Pain During Pregnancy: Pelvic Area, Groin, Legs and Back
Pain During Pregnancy: Pelvic Area, Groin, Legs and Back
Experiencing pain is humbling, and it can be a chance for personal growth. It can be an opportunity to practice techniques that will help with labor, birth and life beyond. Techniques like breathing, mindfulness, befriending and relaxing into intense sensations. Prevalent societal attitudes that include fear, numbing, medicating or escaping symptoms of discomfort as opposed to being with them, surrendering, welcoming, honoring them, listening to and finding meaning and beneficial purpose in their messages. Pain provides a chance to learn patience, acceptance of normal bodily changes associated with pregnancy, and how to prioritize, delegate, let go of activities of overwork or those that create increased stress, and allow others to help.
For pregnancy related aches and pains in the groin, back, or legs, it is recommended that you consult a reputable chiropractor or osteopath who can successfully relieve strained muscles and correct a spine or pelvis that is out of alignment. Other helpful professionals include a massage therapist (especially deep tissue, shiatsu, rolfing and Thai) who can do wonders to release tightened painful or aching muscles in spasm , a homeopath who can suggest a safe natural remedy to effectively treat your specific symptoms, or an acupuncturist skilled at directing needles on the trigger points. Therapeutic yoga can be helpful to reduce tension, increase strength and flexibility of responsible muscles,
Pain in the Groin
Sharp but short lived pain in the groin area that can sometimes travel down into the legs is either related to the stretching of the round ligaments that hold and support your growing uterus within your abdomen, or to the pressure of the uterus or baby on local nerves. This sort of pain usually occurs while walking or movement, and can be enough to stop you in your tracks.
For relief from round ligament pain, stop to rest, bend your knees onto your abdomen while lying down, or get on your hands and knees and rock your pelvis inward and outward. Take a very warm bath with Epsom Salts and a few drops of Lavender or Olbas herbal combination, followed by applying Tiger Balm then a hot or cold pack, or heating pad.
To minimize strain on these ligaments:
Take frequent breaks
Use full body or pregnancy pillows under your uterus and between your legs when lying down on your side
Roll on your side, transition through your hands and knees to use your arm, leg and core muscles when getting up from a supine position
Apply gentle pressure to the area when laughing, coughing, or sneezing
Consider wearing a maternity support garment -like Bellefit’s prenatal support wear.
Practice your kegel (those you use to stop the flow of urine) or even more comprehensive and effective, yoga mula bandha or root lock exercises, daily to strengthen your pelvic floor muscles that help support your uterus. Get out your yoga mat and do a modified bridge pose, supporting your sacrum on a yoga block. In this position it is easy to practice your mula bandha, by placing another yoga block between your thighs. While inhaling, tilt your pelvis up toward your face as you slowly squeeze the block and draw your entire pelvic floor upward and inward, starting from its center. Hold as long as is comfortable, then release and return to resting your sacrum on the block as you exhale. Let the breathing be smooth, relaxed and deep as you do this. It takes practice but you will get it. Start with 25 twice per day, and work up to 50 twice per day. Once you get the hang of it, you can do it in many positions, anywhere, anytime. You will also notice other benefits like easier birthing, reduced tearing, less urinary incontinence, better sex, improved exercise performance and yoga practice, and if done on a deeper level, enhanced overall well-being.
Back Pain
High backache in pregnancy is related to breast enlargement and heaviness, which may produce strain in compensating back muscles, especially if your breasts are not well supported. Wear a well-fitting, comfortable and supportive wire free maternity bra that lifts your breasts upward and inward. Do shoulder rolls and arm exercises that tighten and release your upper back muscles, and get a regular back massage.
Aches and pains in the lower back are related to several factors:
Pressure of your growing uterus or baby on the nerves
Stretching of the ligaments that connect the sides of the enlarging uterus to the lower back
Hormonal relaxation and increased mobility of your joints, especially in the pelvis
The shift in the center of gravity from your expanding belly, which leads your pelvis to tilt forward and your back to arch, straining the back muscles
The problem is made worse by excessive weight gain, prolonged walking or standing, frequent bending or lifting with poor posture and improper body mechanics, ill fitting or high heeled shoes, and weak or separated abdominal muscles or weak back muscles. Wear Bellefit’s prenatal support wear, or try Baby Hugger for more extensive support. They provide wonderful relief of lower abdominal pressure and aching back from weak or stretched abdominal muscles after several pregnancies. It is also helpful for Diastasis Recti.
Diastasis Recti (belly muscle separation) can sometimes cause back pain. More significantly, it can impact pregnancies as lax abdominal muscles do a poor job of supporting the uterus. Sometimes this causes the baby to take on a suboptimal position. This is a normal physiologic separation that takes place during pregnancy for most women. The effort made to correct it postpartum is mostly cosmetic as there are rarely any major medical issues associated with mild separation, especially when the separation is less than 3 finger widths. You can certainly do yoga and can learn corrective exercises to strengthen these muscles as well as bring them together.
Sciatica pain is caused by pressure of the enlarging uterus or baby on nerves that pass through the lower spine into the legs. This pain can travel from the back or thigh all the way down to the feet or toes. It can be severe and associated with other strange sensations like tingling or numbness.
REMEDIES
Watch your weight gain. Remember, under normal circumstances, you only need to gain 3-6 pounds during the first trimester and ½-1 pound per week thereafter, for a grand total of 25-35 pounds. The following strategies should be sufficient to maintain ideal weight throughout your pregnancy:
Regular moderate exercise (like brisk walking, cycling, swimming or dancing) for at least 30 minutes 5 days per week.
Practicing yoga postures modified for pregnancy, aimed specifically to help with your specific location of pain. Good examples are spinal twists, hamstring stretches and hip openers for sciatica; or down dog, forward bends, cat/cow, puppy, bridge, plank, triangle, sphinx, cobra, thread the needle and spinal twists to stretch and strengthen lower back.
A healthy diet high in fresh organic fruits, vegetables, whole grains, nuts, beans, seeds, tempeh, whole organic eggs, beef, chicken or turkey, wild Alaskan salmon, and whole fresh raw goat or sheep dairy.
Reduced intake of sugar, white flour, refined vegetable oils and partially hydrogenated fat, refined processed and deep fried foods.
Consumption of at least 64 ounces of filtered, spring or well water daily, between meals (at least 20-30 minutes before or 2 hours after eating).
Make sure you are eating enough calcium (found in whole dairy foods—ideally goat or sheep, sardines, wild caught salmon, ground sesame seeds/tahini, and dark green leafy vegetables excluding spinach) and magnesium (abundant in fresh green vegetables, apples, wheat germ, seeds, and nuts). You also need sufficient vitamin C, D, E , and B complex easily absorbed from a well-balanced whole food diet as well as natural prenatal supplements to provide needed nourishment not obtained by food alone. If you have inflammation, especially if your pain is more chronic, you may benefit from anti inflammatory diet and supplements adapted for pregnancy. Load up on the tumeric in your cooking!
BETTER BODY MECHANICS FOR PAIN REDUCTION
Know your pregnant body’s limits and pay attention to what your symptoms are telling you. Take frequent breaks or rest periods if you need to be on your feet for prolonged periods of time. Cut down on nonessential burdens in your life and be clear about your priorities. It is OK to say “no” or to leave the housework, pile of papers and long ‘to-do’ list for tomorrow, or better let most of it go, and/or delegate to someone else. Don’t be afraid to ask family or friends to help with chores or child care, or treat yourself to hired help and healthy take-out meals.
Avoid fatigue by making sure you are getting extra needed sleep by going to bed earlier, sleeping later, or taking naps. Rest on a firm supportive mattress or use a bed board, and sleep with pillows positioned to straighten your back and alleviate strain or pulling. Some women find the floor or a futon helpful. Use full body or pregnancy pillows for additional support.
Pay deliberate attention to your posture, especially when standing or walking, by lifting your abdomen up and in (bringing pelvic bone towards breast bone and using your muscles to corset your ribs inward), tucking your pelvis slightly up and in to minimize the arch in your lower back, and relaxing your shoulders down. Even when sitting, take care not to slump by using your abdominal muscles to lift up and keep your back straight. Sit on harder, more supportive chairs. Even better, ditch chairs and squat with your pelvis supported on a yoga block or your heels supported by a wedged yoga blanket. Use an ergonomic work station or standing desk, resting alternate feet on a foot stool while standing for extra relief on your back muscles. The foot stool will also come in handy during labor and life as a mom.
Walk barefoot while home, and wear supportive, well-fitting comfortable flat or rocker bottom shoes when out. Save the high heels until after the baby.
Avoid heavy lifting. Spread out grocery store purchases into several bags and take more trips carrying a lighter load instead of a heavier one all at once. Better yet, ask for help.
Watch your body mechanics by using your stronger stomach, arm, and leg muscles not your weaker back to lift, pull, or push something. Instead of bending at the waist or lifting abruptly, bend at the knees with a broad base and lift carefully. Instead of reaching for an object, come closer to it. Turn and twist more slowly and with caution. If a particular action feels even a bit uncomfortable, STOP!
Take extra precautions during activities requiring balance and walking on wet, icy or slippery surfaces. Remember your sense of balance is changed, your gait is more awkward and you have an increased tendency to fall. Use a non-skid floor mat in the bath and shower.
If you can not tolerate your usual exercise routine, do regular but more gentle exercise. Take a prenatal dance class, gentle yoga, or a pregnancy exercise class. A good instructor can help you maintain proper posture, and learn how to strengthen your abdominal, back and extremity muscles. Swimming is another option, as it allows you to get great exercise without any weight on your back.
Put on a maternity support garment like Bellefit before you start each day, especially if you were out of shape before the pregnancy or have poor abdominal muscle tone after several children, if you are overweight, carrying a big baby or twins, or on your feet a lot. Many specialty stores stock lightweight maternity girdles with soft elastic fronts and an adjustable belt if you are looking for alternatives.
STRESS REDUCTION FOR PAIN REDUCTION
Emotions greatly influence nerve and muscle interaction. Try to put yourself in a more positive, joyful and calm state by reading uplifting books, watching movies and listening to podcasts that inspire or make you laugh, and spending time with those who bring out your finest moods.
Stress leads to increased muscle tension and pain. Although easier said than done, limit your stress and inner tension, and increase feelings of calm by taking a “healing interval” a few minutes several times each day. Sit quietly with your eyes closed and think and do absolutely nothing, meditate, practice breathwork or pray. Do regular yoga (especially Yin, prenatal, gentle and restorative), practice progressive muscle relaxation techniques (yoga nidra), QiGong, Tai Chi, or take a walk outside in nature. Read these recent blog posts on natural remedies for stress and ways to manage your emotions.
The following breathwork exercises are simple to do and can be done any time and place. For example, while traveling, waiting in line, resting, before rising in the morning and going to bed at night, in the bath, on the toilet, or whenever you feel stressed or triggered.
When all is otherwise healthy and well, throughout all the exercises, practice embracing, relaxing into and even magnifying intense sensations without the mental story about them. Can you make friends with discomfort and pain, instead of trying to escape, numb or fight it? Is there something that they can teach you? Get curious about all of their details, including the borders or edges, and parts of you that feels good, or does not have unpleasant sensations. Yes there are remedies to help alleviate pain. But you will be amazed how effective this practice is, and how much it will help you to better cope with childbirth, as well as with the pain that is an inevitable part of being human. It is the suffering from the pain that is optional, so you can choose not to suffer.
Sit up straight but comfortably, with your eyes closed, internally keeping your gaze between your eyes, or open and focused on a nonmoving distant object or place. You can do this reclining, as long as you are not likely to fall asleep - the point is to be conscious throughout. While breathing be mindful, and just observe and release any muscle tension working your way slowly from head to toe. Practice Ujjai breathing. Breathe at the pace and depth that feels right for you, but by inhaling through your mouth or nose, directing the breath into the back of your throat which makes a sound like ocean waves (it is a calm, slow, and smooth circular version of gasping on inhale and fogging a mirror on exhale). This is meditation, combined with the benefits of breathwork.
Breath Awareness
Start with being more conscious about your breath, and simply focusing all of your attention on your breathing. Get curious about all the details of your sensations as you inhale and exhale, without trying to change anything. Notice what you are currently seeing, hearing, smelling, feeling, tasting. Just watch without judgment. This brings you to the present and is deliciously relaxing.
Deep Abdominal Breathing
Exhale slowly with an audible sigh, releasing all muscle tension, especially in your jaw and breathing diaphragm muscle.
Inhale slowly through your nose for a count of 4. Imagine a pump expanding your abdomen, and lower back, down to your pelvic floor, causing you to inhale. Allow ribs to expand with air, then inhale air into your upper chest towards your collarbone and shoulders.
Exhale slowly through your mouth for a count of 4. Release effortlessly, in the same order you inhaled, returning to baseline, your abdomen, ribs, then upper chest. With each exhalation, try to let go and relax even more.
Repeat this cycle a total of 8 times or at least a few minutes. You may need to play with counts, using a count of 3 or maybe even 5 or 6. But keep the counts of inhale the same as the counts of exhale.
Then extend, or double the exhale. For example, if you are inhaling to a count or 3, exhale to a count of 6, or if you are inhaling to a count of 4, exhale to a count of 6. And repeat this cycle for several minutes.
Triangle Breathing
Inhale for a count of 3 or 4, exhale to the same count of 3 or 4, then pause for the same count of 3 or 4, while consciously and deeply relaxing your diaphragm muscle of respiration, as well as all other muscles. Repeat for several cycles or a few minutes.
Box Breathing
Another great breathing technique that disengages your conscious attention from thought and relaxes the nervous system, and can be done any time, is box breathing. With this exercise, you add a timed pause between each inhalation and exhalation.
Set a timer for 5-10 minutes.
Inhale deeply into your belly as above for a count of 3.
Hold without tension for a count of 6.
Exhale to a count of 6 while consciously relaxing more and more.
Hold again without tension for a count of 3.
Repeat until your timer chimes. You may love this so much you will want to do it longer.
Breathing In Varied Ratios
Play with the ratios and counts of inhalation, exhalation and the pauses in between them. For example, exhale slowly through your mouth with an audible sigh. Inhale slowly through your nose for a count of 4, hold for a count of 7, then exhale through your mouth for a count of 8. Repeat for a total of 8 cycles.
Forced Exhalation Breathing
One more breathing exercise to try is forced exhalation:
After a normal breath, try squeezing as much air out as possible using your intercostal muscles.
Next, allow the breath to come in naturally and deeply, but automatically.
Repeat the cycle for several minutes or as long as you like.
See what feels best for you in each situation. Make these sorts of deep breathing and breath awareness practices, meditation and authentic yoga a regular part of your daily routine, even for 20-30 minutes.
Practice abdominal breathing as much as possible so it becomes habitual. This is the ideal form of breathing, as opposed to rapid shallow breathing. Do this by imagining a pump expanding your abdomen and lower back, which causes you to inhale. The pump then releases effortlessly, which causes you to exhale. Then there is a natural pause until you need to inhale again.
If you need video instruction, take my breathwork online course.
Don’t hesitate to schedule a session with me if you need more guidance with mastering breathwork and experiencing its transformative power.
Conscious Relaxation
Notice habits of increased muscle tension, especially around your upper back, shoulders, neck, forehead and jaw, and make an effort to release these tightened muscles while doing slow deep abdominal breathing. Ask someone to massage these areas or treat yourself to regular massage therapy.
It would be very beneficial to you if you could learn how to relax the muscles that are tensing up. It is an essential skill for labor and can be used in any stressful situation. Set aside a 10-15 minute time slot, like during one or two of your “healing intervals,” to focus on releasing all of your muscles:
Get into a comfortable position.
Breathe slowly and deeply while thinking about relaxing each muscle from your head down to your toes.
Visualize feeling heavy and limp like a rag doll, or like your napping dog or cat.
Life is stressful and always has been, and eliminating all outside stress is not an option. But you can learn to activate your own relaxation response and quiet your nervous system with breath work and awareness, meditation, imagery and visualization, progressive muscle relaxation, yoga, and self mastery over your thoughts and reactions to difficulties.
Minimize time online, especially addictive stressful apps, social media and computer games.Try to stay away from things, sounds and people that agitate your mind and raise your internal tension, and instead surround yourself as much as possible with calm centered people, things and sounds that inspire, relax and restore you to inner peace and serenity. Make a conscious effort to work on increasing your own feelings of forgiveness, appreciation, love, joy, optimism and healing, while letting go of anger, resentment, envy, fear, sadness and negativity.
Become conscious of anxiety provoking, tension causing thought patterns that are not serving you, and literally stop them. Shift your attention to something more positive like slow deep breathing, and ultimately change your inner mental state. You have the ability to alter your attitude and reaction to stressful life experiences with more health enhancing responses. For example, you can surrender to and totally accept unpleasant events over which you have no power, or you can view them as a wake-up call, an opportunity for personal growth and redirection. And you can always try to focus as much attention as possible on the present moment, literally without letting your thoughts wander into magnified past or imagined future.
For more information about this and other great ways to improve your physical and emotional well-being, read Natural Health, Natural Medicine by Dr. Andrew Weil, Practicing the Power Of Now by Eckhart Tolle, Loving What Is by Byron Katie, and Prescriptions for Living by Dr. Bernie Siegel.
While it is not only helpful to express your troubling feelings to a sympathetic trained ear, it is more effective to move these emotions through your body with Femme, Ecstatic Dance or Journey Dance and release them through conscious connected breathing type of breathwork. It is also critical to develop skills of self-mastery and empowerment.
HOME REMEDIES
Reputable brands of the supplements and remedies I recommend include Innate Response, Wish Garden, Gaia, Herb Pharm, Wise Woman Herbals, Pure Encapsulations and Eclectic Institute, or any of those in my online holistic apothecary.
When your back hurts, allow time to rest and get into a position that eases the pain. Some women find stretching or pelvic rocking helpful. Take slow deep breaths in through your nose and out through your mouth, and focus on releasing your tense muscles head to toe. Most often pain from muscle spasms heals with rest, excellent self care and time.
One of the most pleasant ways to relieve backache is a massage to the painful area, with arnica oil, mixed with a dropperful each of St John’s wort topical oil, cramp bark and lobelia tinctures. Massage the mixture lovingly into your deep muscle, ligament and joint aches and strains. Try any of the following and regularly use what works best for you: Essential oils of Ginger, Juniper, Cinnamon, Lavender, Marjoram, Chamomile, Lemon Balm/Melissa, Wintergreen, Spearmint or Rosemary can be diluted within it, alone or in combination. You can also apply Comfrey ointment, rubs of Tiger Balm, or Olbas herbal combination. Chinese herbal Zheng Gu Shui can also help, or any product that contains these soothing herbs.
After the massage, apply locally a hot or cold pack, heating pad, hot water bottle, herbal infused hot or cold pack, or try moist heat using a hot damp towel or packs from a hydrocollator (what the professional chiropractors, massage and physical therapists use). Take a hot shower or soak in a very warm Epsom Salts bath for ½ hour with a few drops of any of the above essential oils or add a wonderful Swiss Olbas herbal combination.
Some find that ice packs or cool compresses helps to relieve the pain, especially during the first 24 hours after an injury. For acute spasm and inflammation of your back muscles, apply an ice pack off and on for the first 12-24 hours. Once the pain begins to subside, apply moist heat. Complete rest in positions that feel best are essential for the first 1-2 days. Sometimes the only tolerable position is lying flat on your back on the floor with your buttocks up against a bed or chair and your legs raised at a right angle with your calves resting on the mattress or seat, or lying flat on your yoga mat in Legs Up The Wall, Viparita Karini. Props like yoga blankets, bolsters or blocks make postures more accessible, passive, comfortable and restorative. In this case, use them to support your lower back and head, and elevate your hips. Legs Up The Wall is done lying down flat on your back with your buttocks all the way to the wall, or elevated on a folded yoga blanket, bolster or block. Let your legs rest straight up the wall for 10-20 minutes. It is also a great opportunity for practicing quiet meditation, focusing on slow deep breathing and inner gazing between your eyebrows. A lavender infused eye pillow adds to the yummy relaxation effect.
Use a TENS unit, which relieves back pain of pregnancy, and can also help in labor.
Take a dropperful of Cramp Bark tincture every hour x 4, then 2-4 times per day for no more than a 1-2 weeks, and 1-2 dropperfuls each of St. John’s Wort and Skullcap tinctures 1-3 times daily for several weeks. You can also take Ginger to reduce inflammation and pain 500-1000 mg once or twice per day until you feel better. Place 4-5 pellets of homeopathic Arnica 30c under your tongue every hour while awake, every few hours the next day, then 3-4 times per day for a week. Discontinue topical BenGay or Tiger Balm, if it lessens the effect of your homeopathic remedy.
Chamomile, Lavender or Lemon Balm tea are good options for relaxation and helping to soothe tension related pain.
It is currently considered medically OK to take an occasional dose of acetaminophen (Tylenol), or an occasional ibuprofen (Advil) in the first or second trimester only. But it really is less toxic to avoid these medications which are not as benign as we have been led to believe. Do avoid other drugs before consulting with your practitioner, since many are not safe for use during pregnancy (including aspirin, certain muscle relaxants, and anti-inflammatory medications). Instead, try a turmeric latte for its inflammatory benefits, and Curcumin (turmeric) is researched as being as effective as many common over the counter analgesics.
Avoid hot tubs and whirlpools because getting your body to such high temperatures without allowing you to sweat to cool your body down may not be safe for the baby.
For SPD (Symphysis Pubis Dysfunction):
This can happen when the ligaments and joints connecting the bones of the pelvis become so lax that the pelvic bones go easily out of alignment. It can create very intense pain, especially in the pubic area, and a sense that the pelvic bones are breaking apart even though this is extremely rare and they are really not.
Typical general advice usually given to women includes avoiding activities like strenuous exercise, prolonged standing, vacuum cleaning, stretching exercises and squatting. Women are also frequently advised to:
Have regular chiropractic or osteopathic care.
Brace the pelvic floor muscles before performing any activity that might cause pain using your mula bandha (yoga root lock), and stabilize your pelvic bones with a support belt or belly band. You can also use a belly support garment called Baby Hugger, which uses straps and Velcro over the shoulders and under the belly to use the shoulders to assist in carrying the weight of the baby. This prevents the baby from resting entirely on the pelvis. I joke that the Baby Hugger is Industrial Grade Lingerie, especially when paired with thigh high compression stockings, but I can attest it is helpful for SP pain.
Rest the pelvis.
Sit down for tasks where possible.
Avoid lifting and carrying.
Avoid stepping over things.
Bend the knees and keep the legs 'glued together' when turning in bed and getting in and out of bed.
Place a pillow between the legs when in bed or resting.
Avoid twisting movements of the body.
Avoid straddle movements especially when weight bearing.
When rolling over in bed, go belly DOWN, not UP.
The sign I look for that means there is a true separation and not just inflammation and pain (tenderness to touch) is walking backwards is easier than walking forwards.
If the pain is very severe, you may benefit from physical therapy. Using elbow crutches will help take the weight off the pelvis and assist with mobility. Alternatively, for more extreme cases a wheelchair may be considered advisable.
It is usually recommended that women with SPD give birth in an upright position, with knees slightly apart, and it is often suggested that a woman tie a ribbon to both legs to ensure that the gap never exceeds her maximum comfort zone.
Practices such as placing the feet on the provider’s hips during delivery, stirrups, and interventions such as forceps should be avoided in the delivery room if at all possible, as they can strain ligaments further and cause long term problems. If stirrups must be used, for example during suturing, great care must be taken to move the legs in symmetry, maneuvering them gently into position.
It doesn't always get worse with birth, so I have learned not to be fearful about it and to use hands/knees, side-lying with knees together or upright. Avoid squatting, lunging and pushing on one’s back.
For those with any sort of chronic musculoskeletal pain in which serious causes have been ruled out and none of the natural or allopathic remedies help, get to the root cause and avoid getting dependent on pharmaceuticals and surgery unless absolutely necessary. Consider reading the book The Mindbody Prescription By Dr John Sarno, MD. He is an amazing pioneering physician whose brilliant approach has helped hundreds of thousands of people without drugs, physical measure or surgery.
To release stress and trauma energy often responsible for chronic issues, do conscious connected Clarity breathwork and experience miraculous healing and transformation. Also check out Brandon Bays’ book The Journey, and her website. These are all extremely effective mind-body cutting edge methods that have also lead to transformational healing for thousands of people around the world.
As always, if you need more guidance, schedule a consultation with me.
Remember that not all aches and pains can be blamed on pregnancy. Consult your practitioner if:
The above suggestions do not help.
The pain is different than usual, or is severe, persistent, or continuous.
Pain is associated with other unusual symptoms like fever, chills, changes in bowel or bladder habits, vaginal bleeding or leaking of water-like fluid.
You experience regular pelvic pressure, uterine hardening or cramping.
You have a local area of increased pain, redness, swelling, and redness on your leg.
Normal movement becomes difficult.
You have a history of serious back problems, injury, or surgery.