Back Pain in Women
A Review of the Causes, Preventive Measures and Treatment
By Dr. Walaa Elassuity
Back pain is an unpleasant experience that up to 80% of people may experience at some point of their life. With the increasing standards of luxury in our life we are unconsciously putting more load on our backs, leading to even increasing prevalence of this potentially disabling problem.
With the unique anatomical and physiological characteristics of the women body, they can be susceptible to experience back pain from some gynecological causes. Back pain may be experienced around the menstruation time, during hormonal changes or due to pelvic inflammatory diseases. In this article we will be discussing the common issues from my experience as a spinal specialist. We will try to simply identify the common causes for back pain in women of different age groups, how to avoid it, and how to treat it.
Children and Adolescents
In the growing spine of children, the blood supply to the vertebrae is vulnerable and can easily be affected with minor injuries, resulting in infection in the vertebrae. Infection can also reach the vertebrae from infections in other parts of the body, as in the case of tonsillitis. Children with persisting back pain lasting more than a few days, especially with other ongoing infections such as fever, or a history of trauma, should seek a pediatric orthopedic or spinal specialist for advice.
Up to 5% of adolescents may suffer a fatigue fracture in the posterior arch of one or more of the lower lumbar vertebrae. The exact cause of this is not fully clear. But different theories suggest a genetic weakness in this part makes it susceptible to fracture especially amongst athletes, gymnastic, throwers, and martial art players. The condition does not necessarily cause significant pain, but doctors should be able to identify it and treat the patients depending on their symptoms. Most of the patients can be treated with a simple symptomatic treatment. However, few of the affected patients may require fixation of the fracture.
Scoliosis, an abnormal curving of the spine, mainly affects girls. It is a side and rotational deformity of the spine that can result from congenital anomalies in the spine, neuromuscular disease, or more commonly, it may be the idiopathic type (genetically determined). Apart from the back pain, these young girls may have a progressive disfiguring deformity in their spine. Early diagnosis and supervision is very important. Early detection of abnormal small spinal curves can be controlled using special braces. However, large curves of 40 degrees or more are shown to deteriorate further and faster, particularly during the fast growth phase of puberty. These large curves at that age may require more attention and surgical correction of the deformity.
A simple way to observe children for spinal deformity, is to assure shoulder and waist symmetry when you look at them standing in a relaxed position from the front and back. You may also notice a prominence in the back on one side more than the other when they bend forward.
Sports Related Back Pain
Sports can also cause different types of injuries to the back, starting from the commonly encountered muscle strains that can be very painful and disabling. An acute tendinitis usually results in a localized pain slightly to the side at the lower back (at site of the tendon insertion). If the pain does not improve in few days, it may require a local steroid injection to treat the resultant inflammation, since local and traditional anti-inflammatory are not sufficient at times.
Contact sports as well as sports that may results in a fall (usually in climbing sports, some water sports and horseback riding) may result in vertebral fractures, leading to severe back pain. In case of acute back pain following an injury or a fall, the affected person should seek urgent medical advice. Treatment of such fractures depends upon the extent of the injury, and varies from simple rest and special back braces to fracture fixation.
The nature of different work types may cause back pain in women. Research shows high incidence of back pain amongst women doing extreme physically demanding jobs, such as nursing. Long sitting hours at work may result in an increasing load at the lower lumbar spine, which may lead to chronic discogenic pain. It is always advisable to have a proper ergonomic sitting at work. This means sitting with back and elbow support, maintaining the computer screen at the level of the eye, and frequently getting off the chair every 20–30 minutes even for few seconds. This type of back pain is described as mechanical, as it increases with applying constant load (body weight) to the lower back. Apart from avoiding standing for long hours, patients should also avoid lying on the back with their legs straight. Ideally, they should lie in bed on the side, bending their knees with their elbows in between. This (embryo position) decreases the load on the spine, and also relaxes the hamstrings muscles, leading to more comfort during sleep.
Stress, depression and lack of sleep may result in physical changes and muscle tension, causing back pain. Patients with chronic pain, work or domestic life stress and depression have shown to be directly influenced by their feelings.
A woman’s confidence in her strength and abilities is also very important. Those who feel competent tend to function better and have a better quality of life than those who lack self-confidence or limit their activities for fear of pain or injury. The limitations in movement and activity lead to physical de-conditioning and muscle weakening, which in turn leads to more back pain. Patients with chronic pain should be encouraged to have a strong inner drive to succeed, a great sense of responsibility and being self-motivated and disciplined.
50–80% of women experience back pain at any time during their pregnancy, experiencing a higher intensity of the pain during the last trimester. It commonly affects the lower part of the spine and the back of the pelvis.
Common causes of back pain in pregnancy include:
– Weight gain in pregnancy- applies increasing direct load to the discs at the bottom of the spine, causing pain on sitting, standing and lifting.
– Posture changes- may result in increasing back muscles strain.
– Hormonal changes during pregnancy- levels of the hormone Relaxin increase in the last trimester and near labor in preparation for childbirth. It relaxes the ligaments in the pelvis including those supporting the joints between the spine and pelvis (sacroiliac joints). Normally these joints are strong and have no movement. When the ligaments relax, a small amount of movement may occur resulting in severe instability pain.
– Abdominal muscles weakness- may result in increasing load and consequently pain in the lower back.
– Stress- emotional stress can cause muscle tension in the back, which may be felt as back pain or back spasms. You may find that you experience an increase in back pain during stressful periods of your pregnancy.
Most of pregnancy related back pains can be avoided and improved by avoiding long sitting, standing or lifting. Maintain good posture and regularly perform stretching exercises especially of the hamstrings (muscles in the back of the thigh). Since medication is generally avoided during pregnancy, physiotherapy, acupunctures and heat application may be used to relieve the pain.
Women may start or continue to experience back pain after childbirth, most commonly from muscle weakness and sacroiliac joint dysfunction. This should be identified early. The use of a proper sacroiliac support accelerates healing of these joints. Epidural anesthesia has not shown to increase or cause back pain after delivery as many may believe.
There is a direct relation with increasing BMI and the increasing prevalence of low back pain. Obesity, muscle weakness and increasing abdominal fat were shown to increase the load at the lower (usually degenerated) discs leading to chronic back pain.
Post Menopausal Women
Back pain in women at the menopausal stage can be related to degenerative changes of the spine. This slowly causes changes in the spine starting by decreasing the disc height and followed by arthritis of the facet joints that are joining the vertebrae from the back. Then, the ligaments in the spinal canal get thicker resulting in what is called spinal stenosis. These changes are not uncommon in women aged 50-60, and they may cause severe back and leg pain. Treatment of this condition depends on the symptoms and varies from simple medical treatment to physiotherapy and spinal injections. Some patients may require surgery to stabilize their back and remove the pressure on the nerves in their tight spinal canal.
The bone density in women normally increases gradually with age and reaches its peak at around mid 30s. It then gradually declines by .3% every year. After menopause and decrease in the estrogen levels, the rate of declining increases to around 3% per year, putting many women at risk of fracture mostly around the wrist joints. Women advancing towards 70 years of age experience another phase of bone density reduction, causing what is called senile osteoporosis, which increases the risk of hip and vertebral fractures. Patients with persistent pain due to vertebral osteoporotic fracture are treated with a simple procedure under local anesthesia to augment their fractured vertebra with a special type of cement.
In summary, back pain in women is a common public health problem that can cause significant disability. Good preventive measures include maintaining a healthy body weight, a good posture, healthy trunk muscles and avoid sitting and standing for long hours. Early diagnosis and identification of the source of the pain can result in timely treatment, before leading to further disability or complications.