Low Back Pain in Pregnancy and Chiropractic

The utilization of chiropractic spinal adjusting for the management of low back pain is increasingly less and less controversial. As an example, in December of 2011, the journal Alternative Therapies Health Medicine, published a study titled (1):

Cerebral metabolic changes in men after chiropractic spinal manipulation for neck pain

This study has 9 authors who are from the Division of Cyclotron Nuclear Medicine, Tohoku University (Graduate School of Medicine), Sendai, Japan. Eight of the 9 authors are credentialed with the degrees MD and PhD. The ninth author (the study’s primary author, Ogura) is credentialed DC, PhD. The beginning of this article makes these statements:

“Chiropractic spinal manipulation is an alternative treatment for back pain.”

“Research on chiropractic spinal manipulation has been extensively performed worldwide, and its efficacy on musculoskeletal symptoms has been well documented.”

The purpose of this article is to look at some of the evidence for the utilization of chiropractic spinal adjusting in the management of low back and/or pelvic pain during pregnancy.

Low back and/or pelvic pain in pregnancy is extremely common. A study published in the journal Spine in 1996 indicated that 76% of women reported back pain at some time during pregnancy (2). In a study published in the Australian and New Zealand Journal of Obstetrics and Gynaecology in 2002 indicated that 35.5% of pregnant women recall having moderate to severe back pain during pregnancy, and 68% of those women “continued to experience recurring low back pain with a self reported reduction in their health (3).” Interestingly, these authors listed the 4 most commonly used treatments for this pregnancy back pain as bed rest, pain killing medication, physiotherapy, and chiropractic.

A study published in the journal Obstetrics and Gynecology in 2004 indicated that 68.5% of women reported experiencing low back pain during their current pregnancy (4). This low back pain caused sleep disturbances in 58% and impaired daily living in 57% of the women. The average pain was moderate in severity. Nearly 30% of respondents stopped performing at least one daily activity because of pain and reported that pain also impaired their performance of other routine tasks. In another study published in the journal Spine in 2005, the prevalence of low back/pelvic during pregnancy was 72% (5). “Low back pain during pregnancy is a common problem that causes hardship in this [pregnant women] population.” (4)

Pregnancy low back and/or pelvic pain is prolonged in a significant number of women after giving birth. A study published in the European Spine Journal in 2002 showed that 20% of all women with back pain during pregnancy continued to have back pain 3 years later (6).

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There are a limited number of studies assessing spinal adjusting (manipulation) for women with pregnancy back and/or pelvic pain. Yet, as noted above, it is one of the most commonly used treatments for pregnancy low back and/or pelvic pain (3). In a study published in the Journal of Alternative and Complementary Medicine in 2005, researchers from Yale University School of Medicine found that both providers of prenatal health care and pregnant women are likely to use complementary and alternative medicine (CAM) treatments for pregnancy-induced low back pain (7). In this study, the most common CAM therapies recommended for LBP in pregnancy by the providers of prenatal health care were massage (61.4%), acupuncture (44.6%), relaxation (42.6%), yoga (40.6%), and chiropractic (36.6%).

Accessing the United States National Library of Medicine with the search engine pubmed.gov (www.pubmed.gov), I found these studies using the following key words and results (9/10/13):

• “pregnancy low back pain and chiropractic” – 13 articles
• “low back pain AND pregnancy AND manipulation” – 17 articles

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In both of these searches, the first (most recent) study listed was the same. It was published in the journal Canadian Family Physician last month (August 2013), and titled (8):

Optimizing pain relief during pregnancy using manual therapy

The authors begin by proposing a question:

Many of my pregnant patients have muscle and joint aches, and are reluctant to use analgesics. What is known about chiropractic care during pregnancy?

This article contains no primary research. The authors then proceed to review a limited number of published studies showing the benefits of massage, acupuncture, exercise, and chiropractic spinal adjusting in pregnant women with low back pain, pelvic pain, and sacroiliac joint pain. They note that musculoskeletal pain is extremely common among pregnant women, with approximately 20% of pregnant women experiencing pelvic girdle pain, and 50%-85% experiencing low back pain. They attribute pregnancy musculoskeletal pain to an anterior shift in a woman’s center of mass in the 2^nd and 3^rd trimesters of pregnancy, arguing that therefore the root cause of much pelvic pain during pregnancy is mechanical (stemming from the low back or sacral joints) and not hormonal. The authors make these statements:

“Owing to fears of the potential effects of medications, many women are unsure of what to do about low back and pelvic pain during pregnancy.”

“Increasing recent evidence attests to the effectiveness and safety of treating [pregnancy low back and pelvic girdle] pain using manual therapy.”

“Chiropractors, as primary health care professionals, have the ability to identify and diagnose mechanical problems and to alleviate many cases of undue stress or anxiety. Chiropractic doctors are also trained to understand when symptoms are indicative of something more ominous and to refer the patient to the appropriate professional if a non-mechanical issue is suspected.”

“Massage therapy and chiropractic care, including spinal manipulation, are highly safe and effective evidence-based options for pregnant women suffering from mechanical low back and pelvic pain.”

“Common sacroiliac joint dysfunction can often cause substantial pelvic pain and can be relieved with a simple adjustment by a chiropractor in minutes.”

“Women experiencing musculoskeletal pain related to pregnancy can greatly benefit from manual therapies, including spinal manipulation, acupuncture, and massage therapy.”

It is noted that in addition to spinal adjusting, chiropractors can prescribe exercise and stretches specific to their patients’ needs. Also, some chiropractors are trained in and practice acupuncture.

The authors review a 2008 study published in the journal Midwifery Today / International Midwife titled (9):

Chiropractic Evaluation and Management of the Pregnant Patient:
An Update from Recent Literature

In this study the authors note that many chiropractors work closely with midwives. Fifty-seven percent of midwives recommended complementary and alternative therapies, with chiropractic care being the third most popular choice.

The authors also cite a 2002 study from the journal Spine, titled (10):

Patients Using Chiropractors in North America:
Who are They, and Why are They in Chiropractic Care?

In this study, it was found that “87% of patients demonstrate a high level of satisfaction with their chiropractic experience.”

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A study published in the Journal of Manipulative and Physiological Therapeutics in 1991 showed that there was a statistically significant reduction of degree of back pain during labor in women who received spinal manipulative therapy during pregnancy (12).

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A study published in the Journal of Midwifery and Woman’s Health in 2006, retrospectively evaluated chiropractic spinal manipulation for low back pain of pregnancy (13). The 17 cases that met the inclusion criteria experienced significant improvement in pain attributed to chiropractic care. No adverse effects were reported in any of the 17 cases. The results suggest that chiropractic treatment was safe in these cases and support the hypothesis that it may be effective for reducing pain intensity.

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A study published in the Journal of Manipulative and Physiological Therapeutics in 2009 documented the outcome of pregnancy-related lumbopelvic pain treated with chiropractic care in a prospective observational cohort study (14). Seventy-three percent of the patients reported their improvement as either “excellent” or “good.” These patients showed clinically significant improvements in pain and disability.

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A randomized controlled trial study published in the American Journal of Obstetrics & Gynecology in 2010 evaluated the efficacy of spinal manipulative treatment of back pain and related symptoms during pregnancy (15). The authors were from the University of North Texas Health Science Center in Fort Worth. The 144 subjects in the study were in the third trimester of pregnancy. They were randomized into 3 groups: usual obstetric care and manipulative treatment; usual obstetric care and sham ultrasound treatment (placebo); and usual obstetric care only. Outcomes are summarized in the chart below:

Results of 144 Patients With Pregnancy Low Back Pain

The authors concluded that spinal “manipulative treatment slows or halts the deterioration of back-specific functioning during the third trimester of pregnancy.”

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A study published in the journal Chiropractic & Manual Therapies in 2012, assessed the quality of the treatment experience of patients with low back pain during pregnancy and their chiropractors (16). The study abstract states:

“Chiropractors regularly treat pregnant patients for low back pain during their pregnancy. An increasing amount of literature on this topic supports this form of treatment; however the experience of the pregnant patient with low back pain and their chiropractor has not yet been explored. The objective of this study is to explore the experience of chiropractic treatment for pregnant women with low back pain, and their chiropractors.”

The study participants consisted of 11 pregnant patients in their second or third trimester with low back pain, and their 12 chiropractors. The interviews consisted of 10 open-ended questions for patients, and eight open-ended questions for chiropractors, asking about their treatment experience or impressions of treating pregnant patients with LBP.

The authors note that the structural, postural, or hormonal changes that occur during pregnancy may lead to low back pain. Chiropractic care may include spinal manipulative therapy (SMT), mobilizations and soft tissue therapy, as well as exercise prescription. “Previous studies and systematic reviews of the literature have indicated the relative safety and effectiveness of chiropractic treatment for low back pain during pregnancy.”

Nearly all of the chiropractors indicated that chiropractic treatment was effective in relieving the low back pain of pregnant patients.

“The chiropractors generally emphasized communicating well with their patients as part of providing care and outlining the outcomes to expect. A few of the chiropractors placed great emphasis on patient education about pregnancy, particularly with respect to the changes that are taking place in the patient’s body as they are going through their pregnancy, or the various reasons behind their LBP symptoms.”

Chiropractors were generally open to referring their patients to other professionals, including encouragement to see their midwife or OB-GYN.

The chiropractors in this study tailored each patient’s treatment plan to the specific needs and particular timing in the patient’s pregnancy. “The chiropractors in this study demonstrated concern regarding patient safety and were vigilant in evaluating for the presence of any contraindications to spinal manipulation.”

Exercise prescription appeared to be an important component of the treatment program in this study. Most of the chiropractors advised specific stretches or exercises for their patients.

The comments of the patients and chiropractors lend support to reports in the literature of positive outcomes of chiropractic care for low back pain during pregnancy. In this study it appeared that these women benefited from chiropractic treatment, including spinal manipulation, soft tissue therapy and exercise therapy. No adverse events were reported by the pregnant patients or their chiropractors in response to the spinal manipulation received. The article concluded with:

“Chiropractors approach pregnant patients with low back pain from a patient-centered standpoint, and the pregnant patients interviewed in this study who sought chiropractic care appeared to find this approach helpful for managing their back pain symptoms.”

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An important study was published earlier this year (April 2013), also in the American Journal of Obstetrics & Gynecology, and titled (17):

A randomized controlled trial comparing a multimodal intervention and standard obstetrics care for low back and pelvic pain in pregnancy

These authors examined whether a multimodal approach of musculoskeletal and obstetric management (MOM) was superior to standard obstetric care to reduce pain, impairment, and disability in the antepartum period. The MOM care was provided and directed by chiropractors. It included manual therapy, stabilization exercises, and patient education. The standard obstetric care (STOB) consisted of combinations of these options: rest, aerobic exercise, heating pad for up to 10 minutes, use of acetaminophen for mild pain, or narcotics for discomfort unrelieved by other measures. Both the MOM and STOB groups received routine obstetric care.

This was a prospective study that randomized 169 women to the two groups. Baseline evaluation occurred at 24-28 weeks’ gestation, with follow-up at 33 weeks’ gestation. The authors evaluated these patient populations with 3 subjective questionnaires and 4 physical tests to quantify pain, disability, and physical function.

The authors note that women commonly experience low back pain during pregnancy. Up to 40% of women who have recently given birth have musculoskeletal pain for 18 months after delivery. Ninety-four percent of women who experienced low back pain (LBP) in pregnancy have recurrent symptoms with subsequent pregnancy.

The MOM group had weekly visits with a chiropractor that provided education, manual therapy, and stabilization exercises. The goal of manual therapy was to restore joint motion and reduce muscle tension. Hypomobile joints were treated with routine joint mobilization to help restore proper range of motion.

The stabilization exercises were targeted to strengthen the muscles that support the low back and pelvis. The chiropractic provider individualized the home exercises used for each patient. “Patients were instructed to perform their home exercise program twice daily.”

The MOM group “demonstrated significant reductions” in both pain and disability from baseline to follow-up evaluation. “The group that received standard obstetric care demonstrated no significant improvements.” Additionally, the MOM group reported significantly less trouble sleeping at 33 weeks’ gestation than the STOB group.

Important comments from these authors include:

“A multimodal approach to low back and pelvic pain in mid pregnancy benefits patients more than standard obstetric care.”

“We conclude that a multimodal approach to musculoskeletal LBP/PP that is instituted in the late second and early third trimesters of pregnancy benefits patients above and beyond standard obstetrics provider care.”

“We have shown that a combination of manual therapy, exercise, and patient education reduces pain and disability when applied at 24-33 weeks’ gestation. The benefits derived are both subjective and objective. Patients perceived less pain and disability and an overall global improvement in daily activities. Their physical examinations revealed improved range of motion, stability, and less irritation at the lumbar and pelvic joints.”

“Chiropractic interventions and education, meshed with standard prenatal practice, led to an improvement in the MOM group that were not observed in the STOB group between 24 and 33 weeks’ gestation.”

“These results suggest that the multimodal approach in the MOM treatment in pregnancy reduces pain and discomfort, while improving the quality of daily activities for pregnant women who experience LBP/PP.”

This article supports that pregnant women with low back and/or pelvic pain would benefit from the inclusion of weekly chiropractic care that includes manipulation, mobilization, and patient-specific home exercise coaching, along with the standard management of obstetric care.

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Perhaps the most interesting article pertaining to pregnancy and spinal manipulation was published in 2012 in the Journal of the American Osteopathic Association (18). The author, Dr. John M. Lavelle, DO, is Chief Resident, Department of Physical Medicine and Rehabilitation, Boston University Medical Center. The article is titled:

Osteopathic Manipulative Treatment in Pregnant Women

Dr. Lavelle notes that in the body structure and function are interrelated. “Our body systems depend upon one another to function, and that maintenance of the body in its proper alignment improves the body’s function and its ability to maintain health.” During pregnancy, the maternal body undergoes various structural changes to accommodate the growing fetus. As the pelvis begins to tilt anteriorly, the lumbar lordosis increases, placing increased stretch on the back extensor muscles and on the sacroiliac joints, leading to increased low back and pelvic pain. As the fetus descends into the pelvis, there is increased pressure on the lumbosacral plexus, which can induce sciatic pain and paresthesia in the leg.

Although Dr. Lavelle acknowledges that maternal structural changes in pregnancy increase the risk of low back pain, he also discusses how such changes may also influence whole body homeostasis and wellness. He states:

“The addition of [spinal manipulation] to the standard care of pregnant women has been hypothesized to enhance homeostasis and improve quality of life as the body adapts to these changes.”

“[Spinal manipulation] can ease pain in pregnant women by eliminating somatic dysfunction and maintaining proper structure.”

“The application of [spinal manipulation] may improve and optimize physiologic function, which can alleviate somatic dysfunctions and improve quality of life for pregnant women.

Dr. Lavelle cites two older studies that indicate spinal manipulation to the lumbar spine during pregnancy may alter (shorten) the duration of labor (19, 20). The first study involving 223 pregnant women showed a decrease in the duration of labor in pregnant women who received spinal manipulation compared with pregnant women who did not receive spinal manipulation (19):

Average Duration of Labor for 223 Women

These studies suggest that by manipulating the lumbar spine, it is possible to affect the pelvic viscera and possibly induce uterine contractions. Dr. Lavelle notes that there is a “statistically significant reduction of degree of back pain during labor in women who received spinal manipulative therapy during pregnancy.”

Dr. Lavelle cites a 1982 study of 500 pregnant women that showed manipulation to the lumbar spine not only decreased pain during labor, but also “reduced the need for major narcotic pain medication.” (21)

Dr. Lavelle cites a 1991 study that showed 91% of pregnant patients with sacroiliac dysfunction had alleviation of their low back pain after receiving manipulation (22).

In summary, Dr. Lavelle makes these points:

“The data reviewed support the theory that [spinal] manipulation can have a beneficial effect on back pain in pregnancy.”

Many physical discomforts of pregnancy can be alleviated by using spinal manipulation “at each patient encounter through the duration of pregnancy.”

“Manipulative treatment can alleviate musculoskeletal complaints that arise during pregnancy.”

“Treatment of somatic dysfunction in pregnant women can enhance homeostasis and improve comfort and quality of life as the maternal body adapts to the physiologic and structural changes of pregnancy.”

“[Spinal manipulation] in pregnant women alleviates somatic dysfunctions and improves their quality of life.”

CONCLUDING COMMENTS

There is increasing evidence from good journals, including studies that are randomized clinical trials, for the following key points:

• Most pregnant women experience low back and/or pelvic during pregnancy, especially in the 2^nd and 3^rd trimesters as a consequence of structural changes in the woman’s body.
• Pregnant women with low back and/or pelvic pain tend to respond well when they add chiropractic care to their standard obstetrical care. The chiropractic care is often a combination of spinal manipulation, mobilization, and home exercise instruction.
• Chiropractic care during pregnancy may reduce labor time.
• Chiropractic care during pregnancy may have other health benefits as a consequence of the influence on whole body homeostasis.
• Chiropractic care of the pregnant woman appears to be quite safe for both the mother and the fetus.

References

1. Ogura T, Tashiro M, Masud M, Watanuki s, Shibuya K, Yamaguchi K, Itoh M, Fukuda H, Yanaik; Cerebral metabolic changes in men after chiropractic spinal manipulation for neck pain; Alternative Therapies Health Medicine Nov-Dec 2011;Vol. 17; No. 6; pp. 12-17.
2. Kristiansson P, Svarsudd K, von Schoultz B. Back pain during pregnancy: a prospective study. Spine 1996;21:702-9.
3. Stapleton DB, MacLennan AH, Kristiansson P. The prevalence of recalled low back pain during and after pregnancy: a south Australian population survey. Aust N Z J Obstet Gynaecol 2002;42:482-5.
4. Wang SM, Dezinno P, Maranets I, Berman MR, Caldwell-Andrews AA, Kain ZN. Low back pain during pregnancy: prevalence, risk factors and outcomes. Obstet Gynecol 2004;104: 65-70.
5. Mogren IM, Pohjanen AI. Low back pain and pelvic pain during pregnancy: prevalence and risk factors. Spine 2005;30:983-91.
6. Noren L, Ostgaard S, Johansson G, Ostgaard HC. Lumbar back and posterior pelvic pain during pregnancy: a 3-year follow-up. Eur Spine J 2002;11:267-71.
7. Wang SM, DeZinno P, Fermo L, Williams K, Caldwell-Andrews AA, Kain ZN: Complementary and alternative medicine for low-back pain in pregnancy: a cross-sectional survey. 
J Altern Complement Med 2005, 11:459-64.
8. Oswald C, Higgins CC, Assimakopoulos D; Optimizing pain relief during pregnancy using manual therapy; Canadian Family Physician; August 2013; Vol. 59; No. 8; pp. 841-842.
9. Zerdecki L, Passmore S. Chiropractic evaluation and management of the pregnant patient: an update from recent literature. Midwifery Today Int Midwife; 2008;(87):28-9, 67-8.
10. Coulter ID, Hurwitz EL, Adams AH, Genovese BJ, Hays R, Shekelle PG. Patients using chiropractors in North America: who are they, and why are they in chiropractic care? Spine; Feb 1, 2002, Vol. 27; No. 3, pp. 291-296.
11. Intentionally left blank.
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13. Lisi AJ. Chiropractic spinal manipulation for low back pain of pregnancy: a retrospective case series. J Midwifery Women’s Health 2006; 51:7-10.
14. Murphy DR, Hurwitz EL, McGovern EE. Outcome of pregnancy-related lumbopelvic pain treated according to a diagnosis-based decision rule: a prospective observational cohort study. J Manipulative Physiol Ther 2009;32:616-24.
15. Licciardone JC, Buchanan S, Hensel K, King HH, Fulda KG, Stoll ST. Osteopathic manipulative treatment of back pain and related symptoms during pregnancy: a randomized controlled trial. Am J Obstet Gynecol 2010; 202:43.e1–8.
16. Sadr S, Pourkiani-Allah-Abad N, Stuber KJ; The treatment experience of patients with low back pain during pregnancy and their chiropractors: a qualitative study; Chiropractic & Manual Therapies; 2012 Oct 9;20(1):32.
17. George JW, DC; Skaggs CD, DC; Thompson PA, Nelson DM, Gavard JA, Gilad A. Gross GA; A randomized controlled trial comparing a multimodal intervention and standard obstetrics care for low back and pelvic pain in pregnancy; American Journal of Obstetrics & Gynecology; April 2013;208:295.e1-7.
18. Lavelle JM; Osteopathic Manipulative Treatment in Pregnant Women; Journal of the American Osteopathic Association; June 2012; Vol. 112; No. 6; pp. 343-346.
19. Whiting LM. Can the length of labor be shortened by osteopathic treatment? J Am Osteopath Assoc. 1911;11:917-921.
20. Hart LM. Obstetrical practice. J Am Osteopath Assoc. 1918:609-614.
21. Guthrie RA, Martin RH. Effect of pressure applied to the upper thoracic (placebo) versus lumbar areas (osteopathic manipulative treatment) for inhibition of lumbar myalgia during labor. J Am Osteopath Assoc. 1982;82(4):247-251.
22. Daly JM, Frame PS, Rapoza PA. Sacroiliac subluxation: a common, treatable cause of low-back pain in pregnancy. Fam Pract Res J. 1991;11(2):149-159.

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