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We know, from what our hands and a growing body of scientific evidence tell us, that massage therapy can significantly improve the experience of being pregnant. Back and pelvic pain, as well as other localized musculoskeletal discomforts, is a near-universal experience at some point during pregnancy.

Let’s explore that pain, including its sources and frequency, and how you might offer help.

Structural Imbalance

The ever-increasing anterior weight of the enlarging belly generally challenges a pregnant person’s structural integrity. As pregnancy progresses, her pelvis tends to rotate anteriorly, spilling the uterus forward against the abdominal walls. The lumbar curvature increases and the abdominal muscles stretch. A double compensation then follows: She leans her upper ribcage more posteriorly, and then her head and neck jut forward anterior of the optimal vertical line. This stretch in the abdomen is most pronounced along the midline, called the linea alba; by pregnancy’s third trimester, the stretch will usually separate the abdominal muscles, a condition known as diastasis recti. Trigger points often develop in the abdominal muscle attachments, too.

These compensations also strain the posterior musculature, creating fatigue, tightness, trigger points and fibrosis. Excessive lumbar lordosis correlates with shorter hip flexors, iliopsoas and tensor fasciae latae; it also shortens the thoracolumbar fascia, decreasing spine flexibility. Enlarging breasts pull her pectoral girdle into forward rotation, causing tight pectoral muscles and stretched rhomboids. Increased uterine weight also strains the pelvic floor.

Pregnant people commonly respond by broadening their standing foundation, laterally rotating at the hips. Chronic tension then builds in the piriformis and other external hip rotators. Furthermore, with the knee and foot no longer aligned with the hip joint, the iliopsoas cannot efficiently stabilize or flex the pelvis when walking. In compensation, the gluteus medius must first abduct the thigh for the quadriceps to complete a step. This creates the characteristic waddling gait of many pregnant people. To prevent falling forward with the increased anterior weight, expectant people tend to hyperextend their knees, and their weight collapses into the medial arches of their weary feet.¹

Back and Pelvic Pain Sources

These postural adjustments, along with weight gain, tend to destabilize, strain and compress the weight-bearing joints and associated myofascial structures (see Figure 1.5); pain and functional limitations often follow. It is estimated that one in five women feel pain in the pelvic region that starts during pregnancy or within the first three months after birth, and that does not have an obvious cause—other than the numerous changes of pregnancy! This is known as pregnancy-related pelvic girdle pain, sometimes referred to as perinatal pelvic pain syndrome.² These women feel the greatest discomfort around the sacroiliac joints, lumbosacral joint and pubic symphysis, but other pelvic and leg regions are sometimes painful too, including compression in the hip joints.^3,4,5,6 (See Figures 1.6 and 1.7.)

At the sacroiliac joints, the relationship between each ilium and the sacrum shifts dramatically as the enlarged abdomen protrudes anteriorly. When the pelvis anteriorly rotates, the ligaments of these deep pelvic joints are compressed and strained, and can become either hypermobile or hypomobile, and painful, in response. Sacroiliac joint strain may refer pain to the lower lumbar region, the buttocks and inner thighs, and as far as the lower extremities.^{4, 7}

As pregnancy progresses, relaxin and other hormones begin softening the body’s connective tissue. This allows more pelvic flexibility and space to accommodate the developing fetus—and, most importantly, its passage through the pelvis during birth; however, as with other body systems, the pelvis is not the sole target for these hormones’ effects. Laxity in ligaments, tendons, cartilage and fascia contributes to joint instability and strain on all joints, particularly weight-bearing structures, especially in the lumbar spine and pelvis.

Many people report their first incidence of chronic back pain during a pregnancy,^8,2,9 but it can take various forms. The generalized back pain of pregnancy is usually described as fatigue, tightness and achiness. Sacroiliac pain, in contrast, is felt as chronic soreness in the upper, medial quadrant of the buttocks, across the iliac crest, or at the posterior iliac spine of the pelvis, which can radiate for several inches in any direction. Pain from other pelvic joints varies depending on the source. (See Figure 1.6.) Achiness in the center of the sacral and lumbar areas may indicate strain and compression of the lumbosacral joint. Sharp, stabbing anterior pain in the center of the pelvis indicates instability of the pubic symphysis, known as symphysis pubis dysfunction. Trigger points and fatigue of the gluteus medius also contribute to back and pelvic pain.^3,10,11 (See Figure 1.6.)

The growing uterus itself is also part of the pelvic pain picture. During pregnancy, the pregnant uterus blossoms from a small pear-sized organ to watermelon proportions. There are eight uterine ligaments that make this enormous change possible, by suspending and supporting the uterus in the pelvic cavity. (See Figure 1.7.)

Uterine growth inevitably stretches these ligaments—distortion and pull of their fascial continuations is almost as inevitable.¹² These changes can result in referred pain (See Figure 1.7):

• broad ligaments: low back, buttock and sciatic-like pain.

• round ligaments: diagonal pain from the top of the uterus to groin; usually one-sided, depending on fetal position; can extend as far as the vulva and upper thigh

• sacrouterine ligaments: achiness just lateral to or beneath the sacrum and in the lower back.

There are a few other possible pain culprits in the back and pelvis. Severe postural imbalance in the lumbar spine can cause a radiating pain through the buttocks and down the posterior leg. More commonly, chronic tension in the piriformis entraps and compresses the sciatic nerve; this is known as piriformis syndrome. From either source, this pain burns, sometimes worsened by tingling, numbness and weakness in the legs. Some women have coccygeal and other pelvic floor pain, too. (See Figure 1.5.) The possibilities for back and pelvic pain, in other words, are multiple, especially when there are multiple fetuses!

Other Musculoskeletal Complaints

Although not as common as back and pelvic pain, headaches and pain in the lower extremities are experienced by many expectant people. Edema produces some of this achy, sore, tense feeling, as does strain to the muscles and joints of the feet and legs. Nerve compression of the tibial and lateral cutaneous femoral nerves can create numbness and pain. Cramping in the gastrocnemius, soleus and the peroneals torments some women’s sleep, as do the vibrations and irritations of restless leg syndrome.

Pregnancy often worsens prior postural imbalances and injuries: anything from lumbar and cervical lordosis, to scoliosis and disc dysfunctions, to thoracic outlet syndrome. When strained posture compresses the brachial plexus, there is a characteristic pain, numbness or tingling in the entire hand and along the arm; however, edema-dependent carpal tunnel syndrome pain happens more frequently.^13,1 Rib cage pain may occur in later pregnancy as organ space diminishes. As the lower circumference widens and the ribs spread, they can strain abdominal attachments and intercostal muscles. Trigger points develop, referring pain into the mid- and lower back and sometimes throughout the rib cage. The baby may intensify this discomfort with frequent kicks or stretching. (See Figure 1.5.)

Our Role in Pain Control

Amidst these seemingly endless structural changes, there is much that we can do. Knowledgeable maternity massage therapists may help their clients to prevent, reduce and manage pain by supporting and encouraging the body’s adaptation to these many myofascial and proprioceptive transitions.

The effectiveness of massage therapy for reducing pain has now been validated not just by individual studies,¹⁴ but by a growing number of literature reviews and meta-analyses.^{15,16,17,18,19}

There is much anecdotal testimony to the effectiveness of massage for pregnancy’s pains, but little specific research.²⁰ In one of the few well-structured studies specifically of massage and pregnancy, massaged clients reported less back pain and a similar reduction in leg pain, among other benefits, compared with those who had an equal amount of relaxation therapy.²¹ Depressed second-trimester women had similar reductions in pain when they received massage therapy rather than relaxation sessions or normal prenatal care alone.^{22, 23}

Though we still do not yet fully understand exactly why it works, we have explored and developed a variety of techniques that seem to prevent and reduce pain in our prenatal clients.²⁴ Rhythmic passive movements including small-amplitude Trager^TM movements, and osteopathic strain–counterstrain and muscle energy techniques are all effective in pain management.²⁵ Deep tissue work and other forms of myofascial release may reduce pain by elongating shortened, bunched connective tissue,²⁶ and deep cross-fiber friction may reduce pain and the restricted range of movement of fibrosis.^25,27 Swedish massage, rhythmic movement and any other strokes done with mindful attention, may encourage parasympathetic activation of the client’s nervous system.^28,29

Trigger-point therapy, including focused pressure and appropriate stretching around trigger points, can reduce the pain associated with these points by, scientists speculate, relieving tissue ischemia and allowing restoration of normal tissue blood supply.^30,6 Asian bodywork modalities are also effective. Our pregnant clients welcome the lessening pain these techniques can bring.³¹

In addition to hands-on techniques, education also helps reduce pain and decrease stress on structures. Correct (and safe) abdominal strengthening activities and body-use guidelines for breathing, walking, sitting, sleeping, carrying and other daily activities will further reduce strain in the neck, back and pelvis. These more efficient movement patterns, in turn, reinforce the effectiveness of skilled hands-on therapy.³²

With this introduction to the musculoskeletal system during pregnancy, we hope to have improved your understanding of what your pregnant clients are likely experiencing. We encourage you to expand your understanding of pregnancy, labor and the postpartum period so that, whenever in their childbearing experience and wherever you provide massage therapy, you will offer safe, effective maternity-related work.

[As a special offer to MASSAGE Magazine readers, order “Pre- and Perinatal Massage Therapy: A Comprehensive Guide to Prenatal, Labor and Postpartum Practice, Third Edition” direct from Handspring Publishing here and save 20% off the list price. Order direct at and use discount code MMPRPT22. Offer expires Oct. 31, 2022.]

About the Authors:

Carole Osborne, CMT, is an integrative bodywork practitioner, author, award-winning course developer/instructor and mentor. Her work pioneered the reintroduction of therapeutic massage and bodywork to American maternity health care. She’s in private practice in California and has led training programs worldwide at bodytherapyeducation.com.

Michele Kolakowski, LMT, CD & CPD (DONA), CLC, has decades of diverse experience serving women and babies, including leading a hospital-based postpartum program, since 1992. She founded Sanctuary Healing Arts LLC, which specializes in hands-on maternal and infant care including massage therapy and doula care in Colorado.

David M. Lobenstine, LMT, BCTMB, aims to facilitate ease and awareness for each client at his private practice, Full Breath Massage in New York. He also designs and teaches continuing education workshops, both around the country and online, at bodybrainbreath.com.

This article was excerpted and revised from “Pre- and Perinatal Massage Therapy: A Comprehensive Guide to Prenatal, Labor and Postpartum Practice, Third Edition.” Copyright © Handspring Publishing 2021; reproduced with permission.

Footnotes

1. Werner R. A Massage Therapist’s Guide to Pathology, 7th edn. Books of Discovery. 2019.
2. Katonis P, Kampouroglou A, Aggelopoulos A et al. Pregnancy-related low back pain. Hippokratia. 2011; 15(3):205–210.
3. CPWHC (Chartered Physiotherapists in Women’s Health and Continence and Directorate of Strategy and Clinical Programmes; Health Service Executive) Clinical Practice Guideline: Management of Pelvic Girdle Pain in Pregnancy and Post-Partum. Guideline No. 16. 2014; revised August.
4. Kanakaris NK, Roberts CS, Giannoudis PV. Pregnancy-related pelvic girdle pain: an update. BMC Med. 2011; 9:15.
5. Verstraete EH, Vanderstraeten G, Parewijck W. Pelvic girdle pain during or after pregnancy: a review of recent evidence and a clinical care path proposal. Facts Views Vis Obgyn. 2013; 5(1):33–43.
6. Howard F. Pelvic Pain: Diagnosis and Management. Baltimore: Lippincott, Williams & Wilkins. 2000.
7. Slipman C, Jackson H, Lipetz J et al. Sacroiliac joint pain referral zones. Arch Phys Med Rehabil. 2000; 81(3):334–338.
8. Riczo D. Back and Pelvic Girdle Pain in Pregnancy and Postpartum. Minneapolis: OPTP. 2020.
9. Ostgaard HC, Andersson GBS, Karlsson K. Prevalence of back pain in pregnancy. Spine. 1992; 17:53–55.
10. Jeffcoat H. Help for pubic symphysis pain. Int J Childbirth Educ. Available at: https://feminapt.com/resources/ published-articles/help-for-pubic-symphysis-pain. 2009; [accessed May 27, 2020].
11. Noble E. Essential Exercises for the Childbearing Year, 4th edn. Harwich: New Life Images. 2003.
12. Tully G. Changing Birth on Earth. Bloomington: Maternity House Publishing. 2020.
13. Klein A. Peripheral nerve disease in pregnancy, in Clinical Obstetrics and Gynecology: An Overview. Philadelphia: Lippincott, Williams & Wilkins. 2013.
14. Cherkin DC, Sherman KJ, Kahn J et al. A comparison of the effects of 2 types of massage and usual care on chronic low back pain: a randomized, controlled trial. Ann Intern Med. 2011; 155(1):1–9.
15. Crawford C, Boyd C, Paat CF et al. The impact of massage therapy on function in pain populations-a systematic review and meta-analysis of randomized controlled trials: Part I, Patients experiencing pain in the general population. Pain Med. 2016; 17(7):1353–1375.
16. Boyd C, Crawford C, Paat CF et al. The impact of massage therapy on function in pain populations-a systematic review and meta-analysis of randomized controlled trials: Part II, Cancer pain populations. Pain Med. 2016a; 17(8):1553–1568.
17. Boyd C, Crawford C, Paat CF et al. The impact of massage therapy on function in pain populations-a systematic review and meta-analysis of randomized controlled trials: Part III, Surgical pain populations. Pain Med. 2016b; 17(9):1757–1772.
18. Field T. Massage therapy research review. Complement Ther Clin Pract. 2016; 24:19–31.
19. Miake-Lye IM, Mak S, Lee J et al. Massage for pain: an evidence map. J Altern Complement Med. 2019; 25(5): 475-502.
20. Oswald C, Higgins CC, Assimakopoulos D. Optimizing pain relief during pregnancy using manual therapy. Can Fam Physician. 2013; 59(8):841–842.
21. Field T, Hernandez-Reif M, Hart S et al. Pregnant women benefit from massage therapy. J Psychos Obstet Gynecol. 1999; 20:31–38.
22. Field T, Diego MA, Hernandez-Reif M et al. Massage therapy effects on depressed pregnant women. J Psychos Obstet Gynecol. 2004; 25:115–122.
23. Field T. Prenatal depression risk factors, developmental effects and interventions: a review. J Pregnancy Child Health. 2017; 4(1):301.
24. Çakır Koçak Y, Sevil Ü, Ergenoğlu AM. The Effect of Pregnancy Massage on the General Well-Being and Satisfaction Levels of Pregnant Women: A Randomized Controlled Trial, ISS2018 3rd International Science Symposium, “New Horizons in Science,” Pristine, Kosova, September 5–8. 2018; pp. 97–102 (abstract submission/oral presentation).
25. Thompson DL, Brooks M. Integrative pain management: massage, movement, and mindfulness based approaches. Edinburgh: Handspring. 2016.
26. Ajimsha MS, Al-Mudahka NR, Al-Madzhar JA. Effectiveness of MFR: systematic review of randomized controlled trials. J Bodyw Mov Ther. 2015; 19(1):102–112.
27. Cyriax J, Coldham M. Indications for and against deep friction, in Textbook of Orthopaedic Medicine. Volume 2 Treatment by Manipulation, Massage, and Injection, 11^th edn. Toronto: Bailliere–Tindall. 1984.
28. Guan L, Collet JP, Yuskiv N et al. The effect of massage therapy on autonomic activity in critically ill children. Evid Based Complement Alternat Med. 2014; 2014:656750.
29. Lee YH, Park BN, Kim SH. The effects of heat and massage application on autonomic nervous system. Yonsei Med J. 2011; 52(6):982–989.
30. Liddle SD, Pennick V. Interventions for preventing and treating low-back and pelvic pain during pregnancy. Cochrane Database Syst Rev. 2015; 2015(9):CD001130.
31. Steel A, Adams J, Sibbritt D et al. The outcomes of complementary and alternative medicine use among pregnant and birthing women: current trends and future directions. Womens Health. 2015; 11(3):309–323.
32. Simkin P, Whalley J, Keppler A et al. Pregnancy, Childbirth and the Newborn, 5th edn. New York: Da Capo Press. 2018.