Chiropractic Evaluation and Management of the Pregnant Patient: An Update from Recent Literature
Editor’s note: This article first appeared in Midwifery Today, Issue 87, Autumn 2008.
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Pregnancy should be a time of joy for the expectant mother. However, it’s also a virtually unparalleled period of rapid change in one’s morphology. The stresses placed on a human’s anatomy and physiology result in compensatory altered biomechanics and gait to perform even the most basic activities of daily living. These changes to an individual often result in the onset of a myriad of musculoskeletal issues that can develop during pregnancy. This article details the current explanations of these changes as well as the potential role of chiropractic therapy for the pregnant woman.
Low Back Pain and Physiologic Changes in the Pregnant Patient
Low back pain is a common complaint of the pregnant woman (Ritchie 2003). Research has demonstrated that between 50% and 80% of pregnant patients report low back pain (Skaggs et al. 2004), the majority when the mother is between 20 and 40 weeks pregnant (Kristiansson, Svärdsudd and von Schoultz 1996).
An estimated 25% of women with low back pain during pregnancy have a severity of pain categorized as temporarily disabling (Borg-Stein, Dugan and Gruber 2005). A portion of this back pain can be attributed to the release of the hormones progesterone, estrogen and relaxin during the beginning stages of pregnancy (Borg-Stein, Dugan and Gruber 2005). These hormones primarily cause decreased muscle tone, changes in connective tissue integrity, retention of water and laxity of ligaments. Ligamentous laxity (looseness of the ligaments) in the pelvis can cause hypermobility of the pubic symphysis or the sacroiliac joints, thus affecting lumbar spine stability (Bogduk 1997). This laxity, along with changes in posture, may be the main components of low back pain in the pregnant population. Postural changes in the pregnant patient include: increased lumbar lordosis (leading to shortened lumbar musculature), increased sacral base angle, increased extremity pronation, possible transient reversal of the cervical lordosis, a shift of the plumb line posteriorly and a change in the sacrococcygeal angle (Benizzi DiMarco 2003). These changes in posture cause an increased load on the posterior aspects of the vertebral column including the zygapophyseal joints; intervertebral discs; supraspinous, intraspinous and intertransverse ligaments along with the ligamentum flavum and muscles including the deep spinal muscles; the erectors; the psoas and the muscles of the pelvis. (Editor’s Note: For a better understanding of the psoas in relation to pregnancy, see “Birthing Fear: The Iliopsoas Muscle,” Midwifery Today, Issue 74.) In addition, anterior structures are not spared; stretching of the anterior longitudinal ligament also occurs, yielding spinal instability (Ibid).
Although lumbar disc herniations are uncommon in pregnant women, they do appear in approximately one of 10,000 cases of lumbosacral pain during pregnancy (LaBan et al. 1995). Weight gain, coupled with the previously mentioned hormonal and postural changes, alters biomechanics, which may contribute to disc herniations. Weight gain further increases loads on the joints of the lumbar spine. A weight gain of 20%, which is adequate, increases the load on the zygapophyseal joints by as much as 100% (Ritchie 2003). The morphology and biomechanical strain on a pregnant woman are not unlike that of the man with a pendulous protuberant abdomen or “beer belly.” Differences between the two would be, most notably, the slow onset of weight in males and the lack of hormonally-induced ligamentous laxity. An empirical comparison of these populations in terms of lordosis, stability and response to intervention needs further study.
Another contribution to low back pain in pregnant women is anterior pelvic rotation and subsequent muscle hypertonicity, because pelvic rotation leads to increased lumbar lordosis (Borg-Stein, Dugan and Gruber 2005). Asymmetrically taut hamstrings may also affect pelvic rotation. If one side is more hypertonic than the other it will pull the pelvis toward it (Anonymous 2003).
Beyond Low Back Pain—the Role of the Chiropractor in the Evaluation and Management of the Pregnant Patient
Besides low back pain, other conditions that occur during pregnancy are within a chiropractic scope of practice for management or evaluation. These include peri-
pheral nerve entrapments, headaches, transient osteoporosis or osteonecrosis and pubic pain. Common nerve entrapments at the carpal tunnel (median nerve) and the inguinal region (lateral femoral cutaneous nerve) lead to carpal tunnel symptoms or meralgia paresthetica (numbness in the outer thigh) respectively (Borg-Stein, Dugan and Gruber 2005). Nerve entrapments during pregnancy can be attributed to hormonal changes causing possible edema around a nerve, compression or traction to the nerve itself. Edema around the extensor pollicus brevis and abductor pollicus longus can cause DeQuervain’s syndrome (stenosing tenosynovitis) (Ibid).
The pregnant patient also may present with headache. Melhado, Macial and Guerreiro (2007) found that the majority of women with headaches during pregnancy presented with migraine headaches, which the women had prior to conception. Most disappeared by the second or third trimester (Melhado, Macial and Guerreiro 2007).
Although rare, transient osteoporosis of the femoroacetabular joint can develop during pregnancy. This condition presents with weight-bearing hip pain, usually in the third trimester (Borg-Stein, Dugan and Gruber 2005). The etiology for this condition is unknown (Ritchie 2003). A possibility of osteonecrosis of the femoral head also exists. Causes for the condition are unknown, but some theorize that the higher cortisol levels combined with increased stress of the joint from weight gain may be responsible (Cheng, Burssens and Mulier 1982). Another hypothesis is that the higher levels of estrogen and progesterone along with increased intraosseous pressure may contribute to the development of osteonecrosis of the femoral head (Hungerford and Lennox 1985).
Pubic pain also is commonly seen in pregnant women. Various conditions may be the cause of this pubic pain including: increased motion due to ligamentous laxity, osteitis pubis or a rupture of the symphysis pubis. All of these conditions are considered self-limiting, with rare exceptions, in which case care may be warranted (Borg-Stein, Dugan and Gruber 2005). One must consider the totality of symptoms to determine whether causality may be temporally, anatomically or physiologically attributed to pregnancy, because a patient’s complaint may not be related to the pregnancy at all, but from a previous co-morbid condition (Anonymous 2003). Thorough evaluation and frequent re-evaluation of a patient is essential to avoid failing to diagnose and manage a patient appropriately.
Depression, Pain and Pregnancy
The associations between pain and depression have been studied extensively. Pain is found to be strongly associated with anxiety as well as with depressive disorders (Von Korff and Simon 1996). One study found a relationship between the severity of the pain, the duration/frequency of the pain and the gross number of pains (Fishbain et al. 1997). The extent to which pain interferes with daily activity is correlated with an increase in the likelihood and severity of depression (Von Korff and Simon 1996). As discussed previously, pregnant women may spend nine months or longer with several different pain presentations, ranging from morning sickness to postoperative pain following cesarean delivery. Such pains are likely to interfere with daily activities (25%), thus pregnant women may have a higher likelihood than non pregnant women of developing depression. Depression among pregnant women ranges from 10–25%. Not all cases are due to pain, but as with any case of depression, pain may play a role (Wisner et al. 2000).
Why is this important? Depression in a gravid woman can lead to effects on the developing fetus and also may affect the woman’s labor. Chung et al. (2001) showed that women with depression late in the pregnancy were more likely to receive epidural analgesia and have operative deliveries (cesarean section and instrument-assisted vaginal delivery). This presents an obvious problem for women who want a natural birth, and it increases the risk for both mother and baby of other complications from pain-relieving drugs and instruments.
Pregnant women who are clinically depressed in the early parts of pregnancy also have an increased risk of developing pre-eclampsia (Kurki et al. 2000). In addition, the risk of bleeding during gestation, prematurity(< 37 weeks), low Apgar scores, neonatal unit admissions, neonatal growth retardation, elevated fetal heart rate and low birth weight (<2500 g) also are associated with maternal depression (Preti et al. 2000; Steer et al. 1992; Allister et al. 2001; Chung et al. 2001; Zax, Sameroff and Babigian 1997). According to the National Center for Health Statistics (NCHS), nearly half of all infant deaths are related to low birth weight (National Vital Statistics Report 2004).
Women with depression also are less likely to take care of themselves and are more likely to engage in self-destructive behavior—including using cigarettes, drugs and alcohol, to show poor weight gain and to be less likely to seek prenatal care or use prenatal vitamins (Allister et al. 2001; Zuckerman et al. 1989; Bonari et al. 2004). Clearly, mother and baby may experience many complications when depression is involved. If chiropractic therapy can help decrease pain, that reduction in pain may reduce or decrease associated depression.
Effective Treatment Based on Peer-Reviewed Research
Although chiropractic care cannot alter the physiological endocrine changes related to pregnancy, it may make those nine months more comfortable by helping to relieve some of the patient’s pain. Chiropractors need to change the way in which they adjust pregnant patients, to accommodate patient comfort. In a case series study by Lisi (2006), chiropractic care including advice on body mechanics, exercise instruction, myofascial release, joint mobilization and manipulation was determined to help alleviate low back pain in 94.1% of the cases examined. The average decrease in pain, as indicated by a numerical rating scale (NRS) changed from 5.9 to 1.5, which exceeds a minimally clinically important difference. Patients noted this improvement after only an average of 1.8 visits to their chiropractor. No reports indicated adverse side effects from the treatments (Lisi 2006). This suggests that not only is chiropractic care effective, but it is also safe.
Contraindications to Chiropractic Intervention
According to Benizzi DiMarco (2003) there are contraindications to adjusting a pregnant woman (Table 1). If any of these conditions are noticed by or reported to a chiropractor, rapid referral to an obstetrician/gynecologist would be clinically warranted (Benizzi DiMarco 2003). In addition, common physical modalities (ultrasound, electrical stimulation, diathermy, etc.) are contraindicated over the abdomen, low back and pelvic girdle in the pregnant patient (Borg-Stein, Dugan and Gruber 2005). Aside from cryotherapy, which can be used on a patient with acute low back pain, chiropractors should focus on joint manipulation, soft tissue mobilization and prescriptive exercise (Anonymous 2003).
Appropriate Treatment for the Pregnant Patient
When applying joint manipulation to a pregnant patient, a chiropractor may alter the delivery of treatment to maximize patient comfort. Due to the ligamentous laxity brought about during pregnancy, low velocity, low amplitude mobilization/manipulation such as flexion-distraction, may be substituted for high velocity low amplitude delivery. For patient comfort, the chiropractor can use pregnancy pillows or a table where the abdominal area lowers, while the patient is prone. Other alterations in the delivery of care for comfort may incorporate instrument-assisted delivery (Activator, Graston Technique), special tables (knee-chest), or treatment of the patient in a seated position or decubitus (reclining) position, instead of prone.
In regard to flexion-distraction, the chiropractor can position the patient in the lateral decubitus posture and use the lateral flexion component of the table to distract the spine. If a course of care doesn’t improve pain, the patient may be referred to her primary care physician or obstetrician/gynecologist. As with any patient-clinician relationship, open discussion and good communication with the other members of the health care team are essential (Anonymous 2003).
Another technique commonly used by chiropractors is the Webster Technique. The Webster Technique is based on the theoretical principle that joint manipulation and soft tissue mobilization may alleviate musculoskeletal intrauterine constraints on fetal positioning if a breech presentation is suspected (Pistolese 2002). While this technique has not been scrutinized or supported by randomized clinical control trials, some women try this and other forms of complementary and alternative medicine techniques in an attempt to avoid a cesarean (Founds 2005). According to preliminary results of a practice-based study done by the International Chiropractic Pediatric Association (ICPA), the Webster Technique was found to be 69% effective, although further research is needed in this area (Alcantara and Ohm 2008).
A Final Note
In summary, the pregnant patient may suffer from a variety of conditions that are manageable through chiropractic intervention. Today’s practicing chiropractor must have a thorough awareness of the presentation, common diagnoses and appropriate delivery of treatment (which may require alterations of traditional techniques) to deliver optimal care to their pregnant patients.
To better comprehend the impact of joint manipulation and chiropractic care on pregnancy, more research is needed regarding appropriate treatment scheduling, mechanisms that describe intervention and quantitative outcome measures. This research is needed to further add to the chiropractors’, other health practitioners’ and patients’ understanding of the breadth and limitations of chiropractic care for the pregnant patient.
The doctor of chiropractic is responsible for remaining proactive in the quest for ongoing research and continuing education on this topic. Through education and assertiveness, the chiropractic profession can maximize its ability to deliver the highest quality of health care possible, while empowering the patient to make healthy lifestyle choices to provide a safe environment for her unborn child.
Contraindications to chiropractic care of the pregnant patient:
- High risk of miscarriage
- Vaginal bleeding
- Imminent birth
- Sudden onset of pelvic pain
- Ovarian cysts
- Bowel obstruction
- Placenta previa
- Placenta abruptio
- Ectopic pregnancy
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