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Lumbar back and posterior pelvic pain in pregnancy

INTRODUCTION
Pelvic change in pregnancy is a well-known problem and has been documented since the Hippocratic period. It was believed that the pelvis expanded during the first pregnancy and thereafter remained permanently enlarged throughout life. In the sixteenth century, it was maintained that delivery was possible only because of enormous yielding of the female pelvis. Cantin (1899), at the end of the nineteenth century, found palpable evidence of movement of the pubic symphysis among all but 2% of 500 women late in pregnancy. He believed that increased motion in the pelvic joints was a problem in itself. He also believed that it was the most common and most overlooked problem in pregnancy.

In modern times, pelvic changes in pregnancy have been described by several authors (Berg et al 1988, Farbrot 1952, Kristianss on 1996, MacLennan et al 1986, Ostgaard et al 1994a, Walde 1962, Young 1940). Widening of the symphysis pubis has been illustrated on X-rays from the 8th week in normal pregnancies (Genell 1949). There is no correlation between the degree of symphyseal widening and pain in the pelvis during pregnancy, and pain can not be related to any radiographic finding. In spite of the development of imaging, including computerized tomography (CT) and magnetic resonance tomography (MRT), we still have to rely on a thorough clinical examination and a good history when diagnosing pelvic pain among pregnant women.

EPIDEMIOLOGY
Back pain is frequent among pregnant women (Berg et al 1988, Endresen 1995, Fast et al 1987, Grtinfeld & Qvigstad 1991, Hauge-Lundby et al 1991, Mantle et al 1977, Ostgaard et al 1991a, 1994a, Sydsjö et al 1989) and is often accepted as an unavoidable complaint of normal pregnancy. Several studies have found that more than 50% of all pregnant women have some kind of back pain during pregnancy. Fortunately, the majority of women with back pain during pregnancy recover spontaneously shortly after delivery. Back pain in pregnancy has been regarded as a self-healing condition. Therefore, no effective treatment of these problems or early identification of at-risk patients has been developed. Unfortunately, some women with pain during pregnancy do not get well spontaneously. These women often encounter little understanding when they seek medical advice for their pain. They are often misunderstood and treated as psychosomatic cases. Sometimes pain from the lumbar region of the back is confused with pain from the posterior pelvis, or vice versa. Therefore, treatment for back pain in pregnant women often fails (Dumas et al 1995a, 1995b).

Back pain is reported by more than one out of every two women for longer or shorter periods during pregnancy (Berg et al 1988, Endresen 1995, East et al 1987, Grtinfeld & Qvigstad 1991, Hauge-Lundby et al 1991, Ostgaard et al 1991a, 1994a, SydsjO et al 1989), and the number of pregnant women complaining of some kind of back pain seems to have increased over the past few decades (Grtinfeld z Qvigstad 1991, HaugeLundby et al 1991, SydsjO et al 1989). The reason for this increase is multifactorial and to a large extent unknown. Nowadays, more women are at work, often on low wages and with ergonomically badly planned work places. In most jobs the working day cannot be planned around the capacity of a pregnant woman, who often also has to take care of the house and children. All these factors are known to increase the number of complaints of back pain in a non-pregnant population, and there is no reason to believe that pregnant women should respond differently. Furthermore, pregnant women are being told that pregnancy is not a disease, so normal working capacity is expected. Some pregnant women can initially fulfil these demands, but no woman can do it throughout pregnancy. Pregnancy is not a disease, but it produces a very large and growing burden on the female body.

Pain intensity has been reported to average 4.3 on a 0-10 visual analog (VA) scale, with large variations and a maximum pain intensity around the 30th week of pregnancy. Two studies showed that 70% of all working pregnant women in Sweden took sick leave for some reason at some time during their pregnancy (Hauge-Lundby et al 1991, Sydsjo et al 1989). This sick leave period amounted to on average, 7 weeks, unspecified `back pain' being by far the most prevalent diagnosis (Ostgaard & Andersson 1992). Other studies from Scandinavia have shown the same trend (Granfeld & Qvigstad 1991, HaugeLundby et al 1991), indicating that back pain in pregnancy is also a large socioeconomic problem.

DEFINITIONS
The concept of back pain in pregnancy. is. not well defined, and the anatomic origin of the pain is unknown. Earlier studies have shown that it is important to define two types of back pain during pregnancy (Endresen 1995, Ostgaard et al 1991a, 1994a, 1996b): pain from the lumbar area and pain from the posterior part of the pelvis. Those two types of pain should be treated differently, as inappropriate treatment may increase pain. The two types of pain may occur simultaneously or at different times in the same individual during pregnancy and after delivery. Pain in the pubic symphysis is not an isolated phenomenon but is normally found in women with posterior pelvic pain.

THE POSTERIOR PELVIC PAIN PROVOCATION TEST
The posterior pelvic pain provocation test is very useful in distinguishing between the two types of pain. It is performed with the patient supine and her hip flexed to 90°. When the woman's femur is gently pressed posteriorly by the examiner, simultaneously stabilizing the patient's pelvis, the test is said to be positive when the woman feels a pain that she recognizes in her posterior pelvis (Ostgaard et al 1994a, 1994b) (Fig. 33.1). The test is not specific for any anatomic structure, but it does help to identify women with posterior pelvic pain. Evaluation of the test has shown that in this aspect the test has a specificity of 80% and a sensitivity of 81% (Ostgaard et al 1994b).

PAIN DRAWINGS
Pain drawings are useful when back pain in a nonpregnant population is classified (Ransford et al 1975), and they are also a great help among pregnant women. The drawings can be completed by the patient before the consultation; the markings are different for lumbar pain and posterior pelvic pain. Furthermore, pain drawings will help to identify women with non-physiologic pain patterns.

Lumbar back pain
Lumbar back pain is common in the general population as well as among pregnant women. The condition is not specific for pregnancy but is often found among pregnant women who have had lumbar back pain earlier in life. The same women will often have lumbar back pain after delivery. The pain intensity during pregnancy is less than among women with posterior pelvic pain. Some increase of pain intensity may occur because of the extra load on the spine caused by pregnancy. These women will mark the lumbar area above the pelvis on pain drawings.

Posterior pelvic pain
Pregnancy may also predispose to a different type of pain (Mantle et al 1977). This type is described by a large number of pregnant women and is located in the posterior part of the pelvis distal and lateral to the lumbosacral junction. It is felt deep in the gluteal area and is often described as stabbing. The pain may radiate to the posterior thigh and may extend to the knee. There is a history of time- and weight-bearing-related pain, as well as pain-free intervals with sudden pain attacks. There is free range of motion in the back and hips. Twisting and asymmetric loading of the pelvis is most painful, for example when vacuum cleaning. Overloading of the pelvis will often cause more pain the following day. The condition may be uni- or bilateral and is often misinterpreted as sciatica, facet joint syndrome, or lumbar back insufficiency. The condition is, however, different from sciatica in that it is less specific than the nerve root syndrome in distribution and does not extend down into the foot. It is different from facet joint syndrome and lumbar back insufficiency because it does not emerge from the lumbar area and does not include a reduced range of motion in the spine. Furthermore, there is no initial muscle weakness or sensory impairment, and reflexes are normal. Therefore, the condition should not be treated as lumbar back insufficiency, facet joint syndrome, or sciatica (Mantle et al 1977, Ostgaard et al 1994a). On the contrary, women with posterior pelvic pain may feel more pain if treated with back-strengthening exercise. Pain drawings will be marked distal and lateral to the lumbosacral junction.

Some 10% of all pregnant women suffer from more than one of these conditions, which complicates the problem of back pain in pregnancy (Berg et al 1988, Endresen 1995, Ostgaard et al 1994a).

Synaplaysiollysis
An increased range of motion and pain from the pubic symphysis is often registered in pregnancy but is not an isolated phenomenon. There are three joints in the pelvic ring, and it is therefore not possible to have an increased range of motion isolated to just one joint. To accomplish symphysiolysis, the range of motion must also be increased in at least one of the sacroiliac joints (Sijs). Consequently, anterior pelvic problems are caused by posterior pelvic malfunction. A thorough examination of the pelvis will detect that pain from the pubic symphysis is always combined with posterior pelvic pain (Ostgaard et al 1991a, 1994a).

SUMMARY OF CHARACTERISTICS FOR LUMBAR BACK AND POSTERIOR PELVIC PAIN

Lumbar back pain:
o a history of lumbar back pain even before pregnancy
o a pain drawing with markings cranial to the sacrum
o pain and a decreased range of motion in the lumbar spine
o pain on palpation of the erector spinae muscle
o a negative posterior pelvic pain provocation test.

Posterior pelvic pain:
o no history of back pain before the first pregnancy
o a pain drawing with markings in the gluteal area
o time- and weight-bearing-related pain
o pain-free intervals with sudden pain attacks
o a free range of motion in the hips and spine and no nerve root syndrome
o a positive posterior pelvic pain provocation test.

BIOMECHANICS
Posterior pelvic pain may be caused by a disturbance of the requested coordination of ligaments, muscles, and joints in the posterior part of the pelvis. The problem is probably caused by the combined effect of the pregnancy hormones relaxin, estrogens, and progesterone on the large ligaments in the posterior part of the pelvis. The result is an increased laxity, allowing a small but important instability in the pelvic joints. This is a speculation based on scattered scientific findings, and there is no thorough proof for the theory. However, there is a well-documented increased range of motion in the pelvic joints, which may compromise pelvic stability. Instability in the pelvis is inconsistent with normal body motion. Increased muscular tension in the large muscles of the posterior pelvis and lumbar spine may follow, as an attempt to re-establish pelvic stability. If left untreated, longlasting increased muscle tension will cause pain, leading to secondary muscle insufficiency, and a vicious circle has started. Recent studies have shown a higher incidence of pain in the posterior pelvis among women with elevated levels of relaxin in blood samples taken during pregnancy (Mantle et al 1977, Kristiansson 1996). It has been postulated that the pain should derive from the SIJs, themselves, but there is no strong scientific proof for that. These joints appear normal on X-rays, CT scans, and MRT, so no known skeletal characteristic can be 'detected inthese women. Furthermore, there are no specific tests for SIT dysfunction. Several studies have found an intraexaminer variation of around 50% for most commonly used tests of dysfunction of the SIJ, indicating that these tests are highly unspecific (Laslett & Williams 1994). Apparently, all we know is that pain is found in the area of the posterior pelvis, so this is the expression we have chosen to describe the condition.

The anatomic details of SIJ pain are dealt with in other chapters in this book.


RISK FACTORS
It cannot be clearly anticipated which women will later develop pain in their pregnancy or, if they do, where the pain will present. As different areas may be involved in the same women at different times it is important to identify the areas of pain correctly and treat the women with respect to this. Some women will change pain type during pregnancy. It is not known in detail from which anatomic structures pain emerges, either among women with lumbar back pain or among women with posterior pelvic pain. This ignorance is generally accepted as far as pain in the lumbar spine in a non-pregnant population, i.e. lumbago, is concerned. Likewise, it must be accepted for the pelvis among women in relation to pregnancy.

Women with a history of lumbar back pain earlier in life run a 2.1 times higher risk of getting lumbar back pain in a subsequent pregnancy, and women who are physically fit have a lower (0.7) risk of getting lumbar back pain in pregnancy (Ostgaard & Andersson 1991b). Furthermore, such vocational factors as heavy lifting, monotony at , work, and low job satisfaction have an unfavorable impact on developing lumbar back pain in pregnancy, as do many social factors. In these aspects, pregnant women follow the. same pattern as in a non-pregnant population (Ostgaard et al 1991a). The known risk factors for lumbar back pain in pregnancy cannot be summated in a simple way, so we still know little about which women will develop lumbar pain in a future pregnancy (Ostgaard & Andersson 1991b).

No prepregnancy risk factors for posterior pelvic pain are known. During a first pregnancy, the pelvis is in a totally new condition, and we can only speculate about how it will react. There is evidence that physical exercise before pregnancy is not beneficial, as even well-trained athletes may get serious posterior pelvic pain, although lumbar pain is not as common in this group of women (Ostgaard et al 1994a). Posterior pelvic pain may begin very early in pregnancy, but it begins on average in the 18th week, long before any increase in weight has occurred. This indicates that hormonal changes, rather than increased weight, are connected with this type of pain. Furthermore, there is no correlation between pain and body weight before pregnancy nor between pain and weight increase during pregnancy (Ostgaard et al 1991b). The theory of an early hormonal effect on the ligaments of the body is supported by the correlation between high concentrations of relaxin in the first trimester of pregnancy (MacLennan et al 1986) and a general increase in ligament laxity from the 12th to the 24th week of pregnancy (Ostgaard et al 1993). As no risk factors are known, no prophylaxis against posterior pelvic pain in pregnancy is possible. However, after posterior pelvic pain during pregnancy, there is a small trend for the same pain to recur in subsequent pregnancies. Apparently, only little is to be gained from known risk factors with respect to lumbar pain and almost nothing for posterior pelvic pain. The solution is to wait for the pain to appear and then to classify and treat it as soon as possible. Allpregnant women should be informed early during pregnancy on what to expect from their backs and pelvises later in pregnancy and to seek help promptly if pain appears. A thorough examination should then be made to initiate the correct treatment, be it of the back, the pelvis, or a combination of the two.

DEVELOPMENT OF PAIN
When using the above-mentioned criteria, the types of pain will be distributed in incidence during pregnancy as shown in Fig. 33.3, and the two groups will respond to physiotherapy. Some 10% of the women will have symptoms from the pelvis as well as from the lumbar back. The majority of these women will have had a lumbar back pain problem before pregnancy and have developed posterior pelvic pain later during pregnancy. Pain intensity during pregnancy is higher among women with posterior pelvic pain. After delivery, pain in the lumbar back is more intense. Furthermore, after delivery, women with posterior pelvic pain will improve more than women with lumbar pain (Ostgaard et al 1996b).

TREATMENT
The majority of women with locomotor problems in pregnancy have posterior pelvic pain. The cause of pelvic pain is primarily hormonal changes induced by pregnancy, which, of course, cannot be eliminated without great danger to the fetus. The condition itself cannot be cured during pregnancy, but secondary muscle pain may be prevented. There is evidence that, provided no secondary muscle pain develops, posterior pelvic pain will, largely speaking, always disappear soon after pregnancy. However, muscular pain may become chronic when once established. One study showed that persisting lumbar back and posterior pelvic pain 18 months after delivery existed in more than 35% of all women who had received no treatment during pregnancy. Most of the women, however, experienced some type of regression of symptoms, but 7% had no regression of pain at all (Ostgaard & Andersson 1992). In a study of women who had been treated with physiotherapy and given information about their condition during pregnancy, only 11% had persisting pain 5 months after delivery and only 3% had no regression at all (Ostgaard et al 1996b). In other words, much is to be gained by treating these women during pregnancy.
Treatment of pregnant women with simple lumbar back pain, where muscular insufficiency is predominant, is not complicated. Serious lumbar back disease presenting for the first time during pregnancy is rare. Disc herniations appear in 1 in 10 000 pregnancies (Heliovara et al 1987) and hardly any of these women need an operation during pregnancy. Other degenerative back diseases are rare at the time of life when pregnancy takes place. There is no evidence that scoliosis gets painful or increases in painfulness during pregnancy. However, severe spondylolisthesis may cause increased pain late in pregnancy because of the increased load on the lumbar spine in combination with the hormone-induced ligament laxity.

The treatment of lumbar back pain among pregnant women is basically the same as in a non-pregnant population: for example, education in anatomy and kinesiology, back-strengthening exercises, training in range of motion, and body posture correction to avoid hyperlordosis, which is common among pregnant women (Snijders etal 1976). Later in pregnancy, there is a relative insufficiency of the abdominal muscles because of the normal elongation and separation of the two rectus abdominis muscles caused by the expanding uterus. The muscles of the abdominal wall should be trained specifically to reduce this insufficiency, which cannot be totally avoided. Furthermore, being physically fit before pregnancy reduces the risk of lumbar pain, of which all women should be informed before they become pregnant. It is much easier to become physically fit before getting pregnant than to begin training after pregnancy has started to influence the body.

Posterior pelvic pain
There is no cure for posterior pelvic pain while pregnant. The challenge is to teach these women how to live with a pelvis that is insufficient to serve as the stable center of normal body motion. For simple biomechanic reasons, daily demands of walking, lifting, sitting, housekeeping, or taking care of children may become overwhelming problems. It is possible to increase stability in the pelvis by muscular force, but only for a limited period of time. If the large ligaments in the posterior part of the pelvis are insufficient, the muscles will invariably soon fail, which is why these women can do most things only for a short period of time. After a while, however, they have to change body position, for example from walking to sitting, standing to lying, or vice versa, as even these simple everyday actions become painful. Even in sitting, normally functioning ligaments and muscles are required to keep the sacrum from rotating in relation to the iliac bones. The forces on the pelvis are as large in sitting as in standing, the only difference being that the weight shifts from the hip joints to the ischial tuberosities. However, this small change may be a temporary relief for tense muscles. Education in anatomy and kinesiology is the key for these women to handle their situation. Furthermore, relaxation training is important to release tense muscles.. It is crucial to understand that vigorous exercise will increase pain, as such exercise demands a stable pelvis. Ligament insufficiency cannot be overcome by exercise, a painful lesson many well trained women with posterior pelvic pain have learned. Most musculoskeletal pain disappears without exercising being discontinued, but this is unfortunately not the case with posterior pelvic pain. Typically, the pain increases after exercise and presents on the following day. The insufficiency of the pelvis must be respected, and all exercise performed within the limits of this insufficiency; it must be remembered that normal muscle function is not possible around a malfunctioning joint anywhere in the body.

If the pelvis is unstable, it must be accepted that locomotion is impaired. Avoiding stairs, one-leg standing, an extreme range of motion in the hips and back, overloading the pelvis, and physical monotony is good advice. A pelvic belt will help 80% of the women (Ostgaard et al I994a), and in severe cases walking sticks may be needed.

Following the above advice will not restore normal function but it will reduce pain. A wheelchair should always be avoided, as it will increase muscular insufficiency. This makes rehabilitation more difficult later on, when the ligaments have returned to normal functioning shortly after delivery. For the same reason, prolonged bedrest is not recommended.

Manipulation of the pelvis is a matter of debate. If used, it must be with great care and always in combination with muscle training, relaxation and increased muscle control. Manipulation alone will not help in the long run. A further description of this method is found elsewhere in this book. Cesarean section is never indicated for lumbar back pain, and hardly ever for cases of posterior pelvic pain. Providing that adequate physiotherapy is available, no woman should ever develop a situation in which caesarean section 'is discussed for these reasons. Sick leave because of lumbar back and posterior pelvic pain can be reduced during pregnancy by physiotherapy and information. In a study from Sweden, sick leave for lumbar back and posterior pelvic pain during pregnancy amounted to 54 days per woman among controls, while women who were treated with physiotherapy and given information took sick leave for 30 days during pregnancy, a statistically significant difference (Ostgaard, 1996a). The true reasons for thereduction of pain and sick leave are not known. An education and training program may reduce pain and anxiety by teaching the women how to handle their problems better, but the mere effect of being cared for per se cannot be neglected.

THE MODEL
One model for taking care of pregnant women with back or pelvic pain is as follows (Fig. 33.4). At her first visit to the midwife or obstetrician, the pregnant woman should be informed about possible future back and pelvic problems and where to get help, as well as the usual obstetric topics. A physiotherapist with a special interest in pregnancy problems is often preferable in this discussion. Helping a pregnant woman with such problems calls for teamwork to widen the skills available, as no obstetrician, midwife, or physiotherapist alone possesses all the necessary interdisciplinary knowledge. Whenever back pain occurs, the woman should have a thorough back and pelvic assessment and the problem should be identified as being lumbar back, posterior pelvic, or a combination of the two. An educational and training program should be developed with individual variations depending on the type of pain, and vocational and daily life demands. It has been shown that changes in ergonomics at the workplace are useful in reducing pain even during pregnancy (Ostgaard et al 1994a). If needed, a pelvic belt should be provided. Initially, it is important that women are given at least one individual consultation with the physiotherapist, but later on they may join fitness classes for pregnant women with the same pain type. However, some 15% of the women may change from one pain type to another during pregnancy, and they should also change training program. Furthermore, some women may get worse and may have to return to individual therapy for a time.

Using this model, half the women with back or pelvic pain will need only one individual consultation. One-third of the women will need two individual consultations, and no women will need more than four individual consultations. The subsequent problems can be managed in weekly fitness classes, with special emphasis on pain type, conducted by a physiotherapist (Ostgaard et al 1996a). This means that one physiotherapist is needed for every 1000 pregnant women. From a socioeconomic point of view this is a very good investment. In Sweden, a physiotherapist working in this way saves Social Insurance 10 times her own salary because of the reduction in sick leave among pregnant women (Ostgaard 1996a). How much the costs are reduced by earlier return to work after pregnancy is not known. Furthermore, the increased well-being and reduced pain cannot be expressed in economic terms.

AFTER DELIVERY
After delivery, posterior pelvic pain disappears in the majority of women within 3 months (Ostgaard & Andersson 1992). Some women may have developed a chronic posterior pelvic pain, which will persist even after the pelvis has regained its normal stability. These women should be referred to a physiotherapist for specific training of the muscles of the pelvis, abdomen, and back. It is important that the pelvic muscles are attended to first in order to stabilize the pelvis, and only thereafter should training of the back muscles be initiated. This rehabilitation is slow, 6-12 months, and always contains periods of serious relapse, which is very discouraging. It is important that the women are informed about this at the beginning of rehabilitation. A small group of women may get well spontaneously shortly after delivery and return to aphysically demanding daily life only to experience severe posterior pelvic pain some months later. Unfortunately, this is a bad omen. These women can be difficult to treat, and their rehabilitation may extend over several years. The treatment program is the same, but it should be started at a very low level and increased very slowly, with careful observation of relapses. Some of these women are so handicapped that they can start doing exercises only in a weightless condition in warm water. To avoid this problem, it should be emphasized that after delivery, although pain has disappeared, strenuous work should be avoided for at least 6 months if a woman has had posterior pelvic pain during pregnancy. There is a strong correlation between high pain intensity during pregnancy and persisting problems after delivery (Ostgaard & Andersson 1992, Ostgaard et al 1996b).

Painkillers seldom have any substantial effect and are best avoided during pregnancy and breast-feeding. Among women who have been treated by us during pregnancy, we have not seen severe prolonged postpartum problems. It should therefore be possible to avoid these longlasting pain problems in the future. Women with pain during pregnancy often worry about their own future, harm to the fetus, and their ability to take care of a newborn child when they are so handicapped. However, there is scientific evidence that problems with the child or the delivery itself in no way correlates to lumbar or posterior pelvic pain suffered during pregnancy (Ostgaard et al 1991b). Furthermore, the pain normally reduces substantially directly after delivery, often within a few days, so taking care of the newborn baby is seldom a great problem.

In looking for an explanation for posterior pelvic pain, the question of oral contraception is often raised. However, one published (Ostgaard et al 1991b) and several unpublished studies have shown -that no correlation exists. This indicates that, from an orthopedic point of view, oral contraception can be used as wanted, both before and after pregnancy, by all women.

Because posterior pelvic pain is induced by hormones, speculations about breastfeeding have arisen. Breastfeeding is supposed to change normal hormone levels and block ovulation to prevent a new early pregnancy. This might have an impact on the ligaments of the pelvis and thus on pain. One study (Ostgaard & Andersson 1992) has shown no correlation between breastfeeding and the regression of lumbar or posterior pelvic pain after pregnancy, so this is not a reason to stop breastfeeding. Furthermore, it is not a logical that breastfeeding that blocks a new pregnancy should increase pregnancy-induced problems. If more children are planned, one can speculate about the timing of the next pregnancy. There is no study on this issue, but even severe posterior pelvic pain often disappears within 1 year, provided that treatment is correct. Therefore posterior pelvic pain should not be the limiting factor when timing the next pregnancy. On the contrary, women well educated in the locomotor problems of pregnancy do not have to wait until all symptoms have disappeared before becoming pregnant again. Increased awareness of symptoms and early treatment will be sufficient in most cases.

In some centers, chronic posterior pelvic pain is treated by fusion of the SIJs (described elsewhere in this book). This is, in my opinion, seldom necessary.

CONCLUSIONS
1. Women with any type of back pain should be identified as early as possible and enrolled in a special program.
2. Back pain in relation to pregnancy should always be divided into two types, depending on the pattern of pain: pain in the lumbar area, and pain in the posterior part of the pelvis.
3. Differentiation into the two types of pain can be made by means of a short history-taking and a simple back and pelvis examination, including the posterior pelvic pain provocation test.
4. The two groups of women should be provided with individual information about their specific condition, and a program for muscle-training and relaxation should be developed.
5. The program must respect individual needs at home and at work, and any change in pain
6. A pelvic belt is recommended for women with posterior pelvic pain.
7. Teamwork with an obstetrician, a midwife, and a physiotherapist is necessary to cover the skills needed for these obstetric-orthopedic problems. 8. Most women will need only a few individual consultations, and later training can be performed in groups.
9. It is important that the exercise groups include only women with the same pain type, and changes in the type of pain must be looked for. Some women will need to go back to individual therapy for a short period.
10. With this planning, the intensity of lumbar back and posterior pelvic pain can be reduced during pregnancy and after delivery. The number of women with lumbar back pain can be reduced, and the number of women with chronic back pain after delivery can be diminished. Furthermore, the population of women with persisting posterior pelvic pain after pregnancy can be almost eliminated.
11. The abundant prescription of rest as the only treatment will do few women any good but will complicate rehabilitation because of general muscle wasting. Taking care of a newborn infant is a demanding job, and women who have been resting excessively because of undefined back pain are not best fit to fulfil the task.
12. After pregnancy, posterior pelvic pain should disappear spontaneously within 3 months. If it does not, the woman should consult the physiotherapist who helped her during pregnancy in order to avoid developing a chronic pain condition. Attention is often focused on the newborn, and the problems of the mother are either easily missed or are expected to disappear spontaneously along with other problems of pregnancy. Although newborn babies are fascinating, we ought. to pay more attention to their mothers: they may not be as well as they pretend.