A research Assignment presented to
The Faculty and Students Studying Diploma of Remedial Massage
Massage Schools of Queensland
Diploma of Remedial Massage HLT52015
The effectiveness of massage to alleviate pain during pregnancy
Massage therapy can provide significant relief to women during pregnancy. This article aims to discuss a broad overview of the literature on the effectiveness of massage during the various stages of pregnancy as well as post-partum. I will also discuss briefly other complementary therapies which may be applied.
Conducting of studies during pregnancy, poses researchers with significant ethical issues. The ethical dilemmas seen are a significant reason for a lack of quality studies and therefore lack scientific evidence in this area. Due to this lack of quality evidence I have included for this discussion, a small test group of women receiving treatment during pregnancy. 10 women were followed over a 20-week period to ascertain whether massage provided during gestation was of benefit (see appendix A for questionnaire provided to these women). Though due to ethics issues and lack of resources I have no control group.
I will discuss indications and contraindications and treatment strategies for effective Remedial Massage treatment, as well as the various ailments in which Massage Therapy is indicated during pregnancy. I will also give mention to other alternative therapies which may be of assistance.
Table of contents –
Table of contents……………………………………………………………………………2
Appendix – ……………………………………………………………………………………14
Low back pain(LBP) and pelvic girdle pain (PGP) are common dysfunction in pregnancy and may have a significant impact on the comfort and quality of life during a woman’s pregnancy LBP is characterised by pain between the 12th rib and the gluteal fold, PGP is typically in the sacroiliac joints. This paper will aim to discuss the prevalence and treatment options of these conditions during pregnancy, for which women tend to seek Massage therapy as treatment.
I will discuss the results of a reflective pain measurement survey given to 10 women treated in clinic during their gestational period, as well as reviewing the current literature on physical therapy and complementary therapies in pregnancy. Lower back pain and pelvic pain occurs in 60-70% of pregnancies and generally, symptomatology worsens throughout the pregnancy (as is suggested in my study group) while also with each subsequent pregnancy.
Back pain during pregnancy is extremely common and usually nothing to worry about, it can occur at almost any stage of your pregnancy; Though most common onset is in the second trimester. It is the opinion of the author that a specialised pregnancy table, on which the patient can lie in the prone position through your entire pregnancy is preferred, side-lying positions tend to exacerbate hip pain. The level of pain experienced can vary from patient to patient, and as mentioned earlier patients often experience increased symptoms in subsequent pregnancies. My survey will endeavor to provide evidence of effectiveness of Remedial Massage Therapy as a pain relief strategy for pregnant women. In cases where pain is severe and has not responded to a Pregnancy Massage a referral to a Women’s Health Physiotherapist or other health professionals may be necessary for diagnosis and a more advanced, further treatment.
Common causes of back pain during Pregnancy
Most often, back pain starts around mid-pregnancy, when the belly begins to show and pushes out of the pelvic area, however I have seen women with back pain beginning as early as 12 weeks. Pre-existing conditions may worsen during pregnancy, others may improve. The uterus can offer extra stability in the lumbar region which may improve symptoms of patients with pre-existing disc herniation, depending on the direction of the protrusion.
• Relaxin – hormone is released during pregnancy to allow the ligaments in the pelvis to soften, and the joints to become more flexible. This is a great thing when it comes time to give birth however, these changes are known to put extra strain on the spine and pelvis.
• Posture – As the uterus grows the pelvis tilts forward this puts a strain on the lumbar region which in turn affects the mid and upper thoracic regions.
• Weight Gain –The extra weight gained during pregnancy can put pressure on the entire body. As a Naturopath I recommend a low glycemic index diet with slightly increased protein and plenty of good fats. This style of diet is also helpful with inflammation, as elevated insulin levels are correlated with increased inflammation. However, I also like to advise patients not to obsess over it, every woman’s body responds differently to the hormones of pregnancy.
• Abdominal separation – the two lines of muscle running down the abdominals can begin to separate to accommodate the uterus as it pushes forward. If abdominal separation occurs this is something for which a consultation Women’s Health Physiotherapist indicated. It is crucial that a corrective abdominal exercise program is commenced postpartum ideally within 4 weeks of a natural birth in order to avoid an increased risk of the need for surgical intervention.
• Referred pain – women may experience weakness in other parts of the pelvis, such the pubic symphysis – a consultation with a Physiotherapist who specializes in women’s health is advised, as this may be indicative of pelvic girdle syndrome. This condition often is aided by wearing an SIJ support belt or SRC pregnancy shorts.
Pelvic girdle pain (PGP) also known as symphysis pubis dysfunction (SPD) is a condition which is characterised by pain in the joints at the back and front of the pelvis the sacroiliac joint and the posterior iliac crest. Pain is often deep in the sacral/gluteal region; typical onset is at 18weeks however in 20 years of clinical practice I have observed earlier onset coincides with increased severity of the condition. I have observed this in women as early as 12 weeks’ gestation. My clinical observations have been that women with hypermobility of joints, represent the majority of early pain presentations. Pain associated with SPD is observed to worsen as the pregnancy progresses. The effects of this syndrome may last for up to 2 years after childbirth. The underlying mechanism, leading to pelvic girdle pain in pregnancy is unclear. Factors that influence the development of pelvic girdle syndrome as stated by Physiopedia – Pregnancy related pelvic pain
use of the contraceptive pill
time interval since last pregnancy
higher fetal weight
number of previous pregnancies
genetics between first-degree relatives
the position of the baby
hyper mobility of the joints
long term pain: strenuous work, sick leave delivery rate, higher maternal weight, severe pain, decreased function less than 8 hours’ sleep
progestin- only contraceptive pills
Diagnosis of pelvic girdle syndrome
difficulty walking (pregnancy waddle)
pain on weight bearing on one leg – (eg climbing stairs)
pain and or difficulty in straddle movements -(such as getting out of a bed)
clicking or grinding in the pelvic area, (may be payable or audible)
pain on hip abduction
pain in lying positions -ie side lying
pain during sex
straight leg raise test
-Use of a pelvic support belt (SIJ) and or SRC Shorts
-Specific stabilizing exercises to retain motor control and strength of abdominal muscle. Pilates is an example
-Joint mobilization and massage may be used.
-Acupuncture is also thought to give symptomatic relief as does Chiropractic care, Physiotherapy, Osteopathy and Craniosacral Therapy.
In particular, Deep Tissue Massage, Myofascial Release techniques and if tolerated Trigger Point Therapy. The evidence is conflicting on Massage Therapy in general, however my clinical experience (20 years) has been massage can and more often than not help, and does provide significant relief to women suffering from Pelvic Girdle Syndrome. I recommend treatments to be given at increasing intervals as the pregnancy progresses and in response to pain levels.
Low back pain and pregnancy
Low back pain occurs in 60-70% of pregnancies. Lower back pain may be defined as pain between the 12th rib and the pubic synthesis/gluteal folds. pain may radiate inferiorly in the thigh knee and calf. There is limited research available regarding physical therapy intervention in pregnant women experiencing lower back pain. However much like pelvic girdle syndrome in my clinical experience, I have treated countless women with Remedial Massage techniques with a resounding success rate. I am going to be controversial and state that appropriate massage techniques may be employed throughout the entire pregnancy to treat pain, again I make this statement based on my own vast clinical experience. The prevalence of lower back pain is highest during the third trimester. The cause of lower back may be due to a combination of circulatory, hormonal, mechanical and psychosocial factors.
Disc disease – Morning pain and stiffness, pain weight bearing, pain increased abdominal pressure. (Valsalva test) history of repeated trauma, pain going uphill, pain prolonged sitting, pain with sit to stand. Sleep usually not disturbed, pain may ease during the day, pain eased by movement herniated disc is a rare complication of pregnancy 1/10,000.
Facet joint- can be attributed to a number of factors and circumstances, weight bearing, related to movement, lateral compression, history previous minor pain. Pain is not usually referred to an extremity, pain eases with rest and intra- abdominal pressure does not exacerbate. (negative Valsalva)
Sacroiliac joint – Pain is usually unilateral and not midline, may refer to lower extremities, turning whilst lying in supine provokes pain, getting out of car provokes pain, pain in groin or genitals may occur, pain may be related to menstrual cycle prior to pregnancy.
To diagnose pelvic girdle syndrome Faber test posterior and pelvic pain provocation tests may be used.
Observation of posture and gait, palpation, assessment of mobility, Active straight leg raise.
Vaginal bleeding, dizziness/feeling faint, shortness of breath, chest pain, headache, muscles weakness, calf pain or swelling, uterine contractions, decreased fetal movement, vaginal fluid leakage, neurological impairment – Medical assessment must be sought for these.
As the pregnancy progresses the enlarging uterus changes the load and body mechanics. The centre of gravity shifts, the pelvis tilts anteriorly which increases the stress on the lower back. This anterior shift causes lumbar lordosis an increase in the natural curvature of the lumbar spine. This change in mechanics, places stress on the intervertebral disc, possibly causing a decrease in the overall height of the spine. As the spine curves have shock absorbing capabilities this in turn affects the thoracic and cervical regions of the spine, which can be observed when you exaggerate the pelvic tilt. The abdominal muscles are stretched to accommodate the growing uterus, as they stretch they become weak and lose their ability to maintain normal body posture which also impacts on the resulting lower back pain. The rapid increase in body weight with, abnormal central distribution increases overall load and therefore force placed across joints.
Some woman experience pain during the first trimester of their pregnancy. At this stage of gestation mechanical forces are not expressing significant influence on pregnancy pain onset. It is suggested that hormonal changes may cause inflammation and back pain. The hormone relaxin increases 10 fold during pregnancy. Its role is to soften collagen and increase ligamentous laxity – which is necessary to facilitate a normal vaginal delivery. The sacroiliac and neighboring ligaments which surround the pelvic girdle become loose. This decrease in stability may load up and tighten muscles bringing strain in the pelvic girdle ad producing back pain.
The expanding uterus may press on the inferior vena cava when the patient lies in a supine position. It is important during treatment not to position the patient flat on their back, in most cases a small incline is sufficient to avoid pressure on the inferior vena cava, however the level of incline needed can vary from patient to patient. The practitioner must observe the patient carefully when placing in supine position. Too much pressure on the inferior vena cava may present as pain, nausea, shortness of breath or a feeling of a sudden intense hot flush. If this occurs in the patient, they must be repositioned immediately by increasing the tilt and or sitting upright in some cases. A 45-degree tilt is sufficient in most “position sensitive” patients.
Swollen legs and hands are another common painful condition that can occur during pregnancy, these women often need to wear pregnancy compression stockings. Drainage massage can provide significant though temporary relief to oedema affected limbs. When women present with oedema preeclampsia must be considered, though not every woman with oedema will have it! It is something that the practitioner working with pregnant women must be aware of as it can be dangerous for both the mother and the baby. Preeclampsia is a condition which pregnant women can develop. It is identified by high blood pressure in women who have previously not experienced high blood pressure. Preeclampsia women will have a high levels of protein in their urine and usually have swelling in the feet, legs and hands they will often look flushed in the face and appear short of breath. If preeclampsia is suspected this requires urgent medical attention, these women must be referred to their medical provider for assessment. Cochrane review identified 1 trial indicating a OR 9.09 in favor of reflexology for improving the symptoms of lower limb varicosities.
Carpel Tunnel is another common ailment of pregnancy. During pregnancy hormonal fluctuations, fluid shifts and musculoskeletal changes may predispose some women to carpal tunnel syndrome. Relief can be provided by applying drainage massage techniques to the affected limbs. Carpel Tunnel in pregnancy usually resolves spontaneously after the birth, it is predominantly related to the increase in the volume of fluid retained and subsequent peripheral oedema, this condition usually worsens as the pregnancy progresses.
Leg cramps in pregnancy- Muscle cramp is a painful, physiological disturbance of skeletal muscle. … The relaxation phase of muscle contraction is prolonged in a fatigued muscle, raising the likelihood of fused summation of action potentials if motor neuron activity delivers a sustained high firing frequency, in over words sustained contraction. Muscle cramps in pregnancy tend to occur nocturnally and are often disturbing to sleep. Muscles exhibit post cramp “soreness” this soreness tends to be very responsive to massage therapy in particular to myofascial release and various deep tissue massage techniques. Leg cramping during pregnancy tends to like most pregnancy ailments increase in intensity as the pregnancy progresses. Leg cramps may also respond to topical magnesium application, oral consumption of a high quality magnesium supplement or my preferred and most successful treatment option clinically Blackmore’s professional celluloid CPMP.
Psychological factors may increase pain and stress directly resulting in the increased levels of cortisol. Sleep also allows the body to discharge the effects of everyday stress that can build up and cause anxiety. … Stress can cause physical pain and lead to tension headaches and backaches, unexplained muscle aches, and even chest pain, are all side effects of extreme stress. Hence why even in early stages of pregnancy massage can be useful.
Morning sickness (gravidarum) Morning sickness may mean that many women do not seek help with musculoskeletal conditions due to what can be the debilitating nature of this condition- However constant vomiting ca*&Jetstar&&$$!#&n cause thoracic and or cervical pain, which potentially could be relieved with massage therapy. As nausea subsides and the patient feels well enough to seek treatment for their musculoskeletal conditions shorter sessions may be advisable as morning sickness can spontaneously return. The most severe form of morning sickness is referred to medically by the term Hyperemesis Gravidarum, when this condition is present the vomiting is excessive and women may need to be hospitalized for treatment with IV fluids and or nasogastric tube feeding.
In high risk pregnancies common sense must prevail and in early stages the use of light, non-aggressive techniques such as gentle Swedish Massage and Myofascial Release are indicated. Techniques such as Deep Tissue Massage and Trigger Point Therapy should be avoided here. I advocate the avoidance of essential oils use, unless in the hands of a trained and suitably qualified aromatherapist, though there is a lack of scientific studies to quantify this approach. Women with high risk pregnancies are invariably and understandably stressed and safe nurturing gentle massage here can provide great benefit.
It is noted that studies on pregnant women produce significant and unique ethical challenges, this is an issue that can be reflected across the board for many natural /complementary therapies, however in my opinion knowledge from traditional practices can and should be drawn upon here.
Most women present for pregnancy massage around week 20 onwards this is when the mechanical strains typically begin exerting their effects. During this phase which is known as the second trimester, most women receive significant relief from pregnancy massage. Typically, the hips are sore, trigger points can be located and treated in gluteus medius. Most women tolerate this well though some will need gentler treatments. Quadratus lumborum responds well to myofascial release. Many women at this stage of pregnancy begin to experience neck and should pain, consequential to the changes to the curvatures of the spine. Trapezius and levator scapular will often exhibit trigger points. These muscles respond well and significant relief is obtained by performing these releases on the patient. In most women once a month treatment is sufficient to keep symptoms at bay, though some women will require or want more frequent treatment. The third trimester – of pregnancy begins in week 29, this trimester represents the greatest growth rate of the baby and the woman’s uterus expansion and thus the increases mechanical pressures on the mother’s body. During the first half of this trimester fortnightly sessions are recommended. From week 36 of the pregnancy the vast majority of women are feeling very uncomfortable due to the increasing pressure on their body, weekly massage therapy is indicated at this stage. Most women will now tolerate more aggressive treatment (stronger pressure) as they are seeking relief for their back pain which has often reached intolerable levels.
Referral to Doctor is indicated if experiencing specific pain during pregnancy.
Always consult your doctor if patient is experiencing the following;
• Sudden severe pain
• Fever with back pain
• Loss of sensation
• Pain with vaginal bleeding
Tips for relieving back pain during pregnancy
While back pain is often often unavoidable during pregnancy due to the rapid changes that occur in the body, there are a number of ways in which it can be alleviated. As early as possible during pregnancy, ensure that a well balanced diet is consumed to provide body with essential minerals and vitamins.
Being physically active can also help prevent back pain, Swimming, Pregnancy Pilates or Yoga classes are wonderful for this. Activities to be avoided during pregnancy include – Contact sports, activities with high risk of falling (skiing horseback riding etc), scuba diving, skydiving and hot pilates or hot yoga. Women can who have previously exercised can continue mild to moderate exercise. Five times a week is considered optimal frequency for 20-30 minutes. Exercise should never be to fatigue or exhaustion. Women should avoid activities which raise core temperature above 38’ Celsius including hot baths/spas. The maternal Heart rate should remain under 140bpm.
What else helps?
• Pregnancy Massage
• A heat pack can be helpful
• As side lying sleeping is the recommended position, a support pillow between the knees helps take pressure off the hips
• postural and muscle training and strengthening to help with posture
• Try to make sure you get enough rest every day
Apart from relieving back pain, Pregnancy Massage may also help with circulatory issues, swelling, leg cramps, hip pain, general muscular tension, fatigue, insomnia, headaches and pelvic pain. Drug Free pain relief may prove to be more favorable to analgesic consumption. Recently published epidemiological studies suggested a possible association between paracetamol exposure in utero and attention-deficit-hyperactivity disorder/hyperkinetic disorder (ADHD/HKD) or adverse development issues in children. As eluded to in the abstract the ethical issues surrounding drug studies in pregnant women are vast. I have used a study group participating in the reflective survey have been asked to pain score between 0-10 before and after each treatment the given intervals through their gestation, intervals where increased with the progression of the pregnancy.
Patients were treated both Supine and Prone position on a specialised pregnancy table to ensure comfort during each session. Myofascial Techniques, Deep Tissue Massage and Trigger Point therapy was used while the pressure was modified to suit each patients comfort levels. Treatments were performed at 20,24,28, 30, 32,34, 36, 37, 38, 39 and 40 weeks and pain scores were measured before and after treatment.
Postnatal massage may be provided at any time after a natural birth, or usually around 4 weeks after a caesarean section or once the wound has healed sufficiently to allow the mother to lay in a prone position. However, often the sleeping and feeding pattern of the newborn will determine the woman’s ability to seek therapy of any kind. Often a pillow will need to be used under the mother’s stomach as the abdomen can remain sensitive for some time even with a natural birth, pillows or support rolls/bolsters may be necessary under the arms in order to support the extra breast volume. As relaxin is still exerting its effects on the ligaments of the body, lower back pain is common, aggravated by extra strain from bending over and picking up baby when the mother is in a fatigued state. It is common for new mothers who are breastfeeding to consult a practitioner for cervical treatment, this may be due to increased breast weight due to milk engorgement as well as positional (attachment checking), particularly when the newborn is not yet coming to the breast and the mother must check the position of the baby when feeding.
Yoga may be helpful to patients experiencing lower back pain and can also be useful during the labor process. Breathing, meditation, visualization are techniques which may be invoked during the pregnancy as well as during the labor itself. The position yoga “cat cow’ is an excellent example of a position which may assist lumbar/pelvic pain. While a “Child’s Pose” is another excellent stretch for pregnancy and may relative lower back pain. Squatting with the tailbone tended outwards can be useful, however caution is needed if the patient is displaying the symptoms of the pubic symphysis. Abdominal breathing to strengthen the core is also helpful. Martins and Pinto concluded in the randomized controlled trial that yoga was more effective at reducing lumbopelvic pain intensity compared with postural orientation.
Physical therapy, massage including myofascial release, trigger point therapy and deep tissue massage appears to provide benefit to women in alleviating back/hip pain during pregnancy according to my study. My small sample size of 10 women displayed a reduction in back pain in 100% of participants, though there were varying degrees of the reduction of pain. It has been postulated by Hall et.al that the “influence of the therapist on perceived effectiveness of treatments and adequate dose-response of complimentary manual therapies on low back and pelvic pain during pregnancy” subsequently, it could be argued that in reality patients would generally not continue with more than 3-4 treatments regardless of the influence of the practitioner, i.e. if they are not receiving relief they would try another therapy or therapist. Massage in pregnancy is found to be a safe effective nurturing therapy which provides drug free pain relief to pregnant women and should be employed as the first line of treatment for most pregnancy pain. Patients displaying red flags as discussed should be referred without delay to appropriate medical care. Larger scale well funded studies are needed in this area to solidify the need for Remedial Massage during pregnancy and promote appropriate data regarding this need to the wider medical community. I believe there are many myths that need to be disproved and benefits that need to be scientifically verified.
Assessment of pregnancy Massage Treatment outcome. Subjects present at week 20 with lower back pain treatments where applied at week 20, 24, 28, 30, 32, 34, 36, 37, 38, 39 and 40
Each treatment the following questionnaire was handed to the 10 women
Please rate your back pain before/ after treatment 0-10 scale. Please rate you hip pain before and after treatment 0-10 scale
Table of Results (results are on the same 10 group of women rating pain before and after each treatment.) Treatments where given at 20,24, 28, 30, 32, 36, 37, 38, 39 and 40 indicated in top line weeks of gestation. Treatments ranged from 30 mins to 1 hour each patient scored their pain levels before and after treatment the first figure is before treatment the second figure is immediately after treatment.
Please rate your lower back pain 0-10 before and after treatment
Please rate your lower back pain 0-10 before and after treatment
Burleigh Heads Physiotherapy supplied me with notes from Women’s Health Symposium – Introductory to Womens’s Health Day 4 and 5 Pregnancy and Early Postnatal
Subjects for my study group were patients paying privately to see me
ACOG 2015 Examples of safe and unsafe physical activities during pregnancy.
Introductory to Womens’s Health Day 4 and 5 Pregnancy and Early Postnatal
Women’s Health – A Textbook For Physiotherapists r. Sapsford J Bullock-Saxton Smarkwell Pub W.B. Saunders 1999
The effectiveness of complimentary manual therapies for pregnancy related back and pelvic pain A systemic review with met-analysis. Medicine Baltimore 2016 sep:95 (38):e4723. Hall PhD et.al
Web MD – Pelvic Girdle Pain (PGP) & Symphysis (SPD) in pregnancy https://www.webmd.boots.com/pregnancy/guide/pelvic-girdle-pain-pgp-spd
PubMed Health. A service of the National Library of Medicine, National Institutes of Health.
Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet]. Chichester, UK: John Wiley & Sons, Ltd; 2003-. doi: 10.1002/14651858.CD010655.pub2
Interventions for leg cramps during pregnancy
First published: August 11, 2015.
Sports Med. 1996 Jun;21(6):409-20.
Exercise-induced muscle cramp. Proposed mechanisms and management.
Dev Med Child Neurol. 2015 Aug;57(8):718-24. doi: 10.1111/dmcn.12745. Epub 2015 Apr 7.
Use of paracetamol during pregnancy and child neurological development.
de Fays L1, Van Malderen K1, De Smet K1, Sawchik J1, Verlinden V1, Hamdani J1, Dogné JM2, Dan B3.
Yoga Mama yoga baby 2013 Margo Sharipo Bachman Sounds True,Inc Boulder, CO 80306
J Altern Complement Med. 2014 Jan;20(1):24-31. doi: 10.1089/acm.2012.0715. Epub 2013 Mar 18.
Treatment of pregnancy-related lumbar and pelvic girdle pain by the yoga method: a randomized controlled study.
Martins RF1, Pinto e Silva JL.
Am J Perinatol. 2015 May;32(6):503-14. doi: 10.1055/s-0034-1396701. Epub 2014 Dec 23.
Effects of yoga intervention during pregnancy: a review for current status.
Jiang Q1, Wu Z2, Zhou L1, Dunlop J3, Chen P1.