First Last, D.C.

Low back and/or pelvic pain in pregnancy is extremely common.

A study published in the journal Spine in 1996 indicated that 76% of women reported back pain at some time during pregnancy (1).

A study published in the Australian and New Zealand Journal of Obstetrics and Gynaecology in 2002 indicated that 35.5% of pregnant women recall having moderate to severe back pain during pregnancy, and 68% of those women “continued to experience recurring low back pain with a self-reported reduction in their health (2).” These authors listed the four most commonly used treatments for pregnancy back pain as bed rest, pain drugs, physiotherapy, and chiropractic.

A study published in the journal Obstetrics and Gynecology in 2004 indicated that 68.5% of women reported experiencing low back pain during their pregnancy (3). This low back pain caused sleep disturbances in 58% and impaired daily living in 57% of the women. The average pain was moderate in severity. Nearly 30% of respondents stopped performing at least one daily activity because of pain and reported that pain also impaired their performance of other routine tasks.

Another study published in the journal Spine in 2005 showed the prevalence of low back/pelvic pain during pregnancy was 72% (4). “Low back pain during pregnancy is a common problem that causes hardship in this population.”

Pregnancy low back and/or pelvic pain is prolonged in a significant number of women after giving birth. A study published in the European Spine Journal in 2002 showed that 20% of all women with back pain during pregnancy continued to have back pain 3 years later (5).

•••••••••

For more than a century, studies have assessed the value of chiropractic care and/or spinal manipulation for women with pregnancy back and/or pelvic pain. Accessing the United States National Library of Medicine with the search engine pubmed (www.pubmed.gov) with the following key words located these results (as of 12/1/21):

• “pregnancy low back pain and chiropractic”              34 articles
• “low back pain AND pregnancy AND manipulation”     55 articles

••••

In 1911, the Journal of the American Osteopathic Association published a study titled (6):

Can the Length of Labor be Shortened by Osteopathic Treatment?

The study involved 223 pregnant women; the findings are summarized below:

Average Duration of Labor for 223 Women

The results clearly showed a substantial decrease in the duration of labor in pregnant women who received spinal manipulation throughout their pregnancy compared to those who did not receive spinal manipulation.

••••

In 1918, the Journal of the American Osteopathic Association published another study titled (7):

Obstetrical Practice

This study involved 100 pregnant women and also showed a decrease in labor time in women who received regular lumbar spinal manipulation compared to those who did not:

Average Duration of Labor for 100 Women

••••

 In 1982, the Journal of the American Osteopathic Association published another study titled (8):

Effect of Pressure Applied to the Upper Thoracic (Placebo)
Versus Lumbar Areas (Osteopathic Manipulative Treatment)
for Inhibition of Lumbar Myalgia During Labor

The study involved 500 pregnant women. The results showed that manipulation to the lumbar spine not only decreased pain during labor, but also “reduced the need for major narcotic pain medication.”

•••

 In 1991, the Family Practice Research Journal published a study titled (9):

Sacroiliac Subluxation:
A Common, Treatable Cause of Low-back Pain in Pregnancy

This study showed that 91% of pregnant patients with sacroiliac dysfunction had alleviation of their low back pain after receiving manipulation.

••••

In 1991, the Journal of Manipulative and Physiological Therapeutics published a study titled (10):

Back Pain During Pregnancy and Labor

The authors showed that there was a statistically significant reduction of back pain during labor in women who received spinal manipulative therapy during pregnancy.

••••

In 2005, the Journal of Alternative and Complementary Medicine published a study titled (11):

Complementary and Alternative Medicine
for Low-back Pain in Pregnancy:
A Cross-sectional Survey

The authors, from Yale University School of Medicine, found that both providers of prenatal health care and pregnant women are likely to use complementary and alternative medicine treatments for pregnancy-induced low back pain. In this study, the most common complementary and alternative medicine therapies recommended for pregnancy low back pain were massage (61%), acupuncture (45%), relaxation (43%), yoga (41%), and chiropractic (37%).

••••

In 2006, the Journal of Midwifery and Woman’s Health published a study titled (12):

Chiropractic Spinal Manipulation for Low Back Pain of Pregnancy:
A Retrospective Case Series

The author retrospectively evaluated chiropractic spinal manipulation for low back pain associated with pregnancy in 17 subjects. The subjects reported significant improvement in pain that they attributed to chiropractic care. No adverse effects were reported in any of the cases. The results suggest that chiropractic treatment was safe and effective in these cases for reducing pain intensity.

••••

In 2008, the journal Midwifery Today with International Midwife published a study titled (13):

Chiropractic Evaluation and Management of the Pregnant Patient:
An Update from Recent Literature

The authors note that many chiropractors work closely with midwives. Fifty-seven percent of midwives recommended complementary and alternative therapies, with chiropractic care being the third most popular choice.

••••

In 2009, the Journal of Manipulative and Physiological Therapeutics published a study titled (14):

Outcome of Pregnancy-related Lumbopelvic Pain
Treated According to a Diagnosis-based Decision Rule:
A Prospective Observational Cohort Study

The authors documented the outcome of pregnancy-related lumbopelvic pain treated with chiropractic care in a prospective observational cohort study. Seventy-three percent of the patients reported their improvement as either “excellent” or “good.” These patients showed clinically significant improvements in pain and disability.

••••

In 2010, the journal American Journal of Obstetrics & Gynecology published a study titled (15):

Osteopathic Manipulative Treatment of Back Pain
and Related Symptoms During Pregnancy:
A Randomized Controlled Trial

The authors evaluated the efficacy of spinal manipulative treatment of back pain and related symptoms during pregnancy. The authors were from the University of North Texas Health Science Center in Fort Worth. The 144 subjects in the study were in the third trimester of pregnancy. They were randomized into three groups: usual obstetric care and manipulative treatment, usual obstetric care and sham ultrasound treatment (placebo), and usual obstetric care only. Outcomes are summarized in the chart below:

Results of 144 Patients With Pregnancy Low Back Pain

The authors concluded that spinal “manipulative treatment slows or halts the deterioration of back-specific functioning during the third trimester of pregnancy.”

••••

In 2012, the Journal of the American Osteopathic Association published a study titled (16):

Osteopathic Manipulative Treatment in Pregnant Women

The author (Chief Resident, Department of Physical Medicine and Rehabilitation, Boston University Medical Center) notes that the “maintenance of the body in its proper alignment improves the body’s function and its ability to maintain health.” Yet, during pregnancy, the maternal body undergoes structural changes to accommodate the growing fetus. These changes have a profound effect on the daily functioning of the pregnant patient.

Spinal manipulation to the low back and sacroiliac joint can help alleviate some of the discomfort that occurs because of these maternal physiologic changes. Spinal manipulation can ease pain in pregnant women by eliminating somatic dysfunction and maintaining proper structure.

There is a “statistically significant reduction of degree of back pain during labor in women who received spinal manipulative therapy during pregnancy….Manipulative treatment can alleviate musculoskeletal complaints that arise during pregnancy.”

Dr. Lavelle notes that there is a “statistically significant reduction of degree of back pain during labor in women who received spinal manipulative therapy during pregnancy.”

••••

In 2012, the journal Chiropractic & Manual Therapies published a study titled (17):

The Treatment Experience of Patients with Low Back Pain
During Pregnancy and Their Chiropractors:
A Qualitative Study

The abstract of this study states:

“Chiropractors regularly treat pregnant patients for low back pain during their pregnancy. An increasing amount of literature on this topic supports this form of treatment; however, the experience of the pregnant patient with low back pain and their chiropractor has not yet been explored. The objective of this study is to explore the experience of chiropractic treatment for pregnant women with low back pain, and their chiropractors.”

 The study participants consisted of 11 pregnant patients in their second or third trimester with low back pain and their 12 chiropractors. The interviews consisted of 10 open-ended questions for patients, and eight open-ended questions for chiropractors, asking about their treatment experience or impressions of treating pregnant patients with low back pain.

Chiropractors were generally open to referring their patients to other professionals, including encouragement to see their midwife or OB-GYN.

The chiropractors in this study tailored each patient’s treatment plan to the specific needs and particular timing in the patient’s pregnancy: “The chiropractors in this study demonstrated concern regarding patient safety and were vigilant in evaluating for the presence of any contraindications to spinal manipulation.”

Exercise prescription appeared to be an important component of the treatment program in this study. Most of the chiropractors advised specific stretches or exercises for their patients.

The comments of the patients and chiropractors lend support to reports in the literature of positive outcomes of chiropractic care for low back pain during pregnancy. In this study, it appeared that these women benefited from chiropractic treatment, including spinal manipulation, soft tissue therapy, and exercise therapy. No adverse events were reported by the pregnant patients or their chiropractors in response to the spinal manipulation received. The article concluded with:

“Chiropractors approach pregnant patients with low back pain from a patient-centered standpoint, and the pregnant patients interviewed in this study who sought chiropractic care appeared to find this approach helpful for managing their back pain symptoms.”

••••

In 2013, the journal American Journal of Obstetrics & Gynecology published a study titled (18):

 A Randomized Controlled Trial Comparing
a Multimodal Intervention and Standard Obstetrics Care
for Low Back and Pelvic Pain in Pregnancy

 These authors examined whether a multimodal approach of musculoskeletal and obstetric management was superior to standard obstetric care to reduce pain, impairment, and disability in the antepartum period. This care was provided and directed by chiropractors. It included manual therapy, stabilization exercises, and patient education. This was a prospective study that randomized 169 women to either standard obstetric care alone or to standard obstetric care plus the multimodal chiropractic approach.

The multimodal group had weekly visits with a chiropractor who provided education, manual therapy, and stabilization exercises. The authors evaluated these patients with three subjective questionnaires and four physical tests to quantify pain, disability, and physical function. The authors state:

“The goal of manual therapy was to restore joint motion and reduce muscle tension.”

 “Joint mobilization techniques were performed by gently moving hypomobile joints in their restricted directions to help restore proper range of motion.” 

 The multimodal group “demonstrated significant reductions” in both pain and disability from baseline to follow-up evaluation. “The group that received standard obstetric care demonstrated no significant improvements.”

“A multimodal approach to low back and pelvic pain in mid pregnancy benefits patients more than standard obstetric care.”

 “We conclude that a multimodal approach to musculoskeletal low back pain / pelvic pain that is instituted in the late second and early third trimesters of pregnancy benefits patients above and beyond standard obstetrics provider care.”

 “We have shown that a combination of manual therapy, exercise, and patient education reduces pain and disability when applied at 24-33 weeks’ gestation. The benefits derived are both subjective and objective. Patients perceived less pain and disability and an overall global improvement in daily activities. Their physical examinations revealed improved range of motion, stability, and less irritation at the lumbar and pelvic joints.”

This article supports that pregnant women with low back and/or pelvic pain would benefit from the inclusion of weekly chiropractic care that includes manipulation, mobilization, and patient-specific home exercise coaching, along with the standard management of obstetric care.

••••

 In 2013, the journal Canadian Family Physician published a study titled (19):

Optimizing Pain Relief During Pregnancy Using Manual Therapy

 The authors begin by proposing a question:

“Many of my pregnant patients have muscle and joint aches, and are reluctant to use analgesics. What is known about chiropractic care during pregnancy?”

The authors note that musculoskeletal pain is extremely common among pregnant women, with approximately 20% of pregnant women experiencing pelvic girdle pain, and 50%-85% experiencing low back pain. They attribute pregnancy musculoskeletal pain to an anterior shift in a woman’s center of mass in the 2^nd and 3^rd trimesters of pregnancy, arguing that therefore the root cause of much pelvic pain during pregnancy is mechanical (stemming from the low back or sacral joints) and not hormonal. The authors state:

“Owing to fears of the potential effects of medications, many women are unsure of what to do about low back and pelvic pain during pregnancy.”

 “Increasing recent evidence attests to the effectiveness and safety of treating [pregnancy low back and pelvic girdle] pain using manual therapy.”

 “Chiropractors, as primary health care professionals, have the ability to identify and diagnose mechanical problems and to alleviate many cases of undue stress or anxiety. Chiropractic doctors are also trained to understand when symptoms are indicative of something more ominous and to refer the patient to the appropriate professional if a non-mechanical issue is suspected.”

 “Massage therapy and chiropractic care, including spinal manipulation, are highly safe and effective evidence-based options for pregnant women suffering from mechanical low back and pelvic pain.”

 “Common sacroiliac joint dysfunction can often cause substantial pelvic pain and can be relieved with a simple adjustment by a chiropractor in minutes.”

 “Women experiencing musculoskeletal pain related to pregnancy can greatly benefit from manual therapies, including spinal manipulation, acupuncture, and massage therapy.”

••••

In 2014, the journal Chiropractic & Manual Therapies published a study titled (20):

Outcomes of Pregnant Patients with Low Back Pain
Undergoing Chiropractic Treatment:
A Prospective Cohort Study with Short Term, Medium Term
and 1-Year Follow-up

The authors note, “Low back and pelvic pain in pregnant women is such a common phenomenon that it is often considered a normal part of the pregnancy.” They state that the use of medication to treat pregnancy-related low back pain “is strongly discouraged.”

The authors assessed 115 patients at baseline and at 1 week, 1 month, 3 months, 6 months, and 1 year after the start of treatment. The results were:

• 52% of the patients were improved at 1 week
• 70% of the patients were improved at 1 month
• 85% of the patients were improved at 3 months
• 90% of the patients were improved at 6 months

The authors concluded:

“Most pregnant patients undergoing chiropractic treatment reported clinically relevant improvement at all time points.”

“The results of this current study showed that a high proportion of pregnant patients with LBP undergoing chiropractic treatment reported clinically relevant improvement.”

 “No serious adverse events were reported in this study and over 85% of the patients were happy or very happy with their chiropractic treatment.”

In 2021, the journal Clinical Obstetrics and Gynecology published an article titled (21):

Chiropractic Care for the Pregnant Body

 The article provides an evidence-based review of the epidemiology of chiropractic use in obstetrics, commonly treated conditions, related physiology of pregnancy, and safety of spinal manipulation. The authors note that low back pain and pelvic pain are prevalent in pregnancy and contribute to significant maternal discomfort in many women.

Low Back Pain

Up to 68% of pregnant women report low back pain. In 25% the pain is severe, 17% will also suffer from sciatica, and 8% will become disabled from their low back pain.

Pelvic Pain

Pregnancy-related pelvic pain occurs in about 50% of pregnant women.

Physiology

Beginning in the first trimester of pregnancy, the hormone relaxin is produced which causes relaxation of the ligaments.  The ligament laxity in the pelvis, hips, and back contributes to development of low back and pelvic pain.

Ligamentous laxity and the changing center of gravity from the enlarging uterus leads to increasing lumbar lordosis. Increased lumbar lordosis can cause significant stress on the lower back.

The authors (a physician, an osteopath, and a chiropractor) emphasize the importance of non-pharmacological options for back and pelvic pain in pregnant women. They state:

“Multiple national physician organizations endorse the use of non-pharmacologic treatment including chiropractic for conditions such as low back pain, including American College of Physicians, American Academy of Family Physicians, and North American Spine Society.” 

“Non-pharmacologic therapies to relieve pain are increasingly important during pregnancy because of the opioid epidemic.”

“Non-pharmacologic therapies to relieve pain are even more important during pregnancy to avoid exposure of the fetus to extraneous medications.”

“Identifying optimal non-pharmacologic therapies to treat musculoskeletal pain in pregnancy is imperative.”

“Patients and providers can rely on existing data which supports the safety of spinal manipulative therapy in pregnancy and provides a viable treatment option for musculoskeletal pain in pregnancy.”

“Chiropractic treatment is one of the potential therapies that offers intervention without medications.”

The authors report that 40% of obstetricians and 57% of midwives recommend chiropractic care during pregnancy. They cite 5 references that demonstrate improvements in low back pain in pregnant patients with spinal manipulation. They state:

“Reports of serious adverse outcomes after spinal manipulative therapy in pregnancy are exceedingly rare.”  

••••

SUMMARY

There is ongoing evidence from respected scientific journals, including randomized clinical trials, supporting the use of chiropractic care for pregnancy-related low back and pelvic pain. These studies indicate:

• Most pregnant women experience low back and/or pelvic pain during pregnancy, especially in the 2^nd and 3^rd trimesters as a consequence of structural changes in the woman’s body. These structural changes are also related to hormonal changes that are necessary to prepare the female body for the birthing process.
• Pregnant women with low back and/or pelvic pain tend to respond well when they add chiropractic care to their standard obstetrical care. The chiropractic care is often a combination of spinal manipulation, mobilization, and home exercise instruction.
• Chiropractic care during pregnancy may reduce labor time. This is beneficial for both the mother and her baby.
• Chiropractic care of the pregnant woman appears to be quite safe for both the mother and her baby.

References

1. Kristiansson P, Svarsudd K, von Schoultz B; Back pain during pregnancy: A prospective study; Spine; March 15, 1996; Vol. 21; No. 6; pp. 702-709.
2. Stapleton DB, MacLennan AH, Kristiansson P; The prevalence of recalled low back pain during and after pregnancy: A south Australian population survey; Australian and New Zealand Journal of Obstetrics and Gynaecology; November 2002; Vol. 42; No. 5; pp. 482-485.
3. Wang SM, Dezinno P, Maranets I, Berman MR, Caldwell-Andrews AA, Kain ZN; Low back pain during pregnancy: Prevalence, risk factors and outcomes; Obstetrics & Gynecology; July 2004; Vol. 104; No. 1; pp. 65-70.
4. Mogren IM, Pohjanen AI; Low back pain and pelvic pain during pregnancy: Prevalence and risk factors; Spine; April 15, 2005; Vol. 30; No. 8; pp. 983-991.
5. Noren L, Ostgaard S, Johansson G, Ostgaard HC; Lumbar back and posterior pelvic pain during pregnancy: A 3-year follow-up; European Spine Journal; June 2002; Vol. 11; No. 3; pp. 267-271.
6. Whiting LM; Can the length of labor be shortened by osteopathic treatment?; Journal of the American Osteopathic Association; 1911; Vol. 11; pp. 917-921.
7. Hart LM; Obstetrical practice; Journal of the American Osteopathic Association; 1918; pp. 609-614.
8. Guthrie RA, Martin RH; Effect of pressure applied to the upper thoracic (placebo) versus lumbar areas (osteopathic manipulative treatment) for inhibition of lumbar myalgia during labor; Journal of the American Osteopathic Association; December 1982; Vol. 82; No. 4; pp. 247-251.
9. Daly JM, Frame PS, Rapoza PA; Sacroiliac subluxation: A common, treatable cause of low-back pain in pregnancy; Family Practice Research Journal; June 1991; Vol. 11; No. 2; pp. 149-159.
10. Diakow PR, Gadsby TA, Gadsby JB, Gleddie JG, Leprich DJ, Scales AM; Back pain during pregnancy and labor; Journal of Manipulative and Physiological Therapeutics; February 1991; Vol. 14; No. 2; pp. 116-118.
11. Wang SM, DeZinno P, Fermo L, Williams K, Caldwell-Andrews AA, Kain ZN; Complementary and alternative medicine for low-back pain in pregnancy: A cross-sectional survey; Journal of Alternative and Complementary Medicine; June 2005; Vol. 11; No. 3; pp. 459-464.
12. Lisi AJ; Chiropractic spinal manipulation for low back pain of pregnancy: A retrospective case series; Journal of Midwifery and Woman’s Health; January-February 2006; Vol. 51; No. 1; pp. e7-10.
13. Zerdecki L, Passmore S; Chiropractic evaluation and management of the pregnant patient: an update from recent literature; Midwifery Today with International Midwife; Autumn 2008; Vol. 87; pp. 28-29, 67-68.
14. 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; October 2009; Vol. 32; No. 8; pp. 616-624.
15. Licciardone JC, Buchanan S, Hensel K, King HH, Fulda KG, Stoll ST; Osteopathic manipulative treatment of back pain and related symptoms during pregnancy: a randomized controlled trial; American Journal of Obstetrics & Gynecology; January 2010; 202; No. 1; pp. 43.e1–8.
16. Lavelle JM; Osteopathic Manipulative Treatment in Pregnant Women; Journal of the American Osteopathic Association; June 2012; Vol. 112; No. 6; pp. 343-346.
17. Sadr S, Pourkiani-Allah-Abad N, Stuber KJ; The treatment experience of patients with low back pain during pregnancy and their chiropractors: A qualitative study; Chiropractic & Manual Therapies; October 9, 2012; Vol. 20; No. 1.
18. George JW, Skaggs CD, Thompson PA, Nelson M, Gavard JA, Gross GA; A randomized controlled trial comparing a multimodal intervention and standard obstetrics care for low back and pelvic pain in pregnancy; American Journal of Obstetrics & Gynecology; April 2013; Vol. 208; No, 4; pp 295.e1-7.
19. Oswald C, Higgins CC, Assimakopoulos D; Optimizing pain relief during pregnancy using manual therapy; Canadian Family Physician; August 2013; Vol. 59; No. 8; pp. 841-842.
20. Peterson CK, Muhlemann D, Humphreys BK; Outcomes of Pregnant Patients with Low Back Pain Undergoing Chiropractic Treatment: A Prospective Cohort Study with Short Term, Medium Term and 1-Year Follow-up; Chiropractic & Manual Therapies; April 1, 2014; Vol. 22; No. 1.
21. Conner S, Trudell A, Conner C; Chiropractic Care for the Pregnant Body; Clinical Obstetrics and Gynecology; September 2021; Vol. 64; No. 3; pp. 602–610.

“Authored by Dan Murphy, D.C.. Published by ChiroTrust^® – This publication is not meant to offer treatment advice or protocols. Cited material is not necessarily the opinion of the author or publisher.”