I

Lnofr

ptrwfi

obresapw3csiip

ASa

J©I

BRIEF REPORT

Chiropractic Spinal Manipulation for Low Back Pain ofPregnancy: A Retrospective Case SeriesAnthony J. Lisi, DC

Low back pain is a common complaint in pregnancy, with a reported prevalence of 57% to 69% andincidence of 61%. Although such pain can result in significant disability, it has been shown that as few as32% 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 regardingsuch treatment. This retrospective case series was undertaken to describe the results of a group of pregnantwomen with low back pain who underwent chiropractic treatment including spinal manipulation. Seventeencases met all inclusion criteria. The overall group average Numerical Rating Scale pain score decreased from5.9 (range 2–10) at initial presentation to 1.5 (range 0–5) at termination of care. Sixteen of 17 (94.1%) casesdemonstrated clinically important improvement. The average time to initial clinically important pain reliefwas 4.5 (range 0–13) days after initial presentation, and the average number of visits undergone up to that pointwas 1.8 (range 1–5). No adverse effects were reported in any of the 17 cases. The results suggest that chiropractictreatment was safe in these cases and support the hypothesis that it may be effective for reducing painintensity. J Midwifery Womens Health 2006;51:e7–e10 © 2006 by the American College of Nurse-Midwives.

keywords: pregnancy, back pain, chiropractic, spinal manipulation

prlro

sispb

cpjppttt

vcsattrms

NTRODUCTION

ow back pain is a very common complaint during preg-ancy. European studies have reported the prevalence ratef low back pain during the 9 months of pregnancy to berom 46% to 76%.1,2 Recent US studies found prevalenceates of 57% and 69%.3,4

The incidence of low back pain with an onset duringregnancy has been reported to be 61%.2 It has been shownhat among women with low back pain of pregnancy, 75%eported no low back pain before pregnancy.4 In a study ofomen with chronic low back pain, up to 28% stated that theirrst episode of back pain occurred during a pregnancy.5

Like most cases of low back pain in general, the etiologyf low back pain of pregnancy is not known. It has longeen considered to be related to maternal weight gain andesulting biomechanical changes in the spine; however,pidemiologic data provide a conflicting picture. Severaltudies have found no relationship between onset of painnd gestational age,2,3,5 and indeed, the onset of low backain of pregnancy is often earlier than week 6 of pregnancy,ith the largest proportion often between weeks 13 and0.2,5 Increased lumbar lordosis is commonly considered aause of low back pain in pregnancy. However, it has beenhown that lumbar lordosis does not categorically increasen every pregnant woman; moreover, when lordosis doesncrease, it is not clearly related to severity of low backain.6–8

ddress correspondence to Anthony J. Lisi, DC, VA Connecticut Healthcare

lystem, 950 Campbell Avenue, West Haven, CT 06516. E-mail:nthony.lisi@med.va.gov

ournal of Midwifery & Women’s Health • www.jmwh.org2006 by the American College of Nurse-Midwives

ssued by Elsevier Inc.

Increased joint laxity secondary to relaxin is a knownhenomenon, but its relationship to onset of low back painemains unclear.9 However, one factor supported by pre-iminary work is that asymmetry of sacroiliac joint laxity,ather than absolute laxity alone, is related to low back painf pregnancy.10,11

In most instances, the average pain level is moderate, butevere pain has been reported in 15% of cases.3,4 Painntensity often increases with duration and can result inignificant disability.2 Sleep disturbances have been re-orted by 49% to 58% of women and impaired daily livingy 57% in women with low back pain of pregnancy.3,4

Despite the apparent impact it has on women, manyases of low back pain of pregnancy go unreported torenatal providers and/or untreated. Wang et al. found thatust 32% of women reported their low back pain ofregnancy to their prenatal providers, and just 25% of theseroviders recommended a treatment.3 Skaggs et al. foundhat among women with low back pain of pregnancy, 80%hought that their providers had not offered treatment forheir back pain.4

The clinical management of low back pain of pregnancyaries among prenatal providers,2,3 yet it seems clear thathiropractors are, at times, involved in the management ofuch cases. Chiropractors commonly manage low back painnd other musculoskeletal pain patients,12 and althoughhere are little clear data indicating what percentage ofhose patients are pregnant, a survey of US chiropractorseported 76% of respondents were involved in the manage-ent of pregnant women.13 A recent population-based

urvey of Australian women found that 11% of women with

ow back pain of pregnancy underwent chiropractic treat-

e71526-9523/06/$32.00 • doi:10.1016/j.jmwh.2005.09.001

mwppp

ttpapHsooplrhPcmbm

ps

rlc

M

TdocmCCdifpPadmo

fita(

itoe

cbmlmpsluTarofaptsc

AUf

RE

TBLC

MM

A

POC

*Mtd

e

ent.14 A survey of North Carolina certified nurse-mid-ives found that 93.9% of respondents recommend com-lementary and alternative medicine to their pregnantatients, and more than half of these recommended chiro-ractic treatment, mostly for low back pain of pregnancy.15

Chiropractic treatment includes many therapeutic op-ions, as outlined in Table 1. Spinal manipulation isypically considered the defining element of chiropracticractice. There is reasonable evidence supporting the safetynd effectiveness of spinal manipulation for low backain,16 neck pain,17 and chronic/recurrent headaches.18

owever, at present, there is only minimal evidence on theafety and effectiveness of spinal manipulation along withther alternative therapies for pregnant women.3,15 Scarceutcomes data on any chiropractic treatment of low backain of pregnancy have been presented in the peer-reviewediterature. Two retrospective case series19,20 and one caseeport21 describe pain reduction in the majority of cases;owever, all three reports have methodological limitations.articularly unclear is the role of spinal manipulation, thehiropractic treatment method presently supported by theost evidence of safety and effectiveness for general low

ack pain.22 It has often been written that low back spinalanipulation should be avoided in low back pain of

nthony J. Lisi, DC, is Assistant Professor of Clinical Sciences at the

Table 1. Overview of Chiropractic Treatment Options

Active Care

eassurance/reactivationducation

Natural historySelf-management

herapeutic exerciseody mechanics/ergonomicsifestyle recommendationsAM modalities, e.g., stress reduction

Passive Care

anual therapiesuscularAssisted stretching techniquesMassage/myofascial therapies

rticular*Joint mobilizationJoint manipulation

hysical medicine modalitiesver-the-counter medicationsAM modalities, e.g., acupuncture, herbal/dietary supplements

Articular manual therapies involve the application of passive motion to a joint.obilization typically involves repetitive motions up to the joint’s end range without a

hrust and without joint “popping.” Manipulation typically involves a single thrustelivered slightly beyond the joint’s end range that causes audible joint “popping.”

aniversity of Bridgeport College of Chiropractic and the Staff Chiropractor

or the VA Connecticut Healthcare System.

8

regnancy cases,23,24 but no data have been presented toupport this finding.

The purpose of this study, therefore, is to describe theesponse of a group of consecutive cases of women withow back pain of pregnancy who underwent chiropracticare including spinal manipulation.

ETHODS

his study is a retrospective case series (Level IV Evi-ence) and was approved by the Institutional Review Boardf the University of Bridgeport College of Chiropractic. Allases of pregnant women presenting for chiropractic treat-ent to the author’s private practice in San Francisco,alifornia, during 12 consecutive months were reviewed.ases were retrieved by a search of the practice’s electronicatabase for instances of the ICD code V22.2 (pregnancy,ncidental). The charts of these women were then reviewedor the following inclusion criteria: pregnant woman; com-laint of low back pain; use of the 11-point Numericalain-Rating Scale, a pain measure of established reliabilitynd validity,25 by every woman at each visit; consistentescription of treatments used; clear description of treat-ent frequency and duration; and clear description of

ccurrence or lack of adverse effects.All records were reviewed by the author, and no identi-

able subject information was disclosed during any part ofhis project. Data were extracted from charts that met thebove inclusion criteria and were entered into a spreadsheetMicrosoft Excel) for tabulation.

Diagnostic work-up included standard history and phys-cal examination with regional orthopedic and neurologicalesting. All women were screened for signs and symptomsf serious pathology (fracture, malignancy, infection, caudaquina syndrome) presenting as low back pain.

All women were treated by the same clinician. Activeare consisted of reassurance and education, advice onody mechanics, and exercise instruction. Passive treat-ents were manual myofascial release, manual joint mobi-

ization, and manual spinal manipulation. The most com-only used spinal manipulation maneuvers were

rocedures aimed at the lumbar facet joints and/or theacroiliac joints. This involves the subject lying in theateral decubitus position with the hip and knee flexed,pper extremities folded, and forearms resting on the chest.he chiropractor stands facing the subject at approximately45° angle to the table. The chiropractor contacts the given

egion of the subject’s spine with the hypothenar region ofne hand; the other hand contacts the subject’s crossedorearms. At first, relatively low offsetting forces arepplied to bring the spinal region to the end range ofassive motion. Next, the high-velocity, low-amplitudehrust is delivered. These procedures have been well de-cribed elsewhere.26 For the women in this study, modifi-ations in technique delivery were made to ensure comfort

nd avoid abdominal compression; and the clinician at-

Volume 51, No. 1, January/February 2006

tHw“

R

TaaoshrrsTBTr

stcnFres

cidv

R1dn

aw

D

Wi

ptanpsg

pmM(ipia

sCismsbopap

cplebpc

pccatamowt

appfp

L

J

empted to use the lowest amount of force necessary.owever, the goal of each spinal manipulation procedureas grade V joint motion and articular cavitation or

popping,” and this occurred in most instances.

ESULTS

he electronic search yielded 18 cases. On review, one wascase of headache and neck pain without low back pain

nd, therefore, was excluded. The remaining 17 were casesf low back pain. Of these, 8 complained of local pain atome point between the lowest rib and the gluteal fold; 5ad pain radiating to the posterior thigh; 2 to the inguinalegion; and 2 to the posterior calf. In all women, straight legaise testing was negative, and lower extremity motortrength, deep tendon reflexes, and sensation were intact.hese 17 cases met all inclusion criteria and were analyzed.aseline characteristics of these women are described inable 2. Of these 17 women, 8 were self-referred, 7 were

eferred by obstetricians, and 2 by midwives.The overall group mean Numerical Pain-Rating Scale

core decreased from 5.9 (range 2–10) at initial presen-ation to 1.5 (range 0 –5) at termination of care. Whenonsidered individually, one of the 17 (5.8%) women didot demonstrate any clinically important improvement.or the Numerical Pain-Rating Scale, this has beeneported to be a decrease of 2 or more points.27 Afteright visits in 21 days, the Numerical Pain-Rating Scalecore in this woman changed from 6 to 5.

The remaining 16 of 17 (94.1%) women demonstratedlinically important improvement. The average time tonitial clinically important pain relief was 4.5 (range 0–13)ays after initial presentation, and the average number ofisits undergone up to that point was 1.8 (range 1–5).At termination of care, the average Numerical Pain-

ating Scale score for these 16 women was 1.3 (range–4). The average time to termination of care was 24.4ays (range 5–62) after initial presentation, and the averageumber of total visits undergone was 5.6 (range 3–15).During the course of care, all women were questioned

bout the occurrence of adverse effects. None of the 17omen reported any adverse effects.

ISCUSSION

hether low back pain of pregnancy is a unique pathology or

Table 2. Baseline Characteristics

Mean (Range)

Age 32.4 (21–42) yGestational age 23.7 (15–38) wkLBP onset 20.6 (13–34) gestational wkLBP duration 21.7 (3–90) daysLBP intensity 5.9 (2–10) on the NRS

BP � low back pain; NRS � Numerical Pain Rating Scale.

s simply the occurrence of mechanical spinal pain during c

ournal of Midwifery & Women’s Health • www.jmwh.org

regnancy remains controversial.7,9 Present understanding ofhe etiology of low back pain in pregnant women is as limiteds the understanding of the etiology of low back pain inonpregnant individuals. However, it is clear that manyregnant women suffer from low back pain, the pain can beevere and disabling in some, and a large proportion of caseso untreated.

There is no gold standard treatment for low back pain ofregnancy. Minimizing pharmacologic interventions is a com-on goal, but typical nonpharmacologic options are limited.ost physical agents commonly used in physical therapy

therapeutic ultrasound, electrical stimulation, etc.) are contra-ndicated in pregnancy.28 A recent systematic review ofhysical therapy interventions for low back pain of pregnancydentified only three high-quality prospective controlled trialsnd found no evidence supporting effectiveness.29

Chiropractic treatment including spinal manipulation isometimes used for pregnant women with low back pain.urrently, the mechanism of action of spinal manipulation

s poorly understood. However, basic science studies havehown that manipulation results in increased joint range ofotion,30 modulated joint kinematics,31 regional hypoalge-

ia,32 and altered muscle tone.33 Therefore, patients mayenefit from increased joint motion and/or decreased jointr muscle pain. This may be relevant to low back pain ofregnancy, because preliminary evidence suggests thatsymmetric stiffness of the sacroiliac joints is related to theresence of low back pain in pregnant women.This retrospective case series presents outcome data on

hiropractic treatment for women with low back pain ofregnancy. Yet, this is low level evidence, and there areimitations inherent in this study design. No conclusions onffectiveness can be drawn from any case series. However,ecause no adverse effects occurred during the treatmenteriod, this work does provide preliminary evidence thathiropractic treatment was safe for this group of women.

About half of the women in this study were referred byrenatal providers, and half were self-referred. However,omparisons of expectations and outcomes of either groupannot be made because of the small number of subjects. Inddition, multiple treatments were used in each case. Althoughhis is typical of chiropractic practice in the field, there was nottempt to characterize the response to any individual treat-ent component. Furthermore, all treatment was delivered by

ne provider in one private practice location. Finally, thereas no attempt to follow cases beyond the termination of care;

herefore, the duration of apparent pain relief is not known.Further work is needed to better understand the safety

nd effectiveness of chiropractic treatment for low backain of pregnancy. A reasonable approach would be arospective cohort study comparing two groups of womenrom one prenatal facility, with one group receiving chiro-ractic treatment and the other receiving standard medical

are not involving chiropractic referral or treatment.

e9

C

Tipstosart

R

1

p

Al

c1

p1

pP

b

AI1

p

Cs2

SpO

Pw

cE

o

A2

nn

am

Pm2

sr

p

SP

mT

Ml

tJ

r

S

aM

p

rG

pb

sB

d

s

e

ONCLUSION

his study described the results of chiropractic treatmentncluding spinal manipulation for 17 women with low backain of pregnancy. Sixteen of the 17 cases (95%) demon-trated clinically important improvement in pain intensityhroughout the course of treatment. No adverse effectsccurred in any of the 17 cases. The results of this studyuggest that chiropractic treatment was safe in these casesnd support the hypothesis that it may be effective foreducing intensity of low back pain of pregnancy. Substan-ial prospective work is needed to test this hypothesis.

EFERENCES

1. Ostgaard HC. Prevalence of back pain in pregnancy. Spine991;16:549–52.

2. Kristiansson P, Svärdsudd K, von Schoultz B. Back pain duringregnancy: A prospective study. Spine 1996;21:702–8.

3. Wang SM, Dezinno P, Maranets I, Berman MR, Caldwell-ndrews AA, Kain ZN. Low back pain during pregnancy: Preva-

ence, risk factors, and outcomes. Obstet Gynecol 2004;104:65–70.

4. Skaggs C, Nelson M, Prather H, Gross G. Documentation andlassification of musculoskeletal pain in pregnancy. J Chiro Educ 2004;8:83–4.

5. Mens JMA, Vleeming A, Stoeckart R, et al. Understandingeripartum pelvic pain: Implications of a patient survey. Spine 1996;21:363–70.

6. Franklin ME, Conner-Kerr T. An analysis of posture and backain in the first and third trimesters of pregnancy. J Orthop Sportshys Ther 1998;28:133–8.

7. Ostgaard HC. Influence of some biomechanical factors on lowack pain in pregnancy. Spine 1993;18:61–5.

8. Hirabayashi Y, Shimizu R, Fukuda H, Saitoh K, Furuse M.natomical configuration of the spinal column in the supine position.

I. Comparison of pregnant and non-pregnant women. Br J Anaesth995;75:6–8.

9. Mogren IM, Pohjanen AI. Low back pain and pelvic pain duringregnancy: Prevalence and risk factors. Spine 2005;30:983–91.

10. Damen L, Buyruk HM, Guler-Uysal F, Lotgering FK, SnijdersJ, Stam HJ. The prognostic value of asymmetric laxity of the

acroiliac joints in pregnancy-related pelvic pain. Spine 2002;27:820–4.

11. Buyruk HM, Stam HJ, Snijders CJ, Lameris JS, Holland WP,tijnen TH. Measurement of sacroiliac joint stiffness in peripartumelvic pain patients with Doppler imaging of vibrations (DIV). Eur Jbstet Gynecol Reprod Biol 1999;83:159–63.

12. Coulter ID, Hurwitz EL, Adams AH, Genovese BJ, ShekelleG. Patients using chiropractors in North America: Who are they, andhy are they in chiropractic care? Spine 2002;27:291–8.

13. Christensen MG, Kerkhoff D, Kollasch MW. Job analysis ofhiropractic 2000. Greeley (CO): National Board of Chiropracticxaminers, 2000.

14. Stapleton DB, MacLennan AH, Kristiansson P. The prevalence

10

ustralian population survey. Aust N Z J Obstet Gynaecol002;42:482–5.

15. Allaire AD, Moos MK, Wells SR. Complementary and alter-ative medicine in pregnancy: A survey of North Carolina certifiedurse-midwives. Obstet Gynecol 2000;95:19–23.

16. van Tulder MW, Furlan AD, Gagnier JJ. Complementary andlternative therapies for low back pain. Best Pract Res Clin Rheu-atol 2005;19:639–54.

17. Gross AR, Hoving JL, Haines TA, Goldsmith CH, Kay T, Aker, Bronfort G, Cervical Overview Group. A Cochrane review ofanipulation and mobilization for mechanical neck disorders. Spine

004;29:1541–8.

18. Bronfort G, Nilsson N, Haas M, Evans R, Goldsmith CH, As-endelft WJ, Bouter LM. Non-invasive physical treatments for chronic/ecurrent headache. Cochrane Database Syst Rev 2004;3:CD001878.

19. Guadagnino MR. Spinal manipulative therapy for 12 pregnantatients suffering from low back pain. Chiro Tech 1999;11:108–11.

20. Diakow PR, Gadsby TA, Gadsby JB, Gleddie JG, Leprich DJ,cales AM. Back pain during pregnancy and labor. J Manipulativehysiol Ther 1991;14:116–8.

21. Potter GE, Cassidy JD. Diagnosis and manipulative manage-ent of post-partum back pain: a case study. J Manipulative Physiolher 1979;2:99–102.

22. Gatterman MI, Cooperstein R, Lantz C, Perle SM, SchneiderJ. Rating specific chiropractic technique procedures for common

ow back conditions. J Manipulative Physiol Ther 2001;24:449–56.

23. DiMarco DB. The female patient: Enhancing and broadeninghe chiropractic encounter with pregnant and postpartum patients.Amer Chir Assoc 2003;40:18–24.

24. Parsons C. Back care in pregnancy. Mod Midwife 1994;4:16–9.

25. Flaherty SA. Pain measurement tools for clinical practice andesearch. AANA J 1996;64:133–40.

26. Triano JJ, Schulz A. Loads transmitted during lumbosacralMT. Spine 1997;22:1955–64.

27. Farrar JT, Berlin JA, Strom BL. Clinically important changes incute pain outcome measures: A validation study. J Pain Symptomanage 2003;25:406–11.

28. Borg-Stein J, Dugan SA, Gruber J. Musculoskeletal aspects ofregnancy. Am J Phys Med Rehabil 2005;84:180–92.

29. Stuge B, Hilde G, Vollestad N. Physical therapy for pregnancy-elated low back and pelvic pain: A systematic review. Acta Obstetynecol Scand 2003;82:983–90.

30. Nilsson N, Christensen HW, Hartvigsen J. Lasting changes inassive range of motion after spinal manipulation: A randomized,lind, controlled trial. J Manipulative Physiol Ther 1996;19:165–8.

31. Lehman GJ, McGill SM. Spinal manipulation causes variablepine kinematic and trunk muscle electromyographic responses. Cliniomech 2001;16:293–9.

32. Vernon H. Qualitative review of studies of manipulation-in-uced hypoalgesia. J Manipulative Physiol Ther 2000;23:134–8.

33. Herzog W, Scheele D, Conway PJ. Electromyographic re-ponses of back and limb muscles associated with spinal manipula-

f recalled low back pain during and after pregnancy: A South tive therapy. Spine 1999;24:146–152.

Volume 51, No. 1, January/February 2006