Part 1
The current state of the literature regarding chiropractic manipulative therapy during pregnancy.

     Many women during pregnancy experience conditions that are painful, disabling, and to some extent costly to both the affected patient and the society. The majority of these conditions could be summarized as Low Back Pain (LBP), Pelvic Girdle Pain  (PGP), sacroiliac joint dysfunction (SIJD), intercostal neuralgia, musculoskeletal and radicular pain, and etc. Many case studies and researches have shown that conservative chiropractic care could be beneficial in treating many of these conditions that arise during pregnancy, as well as facilitate a healthy pregnancy. Chiropractic care has also been sought by pregnant women to ensure the patient has a comfortable pregnancy and an uncomplicated labor and delivery. In this paper I will present the current state of literature with respect to manipulative care of pregnant women. As the use of electrical modalities, ultrasound, and radiodiagnostic imaging is contraindicated during pregnancy, the term ‘chiropractic care’ in this paper mainly refers to manipulative therapy. [1,3,8,9].
     One of the common conditions during pregnancy is PGP and LBP. Studies show that about 20% of pregnant women suffer from PGP and this number goes up to 84% if LBP is included as well. One of the main risk factors for developing these conditions during pregnancy is previous history of these conditions. Another risk factor was thought to be the role of relaxin. However, not many studies have supported this idea. In fact, it is believed that because of the anatomy of the sacroiliac joint, it experiences the highest coefficient of friction among human joints. Loading situations and nutation of the sacrum can influence and alter this friction and stabilize the pelvic girdle through functional adaptations. Therefore, because of postural adaptations during pregnancy, sacroiliac joints experience an increase load and friction. There are a range of clinical tests that chiropractors use to assess LBP and PGP. Some of the recommended tests for the diagnosis of PGP are [2,8]:
     Thigh thrust or p4 test
     Patrick Faber test
     Gaenslens test
     Tenderness on palpation of the long dorsal sacroiliac ligament
     Active straight leg raise for testing the pelvic function and stability
     Tests to identify pain originating from symphysis pubis are:
     Modified trendelenberg test
     Tenderness on palpation of the symphysis pubis
     Systemic review of 6 studies concluded that there is evidence in support of effectiveness of spinal manipulative therapy (SMT) during pregnancy and improved outcome in pregnancy related LBP and PGP. Other studies have shown that SMT may be of clinical benefit for conditions related to pregnancy like back pain during pregnancy, back pain during labor and delivery, and breech presentation. Yet another study reports that 75% of pregnant patients who received chiropractic care during their pregnancies found relief from LBP. Studies have also shown that there may exist a relationship between back pain during pregnancy and a prolonged period of labor and delivery. According to a retrospective review of statics, primigravida or first time pregnant women who seek chiropractic care during gestation have an average of 25% shorter labor time and multiparous women with chiropractic care during their pregnancy  have on average 31% shorter labor times [2,9,10].
     Another case study reports the effectiveness of spinal adjustment in SIJD in pregnancy. As SIJD can have wide range of disabling effects on the patient, it is important to address this issue properly. This case study looked at a 37-year-old mulitparous patient in her fourth pregnancy, with three successful deliveries in the past and no miscarriages, being diagnosed with sacroiliac joint stain on the left causing concurrent symphysis pubis dysfunction. Her treatment consisted of chiropractic adjustment at L5-S1, T4-T5, C1-C2 and sacrum and ice therapy. The patient reported immediate relief after the first treatment [6].
     There is also evidence of specific chiropractic adjustment called Webster Technique, which  is used to correct potential musculoskeletal causes of intrauterine constraint mainly in women in the eight month of pregnancy with breech presentation. The intrauterine constraint has been defined as any external force acting on the developing fetus that hinders the normal development of the fetus. What the chiropractor does in breech position is to try to remove the constraint to the patient’s uterus by balancing the pelvis and the corresponding muscles and ligaments, to allow the fetus to assume the right position. It is important to note that the chiropractor does not try to change the position of the fetus, but only to correct the potential cause of the intrauterine constraint [4,9].
     Further studies report that other common conditions during pregnancy are musculoskeletal pain and radiculitis with approximately 48-56% of pregnant women complaining of high level of discomfort. Because the origin of the pain usually appears to be unrelated to pregnancy, mechanical complaints are usually ignored by the conventional doctors and the pain that occurs during pregnancy is often not resolved by exercise or support belts. Women who experience increasing pain during pregnancy are at a higher risk of having back pain during labor and the chances of experiencing back pain in the future pregnancies increases three-fold. Different studies have shown that biomechanical changes and stress to the neuromusculoskeletal system start during and after pregnancy and chiropractic treatment has been shown to be a safe and effective way of treating common musculoskeletal symptoms during pregnancy. Studies have also shown that SMT in conjunction with other techniques like dynamic body balancing techniques and craniosacral therapy are beneficial to these patients [5,9].
     Another study done on  pregnancy-related lumbopelvic pain (PRLP) specifically looked at pregnant patients with lumbar pain (LP), posterior pelvic pain (PPP), and those with a combination of both. Patients received treatment based on a diagnosis-based clinical decision rule (DBCDR), where the treatment was based on differential diagnosis, pain generating structure and tissue, and perpetuating factors. 115 patients were included in the study and screened to make sure they don’t have any underlying condition that would be a contraindication to SMT. Out of 115 patients in the study all but 10 received some form of chiropractic manual therapy. Other forms of treatment included stretching, strengthening, stabilization, pelvic tilt exercises, and acupuncture. The study found improvements with respect to pain in all three categories of LP, PPP, and both at the end of treatment. Improvements increased significantly at the long-term follow-ups, almost 11 months after the  end of the treatment. The study concluded that a treatment approach that includes manual therapy is both safe and beneficial in pregnant patient with lumbopelvic pain [8].
     Intercostal neuralgia is another condition that could occur during pregnancy. Intercostal neuralgia usually occurs because of irritation of intercostal nerve or nerves that pass between the internal and external intercostal muscles from the thoracic spine to the anterior side of the body and adjacent to the sternum. During pregnancy, there is an upward movement of abdominal organs due to the expanding uterus, causing the flare out of lower limbs and a decrease in costophrenic angle. There is an upward displacement of about 4cm of the diaphragm from its normal position and there is also an increase of about 10cm of thoracic circumference by the end of the pregnancy. These changes cause the intercostal muscles to stretch out and compress the intercostal nerve and cause pain. The conservative chiropractic care have been shown to be effective in this condition by appropriate movement of thoracic spine and ribs without changing the position of the uterus or the fetus [3].
     Specific studies have also looked into the safety of chiropractic care during pregnancy. In a retrospective case study 17 pregnant patient given chiropractic treatment out of which 16 patients reported clinically important improvements with no adverse effects reported. This is another evidence in support of the hypothesis that chiropractic treatment could be considered an effective treatment in reducing LBP symptoms during pregnancy. However, it is important to mention that the literature on this subject is not comprehensive and more research is needed with respect to chiropractic treatment in pregnancy and of course, there are situations where SMT is contraindicated. These situations include vaginal bleeding, sudden onset of pelvic pain, placenta abruption, ectopic pregnancy, ruptured amniotic membranes, cramping, and toxemia. Furthermore, because of ligamentous laxity during pregnancy, adjustment procedures should be performed with less forceful thrust [9].


1) Jakobsen EA, Miller JE, Chiropractic Care during Pregnancy: Survey of 100 patients presenting to a private clinic in           Oslo, Norway. Journal of Clinical Chiropractic Pediatrics. 2010 Dec;11(2):771-774.
2) Browning MC, Low Back and Pelvic Girdle Pain of Pregnancy: Recommendations for Diagnosis and Clinical                       Management. Journal of Clinical Chiropractic Pediatrics. 2010 Dec; 11(2):775-779.
3) Van Loop M, Intercostal Neuralgia during Pregnancy and Chiropractic Care. Journal of Clinical Chiropractic                       Pediatrics. 2010 Dec;11(2):780-782.
4) Andrew CG, Considering Non-Optimal Fetal Positioning and Pelvic Girdle Dysfunction in Pregnancy: Increasing the         Available Space. Journal of Clinical Chiropractic Pediatrics. 2010 Dec;11(2):783-787.
5) Phillips CJ, Musculoskeletal and Radicular Pain during Pregnancy, Labor and Delivery: The Concurrent Use of Spinal      Manipulative Therapy (SMT), Craniosacral Therapy (CST) and Dynamic Body Balancing Techniques (DBB): Five Case         Reports. Journal of Clinical Chiropractic Pediatrics. 2010 Dec;11(2):797-802.
6) Siddle B, Grand Rounds Case #1: Sacroiliac Joint Dysfunction in Pregnancy. Journal of Clinical Chiropractic Pediatrics.     Dec 2010;11(2):811-815.
7) Hughes TT, Grand Rounds Case #2: Multi-Disciplinary Management of Pelvic Girdle Instability. Journal of Clinical             Chiropractic Pediatrics. 2010 Dec;11(2):816-822.
8) 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. Journal of Manipulative and Physiological     Therapeutics. 2009 Oct;32(8):616-623.
9) Borggren CL, Pregnancy and Chiropractic: a Narrative Review of the Literature. Journal of Chiropractic Medicine.             2007 June;70-74.
10) Maizes V, Dog TL, Integrative Women’s Health. New York: Oxford University Press, Inc. 2010.