J Midwifery Womens Health 2006 (Jan); 51 (1): e7-10 ~ FULL TEXT
Anthony J. Lisi
University of Bridgeport College of Chiropractic.
Low back pain is a common complaint in pregnancy, with a reported prevalence of 57% to 69% and incidence of 61%. Although such pain can result in significant disability, it has been shown that as few as 32% of women report symptoms to their prenatal provider, and only 25% of providers recommend treatment. Chiropractors sometimes manage low back pain in pregnant women; however, scarce data exist regarding such treatment. This retrospective case series was undertaken to describe the results of a group of pregnant women with low back pain who underwent chiropractic treatment including spinal manipulation. Seventeen cases met all inclusion criteria.
The overall group average Numerical Rating Scale pain score decreased from 5.9 (range 2-10) at initial presentation to 1.5 (range 0-5) at termination of care. Sixteen of 17 (94.1%) cases demonstrated clinically important improvement. The average time to initial clinically important pain relief was 4.5 (range 0-13) days after initial presentation, and the average number of visits undergone up to that point was 1.8 (range 1-5). 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.
From the FULL TEXT Article:
Low back pain is a very common complaint during pregnancy.
European studies have reported the prevalence rate
of low back pain during the 9 months of pregnancy to be
from 46% to 76%. [1, 2] Recent US studies found prevalence
rates of 57% and 69%. [3, 4]
The incidence of low back pain with an onset during
pregnancy has been reported to be 61%.  It has been shown
that among women with low back pain of pregnancy, 75%
reported no low back pain before pregnancy.  In a study of
women with chronic low back pain, up to 28% stated that their
first episode of back pain occurred during a pregnancy. 
Like most cases of low back pain in general, the etiology
of low back pain of pregnancy is not known. It has long
been considered to be related to maternal weight gain and
resulting biomechanical changes in the spine; however,
epidemiologic data provide a conflicting picture. Several
studies have found no relationship between onset of pain
and gestational age, [2, 3, 5] and indeed, the onset of low back
pain of pregnancy is often earlier than week 6 of pregnancy,
with the largest proportion often between weeks 13 and
30. [2, 5] Increased lumbar lordosis is commonly considered a
cause of low back pain in pregnancy. However, it has been
shown that lumbar lordosis does not categorically increase
in every pregnant woman; moreover, when lordosis does
increase, it is not clearly related to severity of low back
Increased joint laxity secondary to relaxin is a known
phenomenon, but its relationship to onset of low back pain
remains unclear.  However, one factor supported by preliminary
work is that asymmetry of sacroiliac joint laxity,
rather than absolute laxity alone, is related to low back pain
of pregnancy. [10, 11]
In most instances, the average pain level is moderate, but
severe pain has been reported in 15% of cases. [3, 4] Pain
intensity often increases with duration and can result in
significant disability.  Sleep disturbances have been reported
by 49% to 58% of women and impaired daily living
by 57% in women with low back pain of pregnancy. [3, 4]
Despite the apparent impact it has on women, many
cases of low back pain of pregnancy go unreported to
prenatal providers and/or untreated. Wang et al. found that
just 32% of women reported their low back pain of
pregnancy to their prenatal providers, and just 25% of these
providers recommended a treatment.3 Skaggs et al. found
that among women with low back pain of pregnancy, 80%
thought that their providers had not offered treatment for
their back pain. 
The clinical management of low back pain of pregnancy
varies among prenatal providers, [2, 3] yet it seems clear that
chiropractors are, at times, involved in the management of
such cases. Chiropractors commonly manage low back pain
and other musculoskeletal pain patients,  and although
there are little clear data indicating what percentage of
those patients are pregnant, a survey of US chiropractors
reported 76% of respondents were involved in the management
of pregnant women.  A recent population-based
survey of Australian women found that 11% of women with
low back pain of pregnancy underwent chiropractic treatment. 
A survey of North Carolina certified nurse-midwives
found that 93.9% of respondents recommend complementary
and alternative medicine to their pregnant
patients, and more than half of these recommended chiropractic
treatment, mostly for low back pain of pregnancy. 
Chiropractic treatment includes many therapeutic options,
as outlined in Table 1. Spinal manipulation is
typically considered the defining element of chiropractic
practice. There is reasonable evidence supporting the safety
and effectiveness of spinal manipulation for low back
pain,  neck pain,  and chronic/recurrent headaches. 
However, at present, there is only minimal evidence on the
safety and effectiveness of spinal manipulation along with
other alternative therapies for pregnant women. [3, 15] Scarce
outcomes data on any chiropractic treatment of low back
pain of pregnancy have been presented in the peer-reviewed
literature. Two retrospective case series [19, 20] and one case
report  describe pain reduction in the majority of cases;
however, all three reports have methodological limitations.
Particularly unclear is the role of spinal manipulation, the
chiropractic treatment method presently supported by the
most evidence of safety and effectiveness for general low
back pain.  It has often been written that low back spinal
manipulation should be avoided in low back pain of
pregnancy cases, [23, 24] but no data have been presented to
support this finding.
The purpose of this study, therefore, is to describe the
response of a group of consecutive cases of women with
low back pain of pregnancy who underwent chiropractic
care including spinal manipulation.
This study is a retrospective case series (Level IV Evidence)
and was approved by the Institutional Review Board
of the University of Bridgeport College of Chiropractic. All
cases of pregnant women presenting for chiropractic treatment
to the author’s private practice in San Francisco,
California, during 12 consecutive months were reviewed.
Cases were retrieved by a search of the practice’s electronic
database for instances of the ICD code V22.2 (pregnancy,
incidental). The charts of these women were then reviewed
for the following inclusion criteria: pregnant woman; complaint
of low back pain; use of the 11-point Numerical
Pain-Rating Scale, a pain measure of established reliability
and validity,  by every woman at each visit; consistent
description of treatments used; clear description of treatment
frequency and duration; and clear description of
occurrence or lack of adverse effects.
All records were reviewed by the author, and no identifiable
subject information was disclosed during any part of
this project. Data were extracted from charts that met the
above inclusion criteria and were entered into a spreadsheet
(Microsoft Excel) for tabulation.
Diagnostic work-up included standard history and physical
examination with regional orthopedic and neurological
testing. All women were screened for signs and symptoms
of serious pathology (fracture, malignancy, infection, cauda
equina syndrome) presenting as low back pain.
All women were treated by the same clinician. Active
care consisted of reassurance and education, advice on
body mechanics, and exercise instruction. Passive treatments
were manual myofascial release, manual joint mobilization,
and manual spinal manipulation. The most commonly
used spinal manipulation maneuvers were
procedures aimed at the lumbar facet joints and/or the
sacroiliac joints. This involves the subject lying in the
lateral decubitus position with the hip and knee flexed,
upper extremities folded, and forearms resting on the chest.
The chiropractor stands facing the subject at approximately
a 45° angle to the table. The chiropractor contacts the given
region of the subject’s spine with the hypothenar region of
one hand; the other hand contacts the subject’s crossed
forearms. At first, relatively low offsetting forces are
applied to bring the spinal region to the end range of
passive motion. Next, the high-velocity, low-amplitude
thrust is delivered. These procedures have been well described
elsewhere.  For the women in this study, modifications
in technique delivery were made to ensure comfort
and avoid abdominal compression; and the clinician attempted to use the lowest amount of force necessary.
However, the goal of each spinal manipulation procedure
was grade V joint motion and articular cavitation or
“popping,” and this occurred in most instances.
The electronic search yielded 18 cases. On review, one was
a case of headache and neck pain without low back pain
and, therefore, was excluded. The remaining 17 were cases
of low back pain. Of these, 8 complained of local pain at
some point between the lowest rib and the gluteal fold; 5
had pain radiating to the posterior thigh; 2 to the inguinal
region; and 2 to the posterior calf. In all women, straight leg
raise testing was negative, and lower extremity motor
strength, deep tendon reflexes, and sensation were intact.
These 17 cases met all inclusion criteria and were analyzed.
Baseline characteristics of these women are described in
Table 2. Of these 17 women, 8 were self-referred, 7 were
referred by obstetricians, and 2 by midwives.
The overall group mean Numerical Pain-Rating Scale
score decreased from 5.9 (range 2–10) at initial presentation
to 1.5 (range 0 –5) at termination of care. When
considered individually, one of the 17 (5.8%) women did
not demonstrate any clinically important improvement.
For the Numerical Pain-Rating Scale, this has been
reported to be a decrease of 2 or more points.  After
eight visits in 21 days, the Numerical Pain-Rating Scale
score in this woman changed from 6 to 5.
The remaining 16 of 17 (94.1%) women demonstrated
clinically important improvement. The average time to
initial clinically important pain relief was 4.5 (range 0–13)
days after initial presentation, and the average number of
visits undergone up to that point was 1.8 (range 1–5).
At termination of care, the average Numerical Pain-
Rating Scale score for these 16 women was 1.3 (range
1–4). The average time to termination of care was 24.4
days (range 5–62) after initial presentation, and the average
number of total visits undergone was 5.6 (range 3–15).
During the course of care, all women were questioned
about the occurrence of adverse effects. None of the 17
women reported any adverse effects.
Whether low back pain of pregnancy is a unique pathology or
is simply the occurrence of mechanical spinal pain during
pregnancy remains controversial. [7, 9] Present understanding of
the etiology of low back pain in pregnant women is as limited
as the understanding of the etiology of low back pain in
nonpregnant individuals. However, it is clear that many
pregnant women suffer from low back pain, the pain can be
severe and disabling in some, and a large proportion of cases
There is no gold standard treatment for low back pain of
pregnancy. Minimizing pharmacologic interventions is a common
goal, but typical nonpharmacologic options are limited.
Most physical agents commonly used in physical therapy
(therapeutic ultrasound, electrical stimulation, etc.) are contraindicated
in pregnancy.  A recent systematic review of
physical therapy interventions for low back pain of pregnancy
identified only three high-quality prospective controlled trials
and found no evidence supporting effectiveness. 
Chiropractic treatment including spinal manipulation is
sometimes used for pregnant women with low back pain.
Currently, the mechanism of action of spinal manipulation
is poorly understood. However, basic science studies have
shown that manipulation results in increased joint range of
motion,  modulated joint kinematics,  regional hypoalgesia,
 and altered muscle tone.  Therefore, patients may
benefit from increased joint motion and/or decreased joint
or muscle pain. This may be relevant to low back pain of
pregnancy, because preliminary evidence suggests that
asymmetric stiffness of the sacroiliac joints is related to the
presence of low back pain in pregnant women.
This retrospective case series presents outcome data on
chiropractic treatment for women with low back pain of
pregnancy. Yet, this is low level evidence, and there are
limitations inherent in this study design. No conclusions on
effectiveness can be drawn from any case series. However,
because no adverse effects occurred during the treatment
period, this work does provide preliminary evidence that
chiropractic treatment was safe for this group of women.
About half of the women in this study were referred by
prenatal providers, and half were self-referred. However,
comparisons of expectations and outcomes of either group
cannot be made because of the small number of subjects. In
addition, multiple treatments were used in each case. Although
this is typical of chiropractic practice in the field, there was no
attempt to characterize the response to any individual treatment
component. Furthermore, all treatment was delivered by
one provider in one private practice location. Finally, there
was no attempt to follow cases beyond the termination of care;
therefore, the duration of apparent pain relief is not known.
Further work is needed to better understand the safety
and effectiveness of chiropractic treatment for low back
pain of pregnancy. A reasonable approach would be a
prospective cohort study comparing two groups of women
from one prenatal facility, with one group receiving chiropractic
treatment and the other receiving standard medical
care not involving chiropractic referral or treatment.
This study described the results of chiropractic treatment
including spinal manipulation for 17 women with low back
pain of pregnancy. Sixteen of the 17 cases (95%) demonstrated
clinically important improvement in pain intensity
throughout the course of treatment. No adverse effects
occurred in any of the 17 cases. The results of this study
suggest that chiropractic treatment was safe in these cases
and support the hypothesis that it may be effective for
reducing intensity of low back pain of pregnancy. Substantial
prospective work is needed to test this hypothesis.
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