Research Review By Dr. Ceara Higgins©

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Date Posted:

November 2020

Study Title:

Chiropractic Care for Adults with Pregnancy-Related Low Back, Pelvic Girdle Pain, or Combination Pain: A Systematic Review

Authors:

Weis CA, Pohlman K, Draper C, da Silva-Oolup S, Stuber K & Hawk C

Author's Affiliations:

Canadian Memorial Chiropractic College, Toronto, Canada; Parker University, Dallas, Texas; Texas Chiropractic College, Pasadena, Texas, USA

Publication Information:

Journal of Manipulative and Physiological Therapeutics 2020; Sep 5: S0161-4754(20)30128-7. doi: 10.1016/j.jmpt.2020.05.005.

Background Information:

Low back pain (LBP), pelvic girdle pain (PGP) or a combination of the two are common in pregnancy and the postpartum period for many women. In fact, up to 90% of women report LBP during pregnancy (5), and for over 30% of pregnant women this represents their first occurrence of LBP (4). LBP or PGP may resolve shortly after birth, but this is not always the case. Overall, the etiology of these afflictions remains unknown, but proposed mechanisms include maternal weight gain, biomechanical changes and changes in hormonal levels such as relaxin, which lead to ligament laxity (2, 3).

Despite interference with activities of daily living and substantial rates of disability, it is still common for both patients and clinicians to regard LBP or PGP as a normal and acceptable aspect of pregnancy (6). Approximately 5-11% of pregnant patients with LBP report seeing a chiropractor (1) and receive care which commonly includes manual therapy (including mobilization or spinal manipulative therapy [SMT]), soft tissue techniques, and active treatments including exercise and self-management.

This study aimed to evaluate the evidence for chiropractic care for pregnancy-related LBP, PGP, or combination pain (both LBP and PGP). This was done with the goal of making a best-practices document feasible.

Pertinent Results:

Literature Search Results:
18 systematic reviews (SRs), 4 of high quality, 11 of acceptable quality, and 3 of low quality, were included in this review. Due to the heterogeneity among the trials, only a qualitative analysis could be performed. In addition, 30 RCTs and 2 cohort studies were included. 13 involving LBP, 4 involving PGP, and 15 including both LBP and PGP.

Pregnancy-Related Low Back Pain:
 
Chiropractic & SMT:
One SR of acceptable quality, including 6 studies, looked at chiropractic care and found improved outcomes. However, the reviewers rated the included studies as moderate- to low-quality. Regarding SMT specifically, two other SRs examined the same RCT for SMT, but drew differing conclusions. One SR (rated as high-quality by these authors) scored the RCT as low-quality and determined that there was no difference in pain and functional disability between women receiving SMT, exercise, and Neuro Emotional Technique (NET). The second (rated as low-quality) scored the same RCT as high-quality and stated that at least 50% of women in each group showed clinically meaningful improvements in pain symptoms.

Exercise:
1 SR of high quality, 3 of acceptable quality, and 1 of low quality, as well as 1 RCT and 1 cohort study examining land- or water-based exercise were included. All but 1 SR showed that land- or water-based exercise reduced or improved pregnancy-related LBP when compared to no intervention, controls, normal prenatal advice, or usual obstetric care (UOBC). The RCT showed that a seated pelvic tilt exercise may significantly improve LBP for women in the third trimester. The cohort study found that acute increases in daily step count early in pregnancy may be a risk factor for developing LBP, but a gradual increase in average steps per day after mid-pregnancy may actually decrease the risk of LBP.

Osteopathic Manipulative Therapy:
3 SRs (2 high-quality and one acceptable-quality), including 8 RCTs, 2 case controls, 1 observational study, and 1 case series, looked at osteopathic manipulative therapy (OMT). All of the SRs showed that OMT improved disability and pain scores during pregnancy when compared with UOBC. 2 RCTs were also included, with one showing improvements in LBP for individuals receiving OMT and UOBC, remaining unchanged for the group receiving UOBC and sham ultrasound, and worsening in the group receiving UOBC only. The second RCT determined that OMT was effective for mitigating pain and functional deterioration when compared to UOBC.
 
Electrotherapy (TENS):
One high-quality and one acceptable-quality SR on electrotherapy (TENS) both concluded that while evidence is limited, TENS helps to decrease pain and improve function when compared to exercise, acetaminophen, and UOBC. A single high-quality RCT found that while TENS, a home-based exercise program, and acetaminophen all helped relieve LBP in the third trimester, TENS was the most effective.

Support Devices:
A single high-quality SR looking at 2 types of support belts showed no significant improvements. A small RCT showed that kinesiotape may provide significantly more relief than exercise. One low-quality RCT showed that use of a maternity belt may reduce pain and lessen the effects of pregnancy-related LBP while a second showed that a specially designed pillow may be of more help than a regular pillow.
 
Physiotherapy:
One low-quality SR, including 2 RCTs (one of high-quality and one of fair-quality) found that physiotherapy had a positive effect on pain intensity but not on functional ability when compared with no treatment.

Pregnancy-Related Pelvic Girdle Pain:
 
Exercise:
4 SRs provided mixed results for exercise interventions for PGP. 3 SRs suggested that there was little indication that group exercise combined with information improved pain and function when compared to UOBC, while 1 showed that almost all of their included studies, both on home-based or group exercise, reported positive effects on pain and disability. In addition, a high-quality RCT found that individuals receiving stabilizing exercises reported less morning and evening pain compared to the control group, but less improvement than the acupuncture group. An acceptable-quality RCT showed no significant differences between patients receiving home exercise plus information, in-clinic exercise plus information, or information alone.
 
Patient Education & Information:
A low-quality RCT found that a birth preparation plan, including education on exercise and how to manage PGP was no more effective that UOBC, while an acceptable-quality SR showed that education may help to decrease discomfort and pain intensity when part of a multimodal plan. Two low-quality SRs suggested that in order to help reduce pain, information should include information about the disorder, practical and anatomical information, and information on possible contributing factors.
 
Support Devices:
One high- and one acceptable-quality SR both included an RCT suggesting that the use of a nonrigid lumbopelvic belt plus information showed significant reductions in pain and functional disability when compared to exercise and information. However, the reductions in pain were not seen when exercise was provided along with the belt and information. Another RCT found a decrease in pain intensity and disability with the use of a belt combined with either exercise or education. A high-quality RCT looked at an exercise-only group, an exercise plus nonrigid stability belt group, and an exercise plus rigid stability belt group and found decreases in disability and pain in all groups, with no significant differences between groups. Finally, a low-quality RCT found that the use of a rigid belt plus information was superior to information alone.

Pregnancy-Related Low Back Pain or Pelvic Girdle Pain:
 
SMT & Mobilization:
Only two RCTs were found on SMT/mobilization. Although they reported positive effects on disability and pain, there was no significant differences between groups, leading the authors of one of the studies to suggest that there is no evidence to recommend manual therapy for LBP or PGP.
 
Multimodal Care:
Multimodal care was examined in 1 high-quality and 2 acceptable-quality SRs, which included RCTs showing positive results on pain and disability when using an intervention including manual therapy, exercise, and education when compared to UOBC. A second RCT compared an intervention comprised of weekly chiropractic visits, including education, manual therapy, and stability exercises and found that this may reduce pain and disability when applied at 24-33 weeks’ gestation, compared to UOBC.

Exercise:
One high-quality SR included 4 RCTs which found that an 8- to 12-week exercise program improved functional disability and reduced the number of women reporting LBP or PGP. 4 additional acceptable-quality SRs showed that almost all of their included studies on exercise performed at home or in a group showed positive effects on pain and disability. One of them suggested that the most effective exercise programs should focus on functionality, positional transitions and variety and should be supervised by exercise experts. Another SR suggested that core and pelvic floor muscle training and stretching should be included in the program. RCTs showed mixed results. One study suggested that exercise did not affect pain intensity, but did help women manage their pain better, while another showed that a 12-week group training program was effective in preventing LBP or PGP in late gestation, and a third showed that a group exercise program plus home exercises and ergonomic advice did not affect prevalence or severity of LBP or PGP in pregnancy. A fourth study showed that women participating in group and home exercise and receiving back care advice showed improvements in pain intensity and functional ability, and a fifth found no difference in pain prevalence or limitations in activities of daily living when comparing a group exercise program and home exercises to UOBC. A final RCT looked at individualized exercises and education and found improvements in pain and disability when compared to UOBC.

Osteopathic Manipulative Therapy:
2 SRs reported improvements in pain and disability in women receiving Osteopathic Manipulative Therapy (OMT), however, it was noted that the studies were limited and that therefore there was no conclusive evidence.

Complimentary & Alternative Medicine:
One high-quality and 1 acceptable-quality SR looked at ‘Complementary & Alternative Medicine (CAM)’, including chiropractic, massage, and osteopathy but neither could support the use of a specific CAM modality.

Patient Education:
One acceptable SR and 3 RCTs of moderate- to low-quality determined that women receiving patient education had less discomfort and decreased pain when compared to controls.

Support Devices:
3 SRs of acceptable-quality and 1 of low quality looked at support belts and showed that wearing a belt reduced pain intensity. However, the evidence was inconclusive.

Physiotherapy:
One acceptable SR showed no strong evidence to recommend physiotherapy. However, a low-quality RCT suggested that while individualized physiotherapy did not diminish disability and did not relieve pain to the same extent as acupuncture, it did stop the worsening of symptoms.

Clinical Application & Conclusions:

This review focused on interventions that are within the chiropractic scope of practice and do not require additional certification. The evidence can be summarized as follows:

Pregnancy-Related Low Back Pain:

Favorable outcomes and a moderate level of strength of evidence of the evidence was found for osteopathic manipulative therapy (OMT) and electrotherapy, suggesting that osteopathy and TENS may be effective choices for alleviating LBP in pregnancy. Favorable outcomes, but inconclusive strength of evidence was found for chiropractic care and SMT, suggesting that chiropractic care may be effective for treating LBP in this population, however, the outcomes for SMT specifically were unclear. Favorable outcomes of inconclusive strength were also found for exercise and support devices. This means that no firm conclusions could be drawn for these treatments. For exercise, it was noted that supervised training should be used in order to avoid injury. It was suggested that women who participated in an exercise program were better able to manage their pain as evidence by a reduction in sick leave due to back pain.

Pregnancy-Related Pelvic Girdle Pain:

Favorable outcomes from inconclusive evidence were seen with multimodal care. A single acceptable quality RCT showed that a combination of manual therapy (mobilization and soft tissue therapy), exercise, patient education, and UOBC improved pain and disability when applied at 24-33 weeks’ gestation. However, due to the nature of multimodal care, it is impossible to discern which aspect of the treatment provided the clinical benefits. Favorable outcomes from inconclusive evidence were also seen with physiotherapy and patient education. It was noted that physiotherapy should be individualized. However, no firm conclusions can be drawn for either of these treatment options. Exercise was found to have unclear outcomes from moderate strength evidence. It was suggested that exercise programs should be 10-12 weeks in duration and designed for particular joint dysfunction. It was unclear if exercise could be preventative for LBP or PGP.

SMT/mobilization showed unclear outcomes from inconclusive evidence. Information on SMT in a pregnant population is lacking, but research in the area is emerging leading the authors to conclude that clinicians should consider this approach for a short course of care if the patient is in agreement. OMT and support devices also had unclear outcomes from inconclusive evidence due to a lack of good quality research. It was suggested that a support belt could be used as a first treatment to help with pain while waiting for an exercise program to take effect, but that it should be combined with individually designed exercises and education on ergonomics. There was limited evidence to support the use of CAM therapies, including massage, OMT, SMT, chiropractic care, acupuncture, and craniosacral therapy. However, one SR stated that clinicians should consider the use of SMT in healthy pregnant women without contraindications, as it has a good safety profile.

Future research in this population should define the region of the back they are investigating and provide a specific treatment plan in order to determine what treatments are the most effective. Currently, the diagnosis of pain conditions presenting in pregnancy is poorly defined and also needs to be further clarified.

Study Methods:

This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines (7) and the search strategy was developed in conjunction with a health sciences librarian. Titles were screened by 2 independent reviewers with disagreements resolved by discussion and a third reviewer.

Inclusion Criteria:
  • Studies published (in English) before November, 2016 in a peer-reviewed journal
  • Studies including women pregnant with a singleton pregnancy who had lumbar spine or pelvic girdle musculoskeletal complaints
  • Interventions included in the chiropractic scope of care, such as manual therapy, SMT, and modalities commonly used by chiropractors which do not require additional prenatal certifications
  • Outcomes including pain, disability, previous and prevalence of LBP and PGP, average steps per day, Patient-Specific Functional Scale, limitation of activities of daily living and physical activities, back pain classification scale, and sick leave
  • Randomized control trials, cohort studies, or systematic reviews
Exclusion Criteria:
  • Non-peer-reviewed publications
  • Commentaries, editorials, letters, case reports or case series, or non-clinical studies
  • Studies with no treatment outcomes
  • Studies on any treatment that requires an additional prenatal certification
  • Studies which received a score of “unacceptable” by the SIGN criteria for SRs, RCTs, and cohort studies
Systematic reviews/meta-analyses (SRs), RCTs, and cohort studies were evaluated with a modified version of the Scottish Intercollegiate Guideline Network (SIGN) checklist (8) and scored as “high quality, low risk of bias”, “acceptable quality, moderate risk of bias”, “low quality, high risk of bias”, or “unacceptable”. No data was extracted from “unacceptable” articles. An adapted version of the US Preventative Services Task Force criteria from the UK report (9) was used to determine strength of evidence, rated as “high”, “moderate”, or “inconclusive”. Finally, a description of the outcomes was included. If all articles showed improvement, outcomes were classified as “favorable”; if all articles failed to show improvement, outcomes were classified as “non-favorable”; and if all articles showed a mix of improvement, a lack of improvement, or no difference, outcomes were classified as “unclear”.

Study Strengths / Weaknesses:

Strengths:
  • A strong search strategy was employed.
  • The authors employed appropriate methodology for this topic in accordance with PRISMA guidelines, in addition to employing the SIGN criteria to assess risk of bias of the included studies.
Weaknesses:
  • Due to difficulties in discerning the conditions covered in pregnancy populations, it is possible relevant studies were missed.

Additional References:

  1. Stapleton DB, MacLennan AH, Kristiansson. The prevalence of recalled low back pain during and after pregnancy: a South Australian population survey. Aust N Z J Obstet Gynaecol 2002; 42(5): 482-485.
  2. Sipko T, Grygier D, Barczyk K, et al. The occurrence of strain symptoms in the lumbosacral region and pelvis during pregnancy and after childbirth. J Manipulative Physiol Ther 2010; 33(5): 370-377.
  3. Mens J, Vleeming A, Stoeckart R, et al. Understanding peripartum pelvic pain. Implications of a patient survey. Spine 1996; 21(11): 1363-1370.
  4. Ostgaard H, Andersson G. Postpartum low-back pain. Spine 1992; 17(1): 53-55.
  5. Browning M. Low back and pelvic girdle pain of pregnancy: recommendations for diagnosis and clinical management. J Clin Chiropr Pediatr 2010; 11(2): 775-779.
  6. Vermani E, Mittal R, Weeks A. Pelvic girdle pain and low back pain in pregnancy: a review. Pain Pract 2010; 10(1): 60-71.
  7. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Br Med J 2009; 339: b2535.
  8. Hawk C, Minkalis A, Khorsan R, et al. Systematic review of nondrug, nonsurgical treatment of shoulder conditions. J Manipulative Physiol Ther 2017; 40(5): 293-319.
  9. Bronfort G, Haas M, Evans R, et al. Effectiveness of manual therapies: the UK evidence report. Chiropr Osteopat 2010; 18: 3.

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