in this process and an all-inclusive and participatory process should be encouraged.
  • Antenatal care models with a minimum of eight contacts are recommended to reduce perinatal mortality and improve women’s experience of care. Taking this as a foundation, the GDG reviewed how ANC should be delivered in terms of both the timing and content of each of the ANC contacts, and arrived at a new model – the 2016 WHO ANC model – which replaces the previous four-visit focused ANC (FANC) model. For the purpose of developing this new ANC model, the ANC recommendations were mapped to the eight contacts based on the evidence supporting each recommendation and the optimal timing of delivery of the recommended interventions to achieve maximal impact.

 

Research implications

The GDG identified this priority question related to this recommendation

  • What is the prevalence of common physiological symptoms among pregnant women in low-resource settings, and can the offer of treatment of these symptoms reduce health inequality, improve ANC coverage and improve women’s pregnancy experiences?

 

Related links

WHO recommendations on antenatal care for a positive pregnancy experience

(2016) - full document and evidence tables

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

WHO Programmes: Sexual and Reproductive health

Maternal Health

 

References

  1. Albert H, Godskesen M, Westergaard J. Prognosis in four syndromes of pregnancy-related pelvic pain. Acta Obstet Gynecol Scand. 2001;80:505–10.
  2. WHO handbook for guideline development, 2nd edition. Geneva: World Health Organization; 2014 (http://www.who.int/kms/handbook_2nd_ ed.pdf, accessed 6 October 2016).
  3. GRADE [website]. The GRADE Working Group; 2016 (http://gradeworkinggroup.org/, accessed 27 October 2016).
  4. GRADE-CERQual [website]. The GRADECERQual Project Group; 2016 (https://cerqual. org/, accessed 27 October 2016).
  5. The DECIDE Project; 2016 (http://www.decide-collaboration.eu/, accessed 27 October 2016).
  6. Liddle SD, Pennick V. Interventions for preventing and treating low-back and pelvic pain during pregnancy. Cochrane Database Syst Rev.2015;(9):CD001139.
  7. Downe S, Finlayson K, Tunçalp Ö, Gülmezoglu AM. Factors that influence the use of routine antenatal services by pregnant women: a qualitative evidence synthesis. Cochrane Database Syst Rev. 2016;(10):CD012392
  8. Downe S, Finlayson K, Tunçalp Ö, Gülmezoglu AM. Factors that influence the provision of good quality routine antenatal care services by health staff: a qualitative evidence synthesis. Cochrane Database Syst Rev. 2016

 

Citation: WHO Reproductive Health Library. WHO recommendation on interventions for the relief of low back and pelvic pain during pregnancy. (November 2016). The WHO Reproductive Health Library; Geneva: World Health Organization.