Low back pain is among the most common conditions for which patients seek medical care1. Low back pain is defined as pain, muscle tension, or stiffness localized below the costal margin and above the inferior gluteal folds, with or without leg pain. Low back pain can begin in childhood and continue to plague the patient throughout their life. It is a disorder with many possible causes and many explanations, occurring in many groups of populations.
Research indicates that more than 80% of people experience low back pain during their lifetime with its prevalence being slightly more common in females than males across all age groups. Women have increased lower back pain during their menstrual cycle or at the time of ovulation. The resultant inflammation and uterine cramping can increase the intra-abdominal pressure and flare up a preexisting lower back condition.
Age Influences Back Pain
Back pain in women increases significantly with age. A 2019 article in the Journal of Mid-Life Health2 reported an increased incidence of low back pain in females during the post-menopause period. Women spend nearly one-third of their life in menopause. During this time, women suffer from a multitude of musculoskeletal disorders as well3.
A synthetic literature review in 20164 demonstrated females had a higher prevalence of LBP across all age groups. This female vs. male difference was highest for school-age children. Compared with middle-aged subjects, an increased low back pain prevalence in females than in males was noted after menopause age.
Pregnancy and Back Pain
Women usually gain an average of 20 to 25 pounds during pregnancy, have a shift in their center of gravity and undergo several hormonal and anatomical changes. These necessary alterations increase stresses and loads on the lower spine and pelvis. The paraspinal muscles, which support and stabilize the lower back shorten, and become unbalanced by the excessive stretching of the abdominal muscles in the front5.
As the abdomen presses outward, the connective tissue that joins the two sides of the rectus abdominis muscle begins to thin and widen, making the muscles less effective at contracting. The widening of the connective tissue is called a “diastasis recti” and it’s a normal response to the expanding belly during pregnancy.
The growing uterus is another reason for a woman having increasing lower back pain. The expanding uterus shifts a woman’s center of gravity and stretches out and weakens her abdominal muscles. This changes her posture and puts a strain on her back. Plus, the extra weight the mother-to-be carries means more work for her muscles, increased stress on her joints and causes flattening of the three arches under each foot.
A tenfold increase in the hormone relaxin loosens the ligaments in the joints of the pelvis. This makes them more flexible so the uterus can expand to accommodate the pregnancy, makes the abdominal muscles more flexible and relaxes blood vessels to accommodate for the increase in blood volume during pregnancy. Relaxin also helps to relax the pelvis and prepare for the passage of the baby through the birth canal. LBP, sacroiliac joint pain and pain at the pubic bones can occur if the joints become too flexible.
The facet joints in the lumbar spine are also under duress during the whole pregnancy process. They can be strained or injured, or simply become stiff, locked and inflamed. The growing uterus and increased curvature of the lower spine exert additional mechanical loads on the lower back, altering the spinal posture. This altered posture increases stress on the lumbar facet joints and lumbar spinal discs.
After pregnancy a woman’s core musculature is weakened and there is impaired load transfer during activities, which may result in an overload of stress on the pelvic ligaments6. Thus, the pelvis has a tendency to tip forward or anteriorly. This pelvic position further adds to the issues the female had during her pregnancy. Now hip impingement, instability, tears in the labrum and potential early osteoarthritis of the hip joint can occur.
Menopause and back pain
About 70% of perimenopausal women have symptoms related to estrogen deficiency, such as sleep disorders, decreased bone mineral density, and musculoskeletal pain, the latter being reported by more than half of the perimenopausal women. Most studies show that women with a higher menopause symptom burden may be the most vulnerable for chronic back pain7.
Female sex hormones play an important role in the etiology and pathophysiology of a variety of musculoskeletal degenerative diseases. Postmenopausal women show accelerated disc degeneration due to relative estrogen deficiency. Research studies indicate that in the United States, about 25% of women will experience vertebral compression fractures of the middle to lower spine throughout their lifetime. The condition occurs more frequently with age, reaching 40% at age 80. These can cause significant disability and limit function.
The National Institute on Aging reports that osteoporosis is the most common cause of compression fractures and 20% of women over 50 have it. Postmenopausal women have an increased risk of osteoporosis due to hormonal changes that decrease bone mineral density, predisposing bones to fracture.
Women in the Work Force
With the progression of time, women have made strides to become more and more important members of the labor force. Women in the workplace are also obtaining more physically demanding jobs.
According to the United States Department of Labor and Statistics, the top five jobs for women in the labor force are:
- Registered nurses
- Elementary and middle school teachers
- Secretaries and administrative assistants
- Customer service representatives.
A cross-sectional study based on a population survey of 600 individuals was done in 20208. Overall prevalence of LBP was 60.9% in women. The measured associated factors in women were occupational activities that involved heavy lifting, standing posture leaning forward, sitting posture leaning forward, and sitting at the computer three or more days per week.
A Solid Chiropractic Care Plan
Whether they have monthly, cyclic lower back pain, are at any stage of pregnancy, or are engaging in a job/activity that is stressful, women’s bodies benefit from chiropractic.
Obviously specific adjustments to align the pelvis, sacroiliac, hips are key. Equally important is to examine the 26 bones of each foot and adjust the excessive pronation or supination patterns they exhibit.
Utilize custom, three-arch, flexible orthotics for the pedal foundation. It has been shown that supporting the three arches of the feet will provide symmetrical balance from the ground up. With a supported kinetic chain, the joints of the body will have less stress.
When women are expecting, the force onto the three arches gets worse and worse through the course of their pregnancies. If the chiropractor is lucky, the patient is under care from the first trimester so that appropriate orthotic support can be provided during all stages of the pregnancy and postpartum. This will minimize the damaging effects on the plantar fascia, soft tissue and bones of the feet from the effects of pregnancy.
- Core Stabilization Exercises:
In general, but especially in the case of pregnant and postpartum females, core training (including the pelvic floor) exercises are important. The types and frequency of exercises will depend on the state of the patient. An exercise regimen for a woman with general LBP who is not pregnant or in the early stages will look different than for a postpartum female9.
If a woman has given birth, then most OBGYNs suggest waiting until the 6-week check-up before starting core/pelvic floor work. Whether they had a cesarean section or a vaginal delivery is important as that helps determine the timeline of how long before they can begin exercising and how long it may take to return stability and strength to the core.
Typically, the rectus abdominis, the transversus abdominis and the internal and external abdominal oblique muscles are the focuses. When transversus abdominus muscle is engaged, the pelvic floor muscles will engage. These are also considered part of the core. Abdominal bracing with variations, pelvic tilts and kegels are great examples of safe, effective exercises.
- Manek nj, macgregor aj. epidemiology of back disorders: prevalence, risk factors, and prognosis. Curr Opin Rheumatol. 2005 Mar; 17(2): 134-40. doi: 10.1097/01.bor.0000154215.08986.06. PMID: 15711224.
- Mahajan A, Patni R, Verma S. Low Back Pain and Menopause. J Midlife Health. 2019 Oct-Dec;10(4):163-164. doi: 10.4103/jmh.JMH_176_19. PMID: 31942150; PMCID: PMC6947725.
- Gibson CJ, Li Y, Bertenthal D, Huang AJ, Seal KH. Menopause symptoms and chronic pain in a national sample of midlife women veterans. Menopause. 2019 Jul;26(7):708-713. doi: 10.1097/GME.0000000000001312. PMID: 30839364.
- Wáng YX, Wáng JQ, Káplár Z. Increased low back pain prevalence in females than in males after menopause age: evidences based on synthetic literature review. Quant Imaging Med Surg. 2016 Apr;6(2):199-206. doi: 10.21037/qims.2016.04.06. PMID: 27190772; PMCID: PMC4858456.
- Mogren, Ingrid M. MD, PhD*; Pohjanen, Anna I. MD†. Low Back Pain and Pelvic Pain During Pregnancy: Prevalence and Risk Factors. Spine 30(8):p 983-991, April 15, 2005. | DOI: 10.1097/01.brs.0000158957.42198.8e
- Ward RC. Foundations for Osteopathic Medicine. Lippincott Williams & Wilkins; 2003.
- G K P, Arounassalame B. The quality of life during and after menopause among rural women. J Clin Diagn Res. 2013 Jan;7(1):135-9. doi: 10.7860/JCDR/2012/4910.2688. Epub 2013 Jan 1. PMID: 23450244; PMCID: PMC3576769.
- Bento TPF, Genebra CVDS, Maciel NM, Cornelio GP, Simeão SFAP, Vitta A. Low back pain and some associated factors: is there any difference between genders? Braz J Phys Ther. 2020 Jan-Feb;24(1):79-87. doi: 10.1016/j.bjpt.2019.01.012. Epub 2019 Feb 13. PMID: 30782429; PMCID: PMC6994312.
- Stuge B. Evidence of stabilizing exercises for low back- and pelvic girdle pain – a critical review. Braz J Phys Ther. 2019;23(2):181-186. doi:10.1016/j.bjpt.2018.11.006
Dr. Kevin M. Wong, DC is a graduate of the University of California, Davis, and a 1996 Summa Cum Laude graduate of Palmer College of Chiropractic West. He has been in practice for over 25 years and is the owner of Orinda Chiropractic & Laser Center in Orinda, CA.
As a member of Foot Levelers Speakers Bureau since 2004, Dr. Wong travels the country speaking on extremity and spinal adjusting. See upcoming events with Dr. Wong and other Foot Levelers speakers at footlevelers.com/seminars. Check out his monthly blogs with proven practice tips to help you achieve optimal patient outcomes.