Pain in Pregnancy
Musculoskeletal pain is a common problem in pregnancy including low back pain, pubic pain (symphysis pubis syndrome) hand and wrist pain. The are a number of known reasons why this occurs and with this knowledge we can offer treatment and management strategies to ease symptoms and movement. Clearly there are a range of factors to consider such as pre-existing painful problems, general health, the stage of pregnancy, any stress or anxiety, any injurious event surrounding the pain and the goals of the individual. Here is a brief overview of the causes of such problems and the modern approached to treatment.
Pain is a normal experience produced by our brains when there is the implicit perception of threat to ourselves. This is part of a co-ordinated response to promote survival and includes changes in movement, blood flow, the initiation of healing if tissues are damaged or gradually and heightened awareness of our bodies and surroundings. With time in many cases this process diminishes and normal function and sensation is restored. However, it is not uncommon for the problem to persist in terms of pain and reduced ability to perform day to day activities. When there is no reason for the body to continue to protect itself, the pain and symptoms are no longer useful but indeed carry on. This latter scenario affects millions of people with back pain, neck pain, recurring injuries and pain for example. Other conditions can involve recurring bouts of inflammation that causes pain, for example arthritis.
Modern treatment of these different scenarios, acute and chronic, requires that the tissues are considered but also the nervous system (spinal cord and brain) where changes in it’s properties and function lead to persisting and recurring pain states. Other body systems are also important and influential including the immune system, homeostatic systems (e.g. restoring balance, effects of stress), endocrine system (hormones) and the autonomic nervous system.
Pain is a sensation that we feel every day in most cases, whether we knock our elbow, experience a headache, receive bad news or sit too long and develop sore shoulders. We take note of the signal and do something about it, seek help, take a pain killer or perhaps move around. That is the purpose of pain, to motivate some action, like hunger and thirst. So, if pain is normal, are you more likely to experience pain during pregnancy? I believe that this is difficult to answer although there will certainly be some short-term pain and understood pain at the end of the journey usually relieved with gas and air or an epidural!
The typical complaints during pregnancy are back pains, pubic pains and upper limb symptoms. Of course the body is changing during the period of pregnancy including size, shape and tissue quality. The first two points are obvious but they do alter the way you move, your centre of gravity and ability to fully mobilise joints. This has short-term consequences that mean the muscles can feel tight or stiff primarily due to restricted movement that leads to these sensations. If you do not move tissues they tighten up. The physical strain increases as time passes and although females have bend assigned to bear this load it is still hard work (I can only say this on the basis of appearance and what I am told!). Similar to when you increase exercising or take up a new activity, the body must adapt and this can be painful. This is a normal response to this type of change in the body tissues.
With greater laxity developing in the tissues there is more demand on the controlling mechanisms in relation to movement. This is controlled by hormones that have a role in preparing the body for birth. Consequently, there can be greater movement at the joints and in the muscles therefore increasing the demand. Again this can be provocative as the brain seeks to let you know that the area is under strain. However, this is weighed against the clear need for greater laxity for the birthing process.
Most mums-to-be are aware of the changing hormone patterns as they ride waves of emotional change, many of which are again normal. Excitement, joy and anxiety are all common emotions during pregnancy as thoughts trundle through the mind. Other life factors play a role including pre-existing worries and stresses. We know much about stress physiology and pain and how anxieties and anticipation amplify pain. Essentially inter-related, in treating pain we must account for stress and anxiety and provide coping measures and strategies to dampen the effects upon the sensitivity. Emotional state has a clear influence upon pain as shown empirically and through defined anatomical links in the brain. In addition, we know that oestrogen can also have a sensitising effect upon the nervous system and therefore have a role in amplifying danger signals and increasing the likelihood of a pain experience.
Bearing the aforementioned in mind we can then offer a range of strategies and treatments that tackle pain at different levels. This includes tissue based therapies such as massage and joint mobilisation help to ease stiffness and pain enabling freedom of movement, exercise therapy to improve and maintain normal movement, cognitive techniques to reduces stress and anxiety such as breathing and mindfulness and developing understanding of the changes to reduce concerns about movement. Pain in it’s modern sense is a multidimensional experience that requires an approach that recognises this fact. Treatment that works on a spectrum of body, mind and brain is called biopsychosocial and considers the biology of pain, the psychological influences and social impact. The scientific literature tells us clearly that this is the best way to manage and treat pain and indeed with pain during pregnancy this is no exception.
It is wise to seek professional advice if you are suffering pain so that you can be reassured and know what you need to do. Keeping physically and mentally healthy is important with a regular routine of exercise, socialising, rest and learning (read, music, language etc). All in all we can aim to thoroughly enjoy the experience and keep suffering to a minimum.
Richmond Stace MCSP MSc (Pain) BSc (Hons)
Specialist Pain Physiotherapist & Clinic Director
Specialist Pain Physio Clinics, London