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Pregnancy

Doctors of chiropractic can help pregnant women manage back pain through manipulation, modalities and exercise.
By Nataliya Schetchikova, PhD
Back pain is an inconvenience that often comes with the joy of expecting a child. While 57 percent to 69 percent of future mothers experience symptoms, research shows that only half of them report symptoms to their healthcare providers and only a quarter of physicians recommend treatment.1
Yet more than 60 percent of pregnant women and prenatal providers are open to trying CAM therapy for low-back pain management, considering massage (61.4%), acupuncture (44.6%), relaxation (42.6%), yoga (40.6%), and chiropractic (36.6%).2 In another survey, 57.3 percent of midwives reported recommending CAM therapies to more than 10 percent of their patients, ranking chiropractic as their third popular choice.3
Although studies on chiropractic care in pregnancy are limited, existing observational research shows promising results. A retrospective case series showed that 94.1 percent of pregnant women who underwent chiropractic care showed clinical improvement, without noted adverse effects.1 In an observational cohort study presented at ACC-RAC earlier this year, Donald Murphy, DC, DACAN, showed that of patients who underwent chiropractic care for low-back pain, 72.5 percent rated their improvement as “excellent” or “good”, with 51 percent of subjects also showing a clinically significant improvement on the Bournemouth Disability Questionnaire (BDQ).
Working With a Pregnant Woman
Some chiropractors are hesitant to treat pregnant patients, however. “There are no contraindications to adjustments above the lumbar area, but as a patient gets further along in pregnancy, the technique needs to be gentler,” says Marianne Gengenbach, DC, DACBSP, co-author of several textbooks on sports chiropractic. Having adjusted women into their third trimester, she recommends side-posture adjustments and very low-force techniques, but adds that she prefers to work more with muscles than with manipulation. Because of pregnancy hormones having a relaxing effect on ligaments, “adjustments don’t hold as well, especially in the second and third trimester,” she says. 
Adjusting a pregnant woman can be difficult, especially in the third trimester, agrees Steven Zaeske, DC, DABCI, a chiropractic internist in Northern Illinois whose clinic provides gynecology and infertility services. But this is where Activator, acupuncture, massage and other instruments and modalities come into play, he says. He advises against using electrical stimulation or ultrasound over a gravid uterus, however.
It’s very important to remember that back pain in pregnant women is not always pregnancy-induced; instead, it can be related to a problem with the pregnancy, says Dr. Murphy. “When taking the patient’s history, it’s most important to ask them about bleeding, spotting, unusual vaginal discharge, bouts of diarrhea, feeling like the baby is going to fall out, fever, chills, weight loss—these are red flags for problems with the pregnancy itself versus sacroiliac complaints,” he says.
When manipulating healthy pregnant patients, DCs may need to change manipulation “just to manage their changing shapes,” says Randy Hewitt, DC, CCSP, an Oregon chiropractor who has worked with pregnant patients for the past 20 years. He recommends using pregnancy pillows and tables with a spring-loaded abdominal piece that allows the patient to lie down. “Be sure to spend time working with the muscles—massage and stretching—and get them exercising,” he says. (For cardiovascular exercise in pregnancy, see the June issue of ACA News.)
Fighting Pain with Exercise
While pregnancy-induced changes—a shifted center of gravity and balance, increase in the lordotic curve, and loosening and shortening of ligaments and tendons—make exercising more challenging, exercises targeted for balancing the changes can help the body. “Because the pelvis naturally becomes unstable, you want to make sure the patients have optimum muscular compensation for the lack of ligamentous support,” says Dr. Murphy, clinical director of the Rhode Island Spine Center and a member of the faculty of Brown University School of Medicine.
To provide this compensation, Dr. Murphy recommends teaching pregnant patients to co-contract the muscles that stabilize the spine and pelvis. “The exercises are not unlike the stabilization exercises that we give to other back-pain patients—co-contracting the pelvic floor muscles with the trunk muscles,” he says.
Early on in pregnancy, the exercises are done while lying on the back, encouraging patients to hold the co-contraction as they go into a bridge position. To increase the challenge, patients are asked to raise one leg at a time. Anecdotally, the most benefit comes from training motor control in a weight-bearing position. To train the force-closure mechanism to stabilize the pelvis, Dr. Murphy recommends a “good morning” exercise—“stand and maintain a neutral lordosis in the lumbar spine and then flex forward from the hip, with the arms hanging forward.” As patients get more coordinated, the exercise can be done with a weight in each hand—or on a Roman Chair, slightly tilted to further the challenge, he adds.
For people whose trigger points in the piriformis muscles contribute to the pain, Dr. Murphy likes a simple exercise in which the patient holds the co-contraction while standing on one leg for 30 seconds, then on the other leg for another 30 seconds—twice a day for each leg.
For some patients, postural exercises may be a good idea, says Dr. Hewitt. “Their ligaments get loose and muscles get stressed.” To maintain an upright thoracic spine and prevent a sway back, he recommends hip extensions, sometimes with the help of elastic bands, to keep muscles from getting hypertonic.
Since back pain is common throughout pregnancy, it’s best to start patients on exercises early, says Dr. Murphy. “In the third trimester, because of the body size, increased body weight, and difficulty in the ability to maneuver, you are limited in what you can give them,” he says.
Ultimately, working with pregnant patients is extremely rewarding, says Dr. Murphy. “Pregnant ladies are some of the happiest patients you will see,” he says. “Back pain is very common and troublesome and puts a damper on a beautiful time in life. When you can help them with back pain, they are really grateful. I encourage chiropractors to work with pregnant ladies,” he concludes.


References
1. Lisi AJ. Chiropractic spinal manipulation for low back pain of pregnancy: a retrospective case series. J Midwifery Womens Health. 2006 Jan-Feb;51(1):e7-10.
2. Wang SM, et al. Complementary and alternative medicine for low-back pain in pregnancy: a cross-sectional survey. J Altern Complement Med. 2005 Jun;11(3):459-64.
3. Allaire AD, et al. Complementary and alternative medicine in pregnancy: a survey of North Carolina certified nurse-midwives. Obstet Gynecol. 2000 Jan;95(1):19-23.

Additional Articles on Pregnancy and Chiropractic:

ACA: Advice for Expecting Moms-To-Be

ACA Today: Women Need Expanded Musculoskeletal Care During Pregnancy

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