Best Practices for Chiropractic Care for Pregnant & Postpartum Patients +MP3
Research Review By Dr. Ceara Higgins©
Audio:
Date Posted:
July 2022
Study Title:
Best-Practice Recommendations for Chiropractic Care for Pregnant and Postpartum Patients: Results of a Consensus Process
Authors:
Weis CA, Pohlman K, Barrett J, et al.
Author's Affiliations:
Canadian Memorial Chiropractic College, Toronto, ON, Canada; Parker University, Dallas, Texas, USA; McMaster University, Hamilton, ON, Canada; Embody Physiotherapy & Wellness, Sewickley, Pennsylvania, USA; UT Southwestern Medical Center, Dallas, Texas, USA; University of Calgary, AB, Canada; Texas Chiropractic College, Pasadena, Texas, USA.
Publication Information:
Journal of Manipulative and Physiological Therapy 2021 Nov 23; S0161-4754(21)00036-1. doi: 10.1016/j.jmpt.2021.03.002. Online ahead of print.
Background Information:
Chiropractors see pregnant women with back and pelvic pain frequently. Up to 90% of pregnant women will experience pregnancy-related back pain (1) and up to 35% of those will describe their pain as moderate, severe, or disabling, with a negative impact on their activities of daily living (2). Approximately 30% of women have their first episode of back pain while pregnant and while this pain will often resolve after birth, 75% of women will continue to experience pain up to 3 years later (4). Those women experiencing postpartum related back pain 3 months after giving birth have a higher risk of experiencing chronic low back pain (LBP) throughout their lives (5).
LBP and pelvic girdle pain (PGP) are different conditions (3), but are often studied together, making it very difficult to determine safe and effective management strategies for these patients. LBP is defined as pain occurring between the costal margins and the inferior gluteal folds (7), while PGP is defined as pain occurring in the symphysis pubis and/or between the posterior iliac crest and gluteal folds (7). LBP and PGP occurring simultaneously should be called combination or combined pain (8). In addition to the lack of clear research, many health care providers dismiss these conditions as temporary and self-limiting (6), providing little or no recommendations for treatment (2).
It has been suggested that effective chiropractic care should consist of a variety of conservative approaches or multimodal treatment (9). However, most research focuses on a single modality rather than the entire discipline (10). Recent guidelines have suggested that chiropractic care should include patient education and advice, supervised and home exercises, and manual therapy (9). In general, complications associated with spinal manipulative therapy (SMT) are rare (12), so chiropractic care should be considered as a viable health care option for pregnant and postpartum patients with LBP (13). However, there are still important gaps in the literature. This study aimed to develop a best-practices document based on the evidence and a consensus process including a multidisciplinary group of pregnancy and postpartum care experts.
LBP and pelvic girdle pain (PGP) are different conditions (3), but are often studied together, making it very difficult to determine safe and effective management strategies for these patients. LBP is defined as pain occurring between the costal margins and the inferior gluteal folds (7), while PGP is defined as pain occurring in the symphysis pubis and/or between the posterior iliac crest and gluteal folds (7). LBP and PGP occurring simultaneously should be called combination or combined pain (8). In addition to the lack of clear research, many health care providers dismiss these conditions as temporary and self-limiting (6), providing little or no recommendations for treatment (2).
It has been suggested that effective chiropractic care should consist of a variety of conservative approaches or multimodal treatment (9). However, most research focuses on a single modality rather than the entire discipline (10). Recent guidelines have suggested that chiropractic care should include patient education and advice, supervised and home exercises, and manual therapy (9). In general, complications associated with spinal manipulative therapy (SMT) are rare (12), so chiropractic care should be considered as a viable health care option for pregnant and postpartum patients with LBP (13). However, there are still important gaps in the literature. This study aimed to develop a best-practices document based on the evidence and a consensus process including a multidisciplinary group of pregnancy and postpartum care experts.
Pertinent Results:
Delphi Process:
Seventy-eight panelists consented to participate. This included 63 women and 15 men, of which 70 were DCs, 5 were physical therapists (PT), 1 was a family doctor (MD), 1 was a midwife (MW), and 1 was an MD obstetrician-gynecologist (OB/GYN). The panelists represented 7 countries: Canada, the United States, United Kingdom, Australia, The Netherlands, and Sweden. For advanced training, 8 DCs reported being certified in Webster technique and 4 PTs reported extra pregnancy/postnatal training and/or certification. The panelists had been in practice a median of 15 years and their median estimate for proportion of pregnant and postpartum patients was 10% and 15% respectively.
Consensus on all statements was reached after 3 rounds. After round 1, a single panelist withdrew and 5 failed to respond. After round 2, 8 panelists failed to respond. 9 statements failed to reach consensus in round 1 and 3 statements failed to reach consensus after round 2. The final consensus statements are summarized below.
Seventy-eight panelists consented to participate. This included 63 women and 15 men, of which 70 were DCs, 5 were physical therapists (PT), 1 was a family doctor (MD), 1 was a midwife (MW), and 1 was an MD obstetrician-gynecologist (OB/GYN). The panelists represented 7 countries: Canada, the United States, United Kingdom, Australia, The Netherlands, and Sweden. For advanced training, 8 DCs reported being certified in Webster technique and 4 PTs reported extra pregnancy/postnatal training and/or certification. The panelists had been in practice a median of 15 years and their median estimate for proportion of pregnant and postpartum patients was 10% and 15% respectively.
Consensus on all statements was reached after 3 rounds. After round 1, a single panelist withdrew and 5 failed to respond. After round 2, 8 panelists failed to respond. 9 statements failed to reach consensus in round 1 and 3 statements failed to reach consensus after round 2. The final consensus statements are summarized below.
Informed Consent & Risks
Statement 1: Informed Consent
Informed consent is an ever-evolving, dynamic process and should be updated with the unique changes occurring with pregnancy and postpartum conditions. Clinicians should discuss the benefits of treatment, the treatment itself, expected outcomes, material risk, and side effects, including a discussion of rare but potentially serious risks, correlated with various physical and manual therapies inherent within chiropractic care. These discussions should be ongoing and documented.
Informed consent is an ever-evolving, dynamic process and should be updated with the unique changes occurring with pregnancy and postpartum conditions. Clinicians should discuss the benefits of treatment, the treatment itself, expected outcomes, material risk, and side effects, including a discussion of rare but potentially serious risks, correlated with various physical and manual therapies inherent within chiropractic care. These discussions should be ongoing and documented.
Statement 2: Adverse Events
Mild, transient side effects have been reported after lumbar spine SMT and rarely, serious adverse events have been reported following cervical spine SMT in case reports. If red flags are identified, clinicians should fully discuss the risks of SMT in each spinal region they are considering adjusting.
Mild, transient side effects have been reported after lumbar spine SMT and rarely, serious adverse events have been reported following cervical spine SMT in case reports. If red flags are identified, clinicians should fully discuss the risks of SMT in each spinal region they are considering adjusting.
Statement 3: Informed Consent
A thorough history and physical examination may help identify potential red flags. Clinicians should discuss selected procedures in the recommended treatment plan and any potential concerns and ensure informed consent has been obtained. This may include providing the patient with various treatment options.
A thorough history and physical examination may help identify potential red flags. Clinicians should discuss selected procedures in the recommended treatment plan and any potential concerns and ensure informed consent has been obtained. This may include providing the patient with various treatment options.
Statement 4: Possible Modifications
Clinicians should consider instances in which SMT should be modified or may not be warranted. Modifications or alternate procedures should be considered and offered in these cases.
Clinicians should consider instances in which SMT should be modified or may not be warranted. Modifications or alternate procedures should be considered and offered in these cases.
Multidisciplinary Care
Statement 5: All Therapies Pregnant patients may see several health care providers. A complete health history should include a list of these therapies. In cases where patient information should be communicated among health care providers, with permission obtained from the patient, contact information of these providers should be sought from the patient.
Statement 6: Complementary, Integrative, and Alternative Medicine
These therapies have limited evidence. Chiropractors should attempt to provide care based on the best currently available evidence, clinical experience, and patient preference. Chiropractors should understand the current evidence on the effectiveness and safety of these therapies.
These therapies have limited evidence. Chiropractors should attempt to provide care based on the best currently available evidence, clinical experience, and patient preference. Chiropractors should understand the current evidence on the effectiveness and safety of these therapies.
Statement 7: Interprofessional Collaboration
After patient consent is obtained, and jurisdictional privacy requirements are met, a phone call, confidential health records, or reports may be shared among all providers to ensure care provided is transparent and cohesive.
After patient consent is obtained, and jurisdictional privacy requirements are met, a phone call, confidential health records, or reports may be shared among all providers to ensure care provided is transparent and cohesive.
Pregnancy – LBP
Statement 8: Presentation LBP often presents in pregnant patients as pain limited to the lumbar region which is described as dull and may be exacerbated by forward flexion. Spinal movement may be restricted, and palpation of the lumbar erector spine muscles may intensify symptoms. Provocation tests for pelvic pain, such as posterior pelvic pain provocation test (PPPP) and flexion, abduction, external rotation extension (FABERE) test will typically be negative. Clinicians can confirm this pain by asking pregnant patients to point or indicate their pain area on a pain diagram or use a combination of these 2 techniques.
Statement 9: Key Questions for LBP
A complete history will be taken. In addition, key examination questions for pregnant patients with LBP may include, but are not limited to, the questions below:
A complete history will be taken. In addition, key examination questions for pregnant patients with LBP may include, but are not limited to, the questions below:
- How has your pregnancy been? Ask about fatigue, nausea, bleeding, etc.
- Where are you experiencing your pain? Please point to the area.
- What trimester or week did the pain start?
- Which movements provoke your pain? Bending over, lean backwards, rotation, side bending?
- Do you have any pain going into the leg? If yes, where and does it go past the knee?
- What improves your pain? (i.e. position, treatment, etc.)
- Describe or explain the character of your pain? (i.e. achy, sharp, dull, stabbing, stiff, tight?)
- Are you experiencing any numbness or tingling into the lower extremity?
- What movements provoke your pain? (ex. Is pain provoked by prolonged standing, walking, or sitting? Is pain provoked by turning over in bed? Is pain provoked by putting on footwear? Is pain provoked getting in or out of the car?)
- What, if any, activities of daily living are limited because of the pain? (ex. bending over to tie your shoe, climbing stairs, standing on 1 leg, caring for a child in your home)
- Is there pain with vaginal intercourse?
- Are you having difficulty controlling your bladder or bowels? Do you leak when you sneeze, cough, jump or run?
- If you have had a previous delivery: How was the experience? Were any interventions used (forceps, cesarean section, epidural, etc)? Were there any complications?
Statement 10: Risk Factors for LBP
May include: Pre-pregnancy LBP; previous pregnancy or postpartum-related LBP; higher anxiety scores, as measured by the state-trait anxiety inventory; work dissatisfaction.
May include: Pre-pregnancy LBP; previous pregnancy or postpartum-related LBP; higher anxiety scores, as measured by the state-trait anxiety inventory; work dissatisfaction.
Statement 11: Pain Pattern
Characteristic pain patterns in pregnancy-related LBP may include:
Characteristic pain patterns in pregnancy-related LBP may include:
- Pain can start at almost any time during pregnancy but often starts around the 18th week of gestation (peaking between the 24th and 36th weeks).
- LBP occurs in the lumbar region, between the lower rib and the iliac crests
- LBP is not as common as PGP during pregnancy; however, it is more prevalent in the postpartum period
Pregnancy – Pelvic Girdle Pain (PGP)
Statement 12: Presentation
Pain between the tops of the iliac crest to the gluteal folds, predominantly near the sacroiliac joints and symphysis pubis, which may radiate into the posterior thigh. PGP has 5 classifications:
Pain between the tops of the iliac crest to the gluteal folds, predominantly near the sacroiliac joints and symphysis pubis, which may radiate into the posterior thigh. PGP has 5 classifications:
- Anterior pain at the symphysis pubis (best prognosis for recovery)
- Unilateral sacroiliac joint pain
- Bilateral sacroiliac joint pain
- Pain in all 3 areas (worst prognosis)
- Miscellaneous pain (daily pain from one or more pelvic joints, but inconsistent objective findings from the pelvic joints themselves)
Confirm this pain by asking patients to point or indicate their pain area on a pain diagram or use a combination of the 2 techniques.
Statement 13: Diagnosis of PGP
Lumbar diagnoses must be excluded. Pain in the posterior pelvis or posterior thigh generally do not centralize with lumbar spine testing. Pain or functional disturbances must be reproduced by specific clinical tests, such as PPPP, active straight leg raise, FABERE test, modified Trendelenburg, etc.
Lumbar diagnoses must be excluded. Pain in the posterior pelvis or posterior thigh generally do not centralize with lumbar spine testing. Pain or functional disturbances must be reproduced by specific clinical tests, such as PPPP, active straight leg raise, FABERE test, modified Trendelenburg, etc.
Statement 14: Key Questions
Key questions include, but not limited to those in Statement 9.
Key questions include, but not limited to those in Statement 9.
Statement 15: Risk Factors for PGP
- History of LBP (before and during a previous pregnancy)
- Previous trauma to the pelvis
- High number of positive pain provocation tests
- Multiple pregnancy (twins, etc.)
- Polyhydramnios or large for gestational age fetus
- Pelvic floor muscle weakness
- Work dissatisfaction
Statement 16: Pain Pattern for PGP
- Onset during pregnancy
- Pain between the top of the iliac crests and the bottom of the gluteal fold
- Anterior, posterior, or both aspects of the pelvis
- Can occur in conjunction with or separately from pain in the symphysis pubis
- The pain can radiate into the posterior thigh
- PGP is more common during pregnancy than postpartum
Pregnancy – Combined Pain (LBP + PGP)
Statement 17: Presentation
Pain occurring in both the lumbar and pelvic regions simultaneously. Confirm this pain by asking the patient to point or indicate their pain area on a pain diagram, or use a combination of the 2 techniques.
Pain occurring in both the lumbar and pelvic regions simultaneously. Confirm this pain by asking the patient to point or indicate their pain area on a pain diagram, or use a combination of the 2 techniques.
Statement 18: Key Questions
Key questions are outlined, but not limited to those in Statement 9.
Key questions are outlined, but not limited to those in Statement 9.
Statement 19: Risk Factors for Combined Pain
Combined pain (both in the lumbar and pelvic regions) before pregnancy.
Combined pain (both in the lumbar and pelvic regions) before pregnancy.
Statement 20: Pain Pattern
- Pain occurring simultaneously in the lumbar region (LBP) and pain in the pelvic girdle region (PGP)
- Pregnant patients who experience combined pain often experience more disability than those just experiencing LBP or PGP alone
Postpartum – LBP
Statement 21: Presentation Pain in the lumbar region, between the bottom of the 12th rib and the top of the iliac crests, range of motion may be restricted and/or painful, and there may be pain with palpation of the lumbar musculature. Confirm the location of pain by having the patient point or indicate their pain area on a pain diagram or use a combination of the two.
Statement 22: Key Questions
Key questions may include, but are not limited to the following:
Key questions may include, but are not limited to the following:
- How was your most recent pregnancy? (ask about fatigue, nausea, bleeding, etc.)
- When was your baby born?
- How was the delivery for your most recent pregnancy? (ask about intervention, timing of labour, etc.: Were there any complications?; How big was the baby?)
- Have you experienced a previous delivery? (ask about intervention, timing of labour, etc.: Were there any complications?; Did you experience LBP following that delivery?)
- Where are you experiencing your pain? Please point to the area.
- When did the pain start - during pregnancy or following birth?
- Which movements provoke your pain? Bending over, leaning backwards, rotation, side bending?
- Describe or explain the character of your pain?
- Do you have any pain going into the leg? If yes, where and does it go past the knee?
- What improves your pain? (i.e. position, treatment, etc.)
- Are you experiencing any numbness or tingling into the lower extremity?
- What movements provoke your pain? (ex. Is the pain provided by prolonged standing, walking, or sitting? Turning over in bed? Putting on footwear? Getting in or out of the car?)
- What, if any, activities of daily living are limited because of the pain? For example: Bending over to care for your newborn? Climbing stairs? Standing on 1 leg? Caring for a child in your home?
- Is there pain with vaginal intercourse?
- Are you having difficulty controlling your bladder or bowels? Did this difficulty start during your most recent pregnancy or since delivery? Do you have any leaking when you sneeze, cough, jump, or run?
- Do you have any perceptions of heaviness, pressure, or a sensation of dropping in the perineum?
Statement 23: Risk Factors
- A previous history of LBP before or during pregnancy
- A significant earlier onset and worse pain symptoms in the preceding pregnancy
- A higher postpartum weight gain and weight retention leads to a higher incidence of persistent pain symptoms after delivery
Statement 24: Pain Pattern
- Pain experienced in the lumbar region
- Although a patient may experience both types of pain, generally LBP is more common that PGP in the postpartum period
Postpartum – PGP
Statement 25: Presentation
Pain between the tops of the iliac crests to the gluteal folds, predominantly near the SI joints. The pain may radiate into the posterior thigh and may occur together with or separately from pain the symphysis pubis. Confirm by asking the patient to point or indicate their pain area on a pain diagram or use a combination of the two. Statement 26: Key Questions
Key questions include, but are not limited to those in Statement 22.
Pain between the tops of the iliac crests to the gluteal folds, predominantly near the SI joints. The pain may radiate into the posterior thigh and may occur together with or separately from pain the symphysis pubis. Confirm by asking the patient to point or indicate their pain area on a pain diagram or use a combination of the two. Statement 26: Key Questions
Key questions include, but are not limited to those in Statement 22.
Statement 27: Risk Factors for Postpartum PGP
- Higher pain scores during pregnancy
- Combined pain in early pregnancy
- Pain with active straight leg raise
- Pre-pregnancy LBP
- Age > or equal to 29 years
- Low endurance of back flexors
- Lower socioeconomic status
- Type of delivery (i.e. traumatic or forceps delivery)
- Epidural/spinal injection
- Work dissatisfaction
- Pelvic floor weakness
Statement 28: Pain Pattern
- Generally PGP is less common during the postpartum period than during pregnancy.
- There is often a decline in prevalence of postpartum PGP within 3 months of delivery. However, patients whose pain does not resolve within that time frame may have a higher risk of prolonged severe or persistent pain.
- Patients presenting with PGP and combined pain during pregnancy tend to recover more slowly in the postpartum period.
Postpartum – Combined Pain (LBP + PGP)
Statement 29: Presentation
Patients will present with pain in both the lumbar and anterior or posterior pelvic regions. This can be confirmed by having the patient point or indicate their pain on a pain diagram, or a combination of the two. It is important to identify these patients as they have the highest risk for persistent or chronic pain, especially if their pain continues past 3 months postpartum.
Patients will present with pain in both the lumbar and anterior or posterior pelvic regions. This can be confirmed by having the patient point or indicate their pain on a pain diagram, or a combination of the two. It is important to identify these patients as they have the highest risk for persistent or chronic pain, especially if their pain continues past 3 months postpartum.
Statement 30: Key Questions Key questions include but are not limited to those in statement 22.
Statement 31: Risk Factors for Postpartum Combined Pain
- Postpartum patients with combined pain at 3 months after delivery are at increased risk of persistent pain
- Work dissatisfaction
- Combined pain in early pregnancy
- Age > or equal to 29 years
- Low endurance of back flexors
- Type of delivery (i.e. traumatic or forceps delivery)
- Epidural/spinal injection
Statement 32: Pain Pattern
Pregnant patients presenting with PGP and combined pain tend to recovery more slowly, their pain has a greater impact on their activities of daily living, and, if left untreated, 30% are likely to develop persistent or chronic pain in the postpartum period.
Pregnant patients presenting with PGP and combined pain tend to recovery more slowly, their pain has a greater impact on their activities of daily living, and, if left untreated, 30% are likely to develop persistent or chronic pain in the postpartum period.
Examination of a Pregnant Patient
Statement 33: Examination, General
The following tests should be considered: range of motion of affected joints and spinal regions, neurological testing (deep and pathological reflexes), palpation, pain provocation tests for the SI joints and the symphysis pubis, and tests of load transfer, such as active straight leg raise and single legged stance.
The following tests should be considered: range of motion of affected joints and spinal regions, neurological testing (deep and pathological reflexes), palpation, pain provocation tests for the SI joints and the symphysis pubis, and tests of load transfer, such as active straight leg raise and single legged stance.
Statement 34: Vital Signs
Vital signs (which can include heart rate, respiratory rate, blood pressure (BP), weight, and height) should be taken and recorded at the initial visit. Some vital signs, such as blood pressure, may need to be checked more regularly. If there is a concerning change in vital signs or symptomology the patient should be referred to the obstetric provider.
Vital signs (which can include heart rate, respiratory rate, blood pressure (BP), weight, and height) should be taken and recorded at the initial visit. Some vital signs, such as blood pressure, may need to be checked more regularly. If there is a concerning change in vital signs or symptomology the patient should be referred to the obstetric provider.
Statement 35: Blood Pressure and Hypertension, Pregnancy
Pregnant patients may see their chiropractor more regularly than they see their primary health care provider. Since pregnancy-related symptoms can change rapidly, blood pressure should be taken at the initial visit and then once every 4 weeks until 28 weeks (14), then once weekly until delivery (15). If the patient has risk factors for preeclampsia, then blood pressure should be taken at every visit (16). Blood pressure should also be taken if there is a concerning change in vital signs or symptomology, such as persistent headache, visual disturbances (blurring, flashing, dark spots in the field of vision), epigastric pain/right upper quadrant pain, nausea and/or vomiting, chest pain, or shortness of breath (17). Patients should then be referred to their obstetric provider.
Pregnancy-induced hypertension (systolic BP > or equal to 140 mmHg and/or diastolic BP > or equal to 90 mmHg) is a leading cause of maternal and perinatal morbidity and mortality (11). A diagnosis of hypertension should be based on the average of at least 2 measurements, taken at least 15 minutes apart, using the same arm with the patient seated comfortably with their back supported and their arm relaxed and supported on the armrest at heart level. If there is any concern about BP, the patient should be referred to their obstetric provider.
Pregnant patients may see their chiropractor more regularly than they see their primary health care provider. Since pregnancy-related symptoms can change rapidly, blood pressure should be taken at the initial visit and then once every 4 weeks until 28 weeks (14), then once weekly until delivery (15). If the patient has risk factors for preeclampsia, then blood pressure should be taken at every visit (16). Blood pressure should also be taken if there is a concerning change in vital signs or symptomology, such as persistent headache, visual disturbances (blurring, flashing, dark spots in the field of vision), epigastric pain/right upper quadrant pain, nausea and/or vomiting, chest pain, or shortness of breath (17). Patients should then be referred to their obstetric provider.
Pregnancy-induced hypertension (systolic BP > or equal to 140 mmHg and/or diastolic BP > or equal to 90 mmHg) is a leading cause of maternal and perinatal morbidity and mortality (11). A diagnosis of hypertension should be based on the average of at least 2 measurements, taken at least 15 minutes apart, using the same arm with the patient seated comfortably with their back supported and their arm relaxed and supported on the armrest at heart level. If there is any concern about BP, the patient should be referred to their obstetric provider.
Statement 36: Blood Pressure, Postpartum
If a patient is seen within 3-6 days of delivery (the time when BP peaks postpartum) BP should be measured. Patients with high BP should be referred to the obstetric provider or family physician for evaluation for preeclampsia as it can develop postpartum (18).
If a patient is seen within 3-6 days of delivery (the time when BP peaks postpartum) BP should be measured. Patients with high BP should be referred to the obstetric provider or family physician for evaluation for preeclampsia as it can develop postpartum (18).
Statement 37: Hypertension, Postpartum
BP should be taken at the first postpartum visit for patients presenting within the first 6 weeks after delivery. Patients presenting with hypertension should be immediately referred to the family physician or obstetrics provider for further investigation.
BP should be taken at the first postpartum visit for patients presenting within the first 6 weeks after delivery. Patients presenting with hypertension should be immediately referred to the family physician or obstetrics provider for further investigation.
Statement 38: Diastasis Recti, General
Most patients experience an increase in the inter-recti abdominal muscle distance due to stretching and thinning of the linea alba during pregnancy and should be checked for diastasis recti of the abdominal muscles (DRAM) at least once per trimester and postpartum at their first visit and then periodically over the course of care until their issue is resolved. Patients should be tested lying on their back with their hips and knees bent and feet flat on the floor. Hands can be by their sides or across their chests. The patient is then asked to lift their head and shoulder blades off the surface they are lying on while the DC palpates to determine distance between the abdominal muscles. A diagnosis of DRAM is rendered if horizontal palpation of the linea alba is greater than 2 finger-breadths (> 2.5 cm) (15).
Most patients experience an increase in the inter-recti abdominal muscle distance due to stretching and thinning of the linea alba during pregnancy and should be checked for diastasis recti of the abdominal muscles (DRAM) at least once per trimester and postpartum at their first visit and then periodically over the course of care until their issue is resolved. Patients should be tested lying on their back with their hips and knees bent and feet flat on the floor. Hands can be by their sides or across their chests. The patient is then asked to lift their head and shoulder blades off the surface they are lying on while the DC palpates to determine distance between the abdominal muscles. A diagnosis of DRAM is rendered if horizontal palpation of the linea alba is greater than 2 finger-breadths (> 2.5 cm) (15).
Statement 39: Diastasis Recti, Postpartum
DRAM generally resolves spontaneously postpartum, but can persist in some women. It has been suggested that DRAM may influence the strength of the abdominal wall musculature and may lead to poor posture, umbilical hernia, or pain in the low back or hip. Currently there is no generally acceptable therapeutic exercise protocol for DRAM. As a result, an individualized assessment, manual therapy (as needed), and individualized exercise-based rehabilitation prescription has been suggested.
DRAM generally resolves spontaneously postpartum, but can persist in some women. It has been suggested that DRAM may influence the strength of the abdominal wall musculature and may lead to poor posture, umbilical hernia, or pain in the low back or hip. Currently there is no generally acceptable therapeutic exercise protocol for DRAM. As a result, an individualized assessment, manual therapy (as needed), and individualized exercise-based rehabilitation prescription has been suggested.
Statement 40: Low Back Pain, General
LBP should be diagnosed based on reproducible pain and/or change in ROM from repeated movements or different positions of the lumbar spine or an experience of centralization and peripheralization phenomena during examination and negative pain provocation tests (See statements 43 and 44).
LBP should be diagnosed based on reproducible pain and/or change in ROM from repeated movements or different positions of the lumbar spine or an experience of centralization and peripheralization phenomena during examination and negative pain provocation tests (See statements 43 and 44).
Statement 41: Low Back Pain; Specific Tests
At a minimum, a low back examination in a pregnant patient should include range of motion of the lumbar spine, palpation of the low back musculature, and provocation tests (such as PPPP) to rule out PGP.
At a minimum, a low back examination in a pregnant patient should include range of motion of the lumbar spine, palpation of the low back musculature, and provocation tests (such as PPPP) to rule out PGP.
Statement 42: Neurological Testing
Mechanical LBP must be differentiated from radicular pain and other neurological symptoms through a neurological examination including deep and pathological reflexes, motor and sensation, and nerve root tension tests.
Mechanical LBP must be differentiated from radicular pain and other neurological symptoms through a neurological examination including deep and pathological reflexes, motor and sensation, and nerve root tension tests.
Statement 43: Pelvic Girdle Pain, General
PGP should be diagnosed based on 3 or more positive pain provocation tests for the SI joints, testing for symphysis pubis irritation, the absence of centralization or peripheralization phenomena during repeated movements, and no lumbar pain or change in range of motion from repeated movements.
PGP should be diagnosed based on 3 or more positive pain provocation tests for the SI joints, testing for symphysis pubis irritation, the absence of centralization or peripheralization phenomena during repeated movements, and no lumbar pain or change in range of motion from repeated movements.
Statement 44: Pelvic Girdle Pain, Specific Tests
Specific tests for PGP should include pain provocation tests such as PPPP test and FABERE test. Other tests to consider include Gaenslen’s test, compression test, sacral thrust or distraction tests, and palpation of the long dorsal sacroiliac joint ligament. In the presence of persistent pain at the symphysis pubis, testing may include palpation of the symphysis pubis, Modified Trendelenburg test, and the active straight leg raise test.
Specific tests for PGP should include pain provocation tests such as PPPP test and FABERE test. Other tests to consider include Gaenslen’s test, compression test, sacral thrust or distraction tests, and palpation of the long dorsal sacroiliac joint ligament. In the presence of persistent pain at the symphysis pubis, testing may include palpation of the symphysis pubis, Modified Trendelenburg test, and the active straight leg raise test.
Statement 45: Red Flags
Red flags should be identified and monitored (see statement 46). If a patient presents with 1 or more red flags that would be a contraindication to a specific treatment, that treatment should stop, and the patient should be referred to an appropriate provider for further evaluation and/or care. Chiropractic care may need to be modified or adapted during monitoring for red flags and co-management and/or consultation with the patient’s obstetric provider is encouraged.
Red flags should be identified and monitored (see statement 46). If a patient presents with 1 or more red flags that would be a contraindication to a specific treatment, that treatment should stop, and the patient should be referred to an appropriate provider for further evaluation and/or care. Chiropractic care may need to be modified or adapted during monitoring for red flags and co-management and/or consultation with the patient’s obstetric provider is encouraged.
Statement 46: Contraindications and Red Flags
Due to the limited evidence on contraindications to spinal therapies for pregnant patients, caution is recommended when performing high-velocity SMT to the lower thoracic, lumbar, and pelvic regions in patients with the following:
Due to the limited evidence on contraindications to spinal therapies for pregnant patients, caution is recommended when performing high-velocity SMT to the lower thoracic, lumbar, and pelvic regions in patients with the following:
- Vaginal bleeding - without prior clearance from prenatal providers
- Abdominopelvic cramping
- Ruptured membranes, premature labor, imminent birth
- Placenta previa (when placenta completely or partially covers the cervix, normally associated with vaginal bleeding)
- Placenta abruption
- Ectopic pregnancy
- Sudden onset of pelvic pain (not reproducible with orthopedic testing) or other reason to suspect ectopic pregnancy
- Bowel obstruction
- Pregnancy-induced hypertension, pre-eclampsia, or eclampsia
- Pre-eclampsia (moderate or severe)
- Recent trauma (ex. fall, car accident) to the pelvis that might threaten the pregnancy
Caution is recommended for other chiropractic modalities in patients with the following:
- High-risk situations (suggest obtaining prior clearance from obstetric providers), such as: Multiples, history of miscarriages/still births, patients who smoke (due to an increased risk for pregnancy-related complications)
- Pre-eclampsia (moderate to severe)
- Known bleeding disorders
Statement 47: Contraindications
In a non-pregnant population there are contraindications to high-velocity SMT which must also be considered in a pregnant population. These include:
In a non-pregnant population there are contraindications to high-velocity SMT which must also be considered in a pregnant population. These include:
- Anomalies such as dens hypoplasia, unstable os odontoideum, etc.
- Acute fracture
- Spinal cord tumor
- Acute infection such as osteomyelitis, septic discitis, and tuberculosis of the spine
- Meningeal tumor
- Hematomas (spinal cord or intracanalicular)
- Malignancy of the spine
- Frank disc herniation with accompanying signs of progressive neurological deficit
- Basilar invagination of the upper cervical spine
- Arnold-Chiari malformation of the upper cervical spine
- Dislocation of a vertebra
- Aggressive types of benign tumors such as aneurism bone cyst, giant cell tumor, osteoblastoma, or osteoid osteoma
- Internal fixation/stabilization devices
- Neoplastic disease of muscle or other soft tissue
- Positive Kernig’s or Lhermitte’s signs
- Congenital, generalized hypermobility
- Signs or patterns of instability
- Syringomyelia
- Hydrocephalus of unknown etiology
- Diastematomyelia
- Cauda equina syndrome
Diagnostic Imaging
Statement 48: Radiographs
All female patients of child-bearing age should be asked if it is possible that they are pregnant before taking radiographs.
All female patients of child-bearing age should be asked if it is possible that they are pregnant before taking radiographs.
Statement 49: Radiographs
For pregnant patients where radiographs are medically indicated (ex. trauma), ensure the beam is collimated so the fetus will not be in the field of view, the patient is positioned to avoid direct irradiation of the pelvis, and the gravid uterus is covered with a radiation shield.
For pregnant patients where radiographs are medically indicated (ex. trauma), ensure the beam is collimated so the fetus will not be in the field of view, the patient is positioned to avoid direct irradiation of the pelvis, and the gravid uterus is covered with a radiation shield.
Statement 50: Magnetic Resonance Imaging (MRI)
One concern for MRI during pregnancy is the need to lie supine for an extended period. If the patient cannot tolerate lying supine due to lightheadedness, nausea, and/or dizziness, the chiropractor can educate their patient about alternative positions including using a pillow or wedge to help the patient into the lateral decubitus position.
One concern for MRI during pregnancy is the need to lie supine for an extended period. If the patient cannot tolerate lying supine due to lightheadedness, nausea, and/or dizziness, the chiropractor can educate their patient about alternative positions including using a pillow or wedge to help the patient into the lateral decubitus position.
Statement 51: Magnetic Resonance Imaging
MRI should be used with caution during pregnancy, especially in the first trimester. For chiropractors who can order advanced imaging, coordination with the obstetrics provider and radiologist is advised.
MRI should be used with caution during pregnancy, especially in the first trimester. For chiropractors who can order advanced imaging, coordination with the obstetrics provider and radiologist is advised.
Statement 52: Magnetic Resonance Imaging
MRI plus contrast (i.e. gadolinium) should be avoided in pregnant patients unless the benefits outweigh the risks. MRI plus contrast can be administered to postpartum women. Those who are breastfeeding can receive these scans without interruption to their breastfeeding schedule.
MRI plus contrast (i.e. gadolinium) should be avoided in pregnant patients unless the benefits outweigh the risks. MRI plus contrast can be administered to postpartum women. Those who are breastfeeding can receive these scans without interruption to their breastfeeding schedule.
Interventions for Pregnancy and Postpartum
Statement 53: Introductory Statement
Pregnancy related LBP, PGP, and combined pain are very common. In addition to in-office chiropractic treatments, chiropractors can direct patients to use self-care interventions which may help them to manage their pregnancy or postpartum related back pain.
Pregnancy related LBP, PGP, and combined pain are very common. In addition to in-office chiropractic treatments, chiropractors can direct patients to use self-care interventions which may help them to manage their pregnancy or postpartum related back pain.
Statement 54: Self-Care
Pregnant patients with LBP should be encouraged to stay active and continue their normal activities if possible, and to follow an individualized exercise program.
Pregnant patients with LBP should be encouraged to stay active and continue their normal activities if possible, and to follow an individualized exercise program.
Statement 55: Manual Therapy, General
SMT and soft tissue techniques and procedures should be adapted to fit the needs and comfort of the patient.
SMT and soft tissue techniques and procedures should be adapted to fit the needs and comfort of the patient.
Statement 56: Spinal Manipulative Therapy
SMT may be an appropriate treatment for some pregnant and postpartum women.
SMT may be an appropriate treatment for some pregnant and postpartum women.
Statement 57: Spinal Manipulative Therapy & Adverse Events
SMT for the pregnant and postpartum populations can be considered safe. Lumbar SMT may have only minor side effects. Adverse events with cervical SMT are rare.
SMT for the pregnant and postpartum populations can be considered safe. Lumbar SMT may have only minor side effects. Adverse events with cervical SMT are rare.
Statement 58: Spinal Manipulative Therapy & Pelvic Girdle Pain
As there are no studies on SMT and PGP alone, a trial course of care may be warranted to see if relief of symptoms is achieved. If there is no pain relief or improvement to quality of life the patient should be reevaluated, and the management plan modified or discontinued, or the patient referred to another health care provider for evaluation and/or co-management.
As there are no studies on SMT and PGP alone, a trial course of care may be warranted to see if relief of symptoms is achieved. If there is no pain relief or improvement to quality of life the patient should be reevaluated, and the management plan modified or discontinued, or the patient referred to another health care provider for evaluation and/or co-management.
Statement 59: Soft Tissue Therapy (STT)
There is limited evidence for the use of massage therapy in pregnant and postpartum patients and no evidence for soft tissue techniques such as Active Release and Graston. A trial of care for STT may be warranted.
There is limited evidence for the use of massage therapy in pregnant and postpartum patients and no evidence for soft tissue techniques such as Active Release and Graston. A trial of care for STT may be warranted.
Statement 60: Taping
Although there is limited evidence a trial of care may be considered. However, some patients may have an allergy to the tape’s adhesive. Clinicians should ask about skin sensitivity before taping. In addition, if the patient has a reaction to the tape, it should be removed immediately and not reapplied.
Although there is limited evidence a trial of care may be considered. However, some patients may have an allergy to the tape’s adhesive. Clinicians should ask about skin sensitivity before taping. In addition, if the patient has a reaction to the tape, it should be removed immediately and not reapplied.
Statement 61: Pelvic or Abdominal Belts
There is limited evidence for the use of belts. A belt may be tried to provide symptomatic relief and worn for only short periods. Belts for PGP should be worn just below the anterior superior iliac spine rather than at the level of the symphysis pubis.
There is limited evidence for the use of belts. A belt may be tried to provide symptomatic relief and worn for only short periods. Belts for PGP should be worn just below the anterior superior iliac spine rather than at the level of the symphysis pubis.
Statement 62: Transcutaneous Electrical Nerve Stimulation (TENS)
Although there is no evidence for TENS, it has been used in the pregnant population with no known adverse events to the mother or fetus. If other treatment options do not provide pain relief and the alternatives might be medications that would cross the placental barrier, a trial of TENS should be considered. This should be coupled with other recommended treatments such as advice, exercise, and manual therapy (SMT). Cautions and precautions to consider with TENS include:
Although there is no evidence for TENS, it has been used in the pregnant population with no known adverse events to the mother or fetus. If other treatment options do not provide pain relief and the alternatives might be medications that would cross the placental barrier, a trial of TENS should be considered. This should be coupled with other recommended treatments such as advice, exercise, and manual therapy (SMT). Cautions and precautions to consider with TENS include:
- All usual cautions and precautions with TENS.
- Extra caution should be taken if the patient has epilepsy or a very irritable uterus, or if she has a history of early miscarriage or abortion. Informed consent should be obtained, and a clinical judgement made in conjunction with her obstetrics provider.
- Current density should be kept low.
- Placement of pads should be considered. Caution should be taken when placing TENS electrodes on or over acupuncture points that are considered most likely to induce labour.
- If the patient has a pacemaker or defibrillator, TENS should be avoided unless approval and specific parameters are provided by their cardiologist.
Statement 63: Transcutaneous Electrical Nerve Stimulation and Acupuncture
See Statement 62. The most effective electrode placement for LBP and PGP is likely posterior over the lumbosacral nerve roots.
Acupuncture is reasonably safe during pregnancy, but there is still some debate regarding needle points that could induce labour. The sites most contraindicated before 37 weeks include Spleen 6 (SP6), Liver 4 (LI4), Bladder 60 (BL60), Gallbladder 21 (GB21), Lung 7 (LU7), and points in the lower abdomen and sacral region.
See Statement 62. The most effective electrode placement for LBP and PGP is likely posterior over the lumbosacral nerve roots.
Acupuncture is reasonably safe during pregnancy, but there is still some debate regarding needle points that could induce labour. The sites most contraindicated before 37 weeks include Spleen 6 (SP6), Liver 4 (LI4), Bladder 60 (BL60), Gallbladder 21 (GB21), Lung 7 (LU7), and points in the lower abdomen and sacral region.
Statement 64: Transcutaneous Electrical Nerve Stimulation during labour
Although there is no strong evidence for the use of TENS during labour patients who have used in in labour would do so again. Therefore, it may be offered as pain relief.
Although there is no strong evidence for the use of TENS during labour patients who have used in in labour would do so again. Therefore, it may be offered as pain relief.
Statement 65: Manual Therapy, Instrument-Assisted Therapy
There is limited evidence for instrument-assisted manual therapies such as Activator, drop pieces, or instrument-assisted STT. A trial of care may be warranted.
There is limited evidence for instrument-assisted manual therapies such as Activator, drop pieces, or instrument-assisted STT. A trial of care may be warranted.
Lifestyle Factors
Statement 66: Rehabilitation Advice
Patients with LBP and/or PGP should be encouraged to play an active role in their treatment or rehabilitation. Chiropractors should present them with general information on anatomy, biomechanics, and controlled movement patterns. Patients experiencing a healthy pregnancy should be reassured that mild back pr pelvic symptoms due to mechanical musculoskeletal issues are common, not dangerous, and that they should improve and/or recover.
Patients with LBP and/or PGP should be encouraged to play an active role in their treatment or rehabilitation. Chiropractors should present them with general information on anatomy, biomechanics, and controlled movement patterns. Patients experiencing a healthy pregnancy should be reassured that mild back pr pelvic symptoms due to mechanical musculoskeletal issues are common, not dangerous, and that they should improve and/or recover.
Statement 67: Activities of Daily Living, General
Patients with pregnancy or postpartum-related back pain should be encouraged to do their best to continue with the activities of daily living. As well, they should be taught how to avoid maladaptive movement patterns while remaining active and educated to incorporate physical activity into their daily life with periods of rest to recuperate.
Patients with pregnancy or postpartum-related back pain should be encouraged to do their best to continue with the activities of daily living. As well, they should be taught how to avoid maladaptive movement patterns while remaining active and educated to incorporate physical activity into their daily life with periods of rest to recuperate.
Statement 68: Exercise
Land-based exercises:
Land-based exercises:
- Pregnant and postpartum patients with LBP and/or PGP may benefit from a group exercise program
- Exercise plus patient education has a positive effect on pain
- For pregnant and postpartum patients, a supervised treatment program including exercises for local and global muscle systems, individually adapted to fitness and pain levels, shows the best effects
- Exercises should be individualized with a focus on stability exercises as part of a multifactorial treatment plan for PGP
Statement 69: Exercise
Water-based exercises: Pregnant or postpartum patients with LBP and/or PGP should be encouraged to try water-based exercises. They are considered safe and effective and may help reduce pain intensity and sick leave.
Water-based exercises: Pregnant or postpartum patients with LBP and/or PGP should be encouraged to try water-based exercises. They are considered safe and effective and may help reduce pain intensity and sick leave.
Statement 70: Information and Ergonomic Advice
Information and ergonomic advice may be considered as part of a trial of care.
Information and ergonomic advice may be considered as part of a trial of care.
Statement 71: Pillows
Pregnant patients may consider pillow support under the abdomen, legs, or knees to help alleviate pregnancy-related back pain and potentially improve sleep.
Pregnant patients may consider pillow support under the abdomen, legs, or knees to help alleviate pregnancy-related back pain and potentially improve sleep.
Clinical Application & Conclusions:
This is the first comprehensive best practice recommendations publication for chiropractic care of pregnant and postpartum patients with LBP, PGP, or combined pain. The statements contained herein were laid out so the practitioner could identify the specific patient presentation and determine the appropriate management of that population. This may provide additional options for pre- and postnatal back pain management based on safe, reasonable, and rational parameters for clinical management.
Other health care providers can also use this article to understand the types of care chiropractors can provide to these populations and inform their pregnant and postpartum patients about relevant and safe treatment options.
Other health care providers can also use this article to understand the types of care chiropractors can provide to these populations and inform their pregnant and postpartum patients about relevant and safe treatment options.
Study Methods:
Due to the insufficient evidence available on chiropractic care in the pregnancy and postpartum periods, a full clinical practice guideline was determined to be impossible. Best-practice documents, however, can bridge this practice-research gap. Therefore, these authors aimed to outline the most beneficial approach to chiropractic care based on the best available evidence and expert clinical experience. This included manual therapies (including SMT, mobilization, soft tissue therapy, and instrument-assisted soft tissue therapy), adjunctive modalities, and physical agents that chiropractors may use that do not require additional certifications.
A steering committee (SC) was formed composed of nationally recognized experts who work extensively with pregnant and postpartum populations and a research project manager. This included professionals from chiropractic, medicine, and physiotherapy. The lead author developed seed statements on informed consent and risk, history and physical examination for LBP, PGP, and combined pain, risk factors, and interventions which were then presented to the attendees of a workshop at a chiropractic conference for initial review and feedback. Following the workshop, two systematic reviews on chiropractic care for the pregnant and postpartum populations were completed and used to further develop the seed statements (both studies have been reviewed on RRS). The SC then reviewed the seed statements for comprehension, completeness, and relevance before they were sent to panelists. 71 seed statements were developed.
The panel was composed of attendees from an international chiropractic conference, nomination by the SC, and invitations sent to relevant organizations. Panelists were selected based on their experience and diversity of geography, demographics, and profession with an emphasis on identifying pre- and post-natal care experts from outside of the chiropractic profession and chiropractors (DCs) with dual degrees.
The consensus process was conducted through email using a modified version of the RAND-UCLA methodology for conducting the Delphi process. Seed statements and all citations were sent to the panelists with full text for any references sent upon request. Panelists were asked to rate the appropriateness of each statement (expectation that the health benefits to the patient would exceed the expected negative consequences by a sufficiently wide margin, suggesting that it is worth doing, exclusive of cost). Ratings ranged from 1 (highly inappropriate) to 9 (highly appropriate), with rating from 1-3 categorized as inappropriate, 4-6 as undecided, and 7-9 as appropriate. If a panelist rated a statement as inappropriate, they were asked to state reasons and references. If no reason was provided the response was considered incomplete and recorded as missing. Consensus was reached on a seed statement when at least 80% of panelists rated it from 7-9 and the median response score was between 7 and 9.
Seed statements were sent in 2 batches, statements 1-35 in June 2019 and statements 36-71 in July 2019. Panelists had 2 weeks to return the seed statements with any suggested revisions or feedback. Statements not reaching consensus were revised, reviewed, and approved by the SC, and sent back to panelists. This process was repeated until consensus was reached.
A steering committee (SC) was formed composed of nationally recognized experts who work extensively with pregnant and postpartum populations and a research project manager. This included professionals from chiropractic, medicine, and physiotherapy. The lead author developed seed statements on informed consent and risk, history and physical examination for LBP, PGP, and combined pain, risk factors, and interventions which were then presented to the attendees of a workshop at a chiropractic conference for initial review and feedback. Following the workshop, two systematic reviews on chiropractic care for the pregnant and postpartum populations were completed and used to further develop the seed statements (both studies have been reviewed on RRS). The SC then reviewed the seed statements for comprehension, completeness, and relevance before they were sent to panelists. 71 seed statements were developed.
The panel was composed of attendees from an international chiropractic conference, nomination by the SC, and invitations sent to relevant organizations. Panelists were selected based on their experience and diversity of geography, demographics, and profession with an emphasis on identifying pre- and post-natal care experts from outside of the chiropractic profession and chiropractors (DCs) with dual degrees.
The consensus process was conducted through email using a modified version of the RAND-UCLA methodology for conducting the Delphi process. Seed statements and all citations were sent to the panelists with full text for any references sent upon request. Panelists were asked to rate the appropriateness of each statement (expectation that the health benefits to the patient would exceed the expected negative consequences by a sufficiently wide margin, suggesting that it is worth doing, exclusive of cost). Ratings ranged from 1 (highly inappropriate) to 9 (highly appropriate), with rating from 1-3 categorized as inappropriate, 4-6 as undecided, and 7-9 as appropriate. If a panelist rated a statement as inappropriate, they were asked to state reasons and references. If no reason was provided the response was considered incomplete and recorded as missing. Consensus was reached on a seed statement when at least 80% of panelists rated it from 7-9 and the median response score was between 7 and 9.
Seed statements were sent in 2 batches, statements 1-35 in June 2019 and statements 36-71 in July 2019. Panelists had 2 weeks to return the seed statements with any suggested revisions or feedback. Statements not reaching consensus were revised, reviewed, and approved by the SC, and sent back to panelists. This process was repeated until consensus was reached.
Study Strengths / Weaknesses:
Strengths:
- This article attempted to delineate and present information regarding 3 types of musculoskeletal pain (LBP, PGP, and combined pain) to provide the best advice possible for each type of pain. However, the research delineating these conditions is lacking, so expert opinion was often used.
Weaknesses:
- Although the goal was to recruit an international consensus panel, most attendees were from Canada or the United States potentially making these recommendations most applicable to those regions.
- The consensus statements were limited to common treatment options reported in the literature. SMT has the beginnings of an evidence base, however, the literature does not accurately reflect how SMT and its many variations (ex. instrument or table assisted) are offered to patients. In addition, techniques not commonly taught in chiropractic colleges (i.e. Webster technique and STT) could be further explored and included in a similar future consensus process.
- Due to the limitations of using the current literature, it is possible that adverse events from modalities other than SMT may not be reported.
Additional References:
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