Chiropractic Care During Pregnancy

Having had a lot of pregnant women in for treatment recently, I thought I would write a little bit about chiropractic care for pregnant women, why and how it can help. 

Physiological changes during pregnancy

There are a variety of physiological changes that occur during pregnancy, some that affect the prevalence of low back pain and pelvic pain and others that affect other aspects of a pregnant woman’s health.

The first aspect to look at is posture, this is perhaps one of the most obvious changes to us as chiropractors, some aspects seen visibly before any examination has commenced. An increase in lumbar lordosis (that inwards curve just above the buttock) is a common contributory factor to low back pain. Most of the weight gain is concentrated in the lower pelvis with anterior abdominal protuberance. Due to this the woman unconsciously shifts her upper body back over the pelvis to prevent falling. In this manner stress is placed upon the joints and ligaments of the spine causing inflammation to occur, therefore generating pain. Other postural changes can include exacerbated rolling of the shoulders and forward head movement.

There are various endocrine (hormones) changes that occur during pregnancy, caused primarily by the  hormones; progesterone, oestrogen and relaxin. Fluid retention is one by-product of high levels of hormones during pregnancy – fluid retention in the connective tissue around the body can cause laxity of the joints around the vertebral column or other conditions such as carpal tunnel syndrome. Relaxin is the main influencer of this increase in total body water content which can be up to 6-8 litres in a normal pregnancy. 

Relaxin also causes other changes in the body that can directly relate to low back pain during pregnancy. This hormone, softens the ligaments around the pelvic joints. Though this laxity is necessary for the growing foetus, it can also cause pain by excessive stretching (such as pelvic symphysis dysfunction/ diastasis – also known as PSD or SPD) and exaggerated range of motion of these joints, even more prevalent for those with hyper mobility issues. 

Treatment of Low Back pain and Pubic Symphysis Dysfunction

When discussing the benefits overall of chiropractic care of pregnancy related low back pain Stuber and Smith (2008) conducted a literature review that concluded that chiropractic care is associated with improved outcome of low back pain. 

Following examination the correct course of action must be taken to gain maximal relief for the patient. Treatment options will vary not only on the severity of dysfunction and pain but also on the period of the pregnancy. How far along the pregnancy the patient is will depend on the need of a pregnancy pillow. 

One treatment method that is invaluable for treating pregnant patients is soft tissue work. Very gentle massage and trigger point work can be used to relax down tissues such as the adductors, gluteal muscles. With the diaphragm bordering the foetus superiorly it is important to address any tension and restriction in this tissue, making the gentle diaphragmatic release technique valuable in treatment. 

Along with these soft tissue techniques there is a need to address the affected pelvic and spinal joints during pregnancy. This is dome using very gentle mobilisations and traction techniques with what we like to call “eye ball pressure”.

A usual concern by pregnant women is how they are able to be treated. This can be done fairly easily with some small modifications, most common is we use our “pregnancy pillow” which allows pregnant women to lie on their front. 

Exercise

A study by (Haas et al, 2004) suggests that exercise prior to, during and after pregnancy is associated with better health status. The benefits of exercise and activity during exercise include; decreased chance of preeclampsia, decreased chance of operative delivery, decreased chance of developing gestational diabetes, reduction of pregnancy discomforts (back ache and lower extremity oedema), possible prevention of chronic hypertension and an improved mood. 

The level of exercise during pregnancy is somewhat controlled by the level of exercise being undertaken before pregnancy. It is advised to not exceed a level of exercise prior to that of pregnancy or to consult an appropriate medical practitioner beforehand. There are also contraindications to exercise during pregnancy which are advised by the “American College of Obstetricians and Gynecologists”.

Alongside general exercise there are numerous exercises catered to the needs of a pregnant patient. Stretches such as the cat-camel stretch can help give relief. Gym balls are also useful during pregnancy as a mean of exercise and strengthening core musculature. It is particularly important when using a gym ball to ensure the knees are always below the hips.

Aquatic exercises have also shown benefits to women during pregnancy, with buoyancy having the effect of unloading joints to ease painful movements. It can also help control peripheral oedema, which as discussed is a common condition during pregnancy. 

Strengthening the pelvic floor musculature is advisable as it can allow for a less stressful delivery for the mother and baby as well as reduce the risk of pubic symphysis dysfunction. A study by Morkved at al (2003) demonstrated that participants in a 12 week intensive pelvic floor muscle training program had significantly less urinary incontinence during pregnancy and the 3 months following, reinforcing the importance of pelvic floor exercises. 

Patient Advice

Ice or cryotherapy can be used to reduce inflammation and ease pain. The patient should be instructed on the best method to adopt while using ice as to not do more damage than good. 

Some advice should be given to pregnant patient’s to prevent aggravation of their complaint which are as follows:

Pregnant patients should avoid resting in a sitting position with their knees higher than their hips as this causes the lumbar spine to pelvic brim angle to be reduced. So avoid long car journeys as bucket style seats can have this affect. They should also avoid sitting with legs crossed as reduced space in the anterior pelvis available for the fetus. Also avoid squatting as it can promote an undesirable foetus position. 

With Pubic Symphysis Dysfunction there are other advice that can be given such as:

Adopting good posture and avoiding bending or twisting motions. 

If swimming avoid breaststroke.

Roll in and out of bed.

For more advice, or to speak to a chiropractor contact Backworks on 01702 342329 or check out our post on Advice on Maintaining Your Posture During Pregnancy. We also offer online chiropractic consultations (Telehealth appointments), that are designed for people who are unable to attend the clinic.

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References

Pregnancy and Paediatrics: A chiropractic Approach – Stephen Williams

Jain, S et al (2006) Review Symphysis pubis dysfunction: a practical approach to management. The Obstetrician & Gynaecologist, 8 153-158

Manaco, J.E, (1996) ORTHOPEDIC CONSIDERATIONS IN PREGNANCY. Prime care update. 3: (6)

Sandler. S. (1996). The management of low back pain in pregnancy.Manual Therapy. 4 (1), 178-185.

Borgrenn, C. (2007). Pregnancy and chiropractic: a narrative review of the literature. Journal of Chiropractic Medicine. 6 (1), 70–74.

Borg-Stein. J et al. (2005). Musculoskeletal Aspects of Pregnancy.American Journal of Physical Medicine & Rehabilitation. 84 (3), 180-192.

MacEvilly et al. (1996). Back pain and pregnancy: a review. Pain,. 64 (1), 405-414.

Stuber and Smith. (2008). CHIROPRACTIC TREATMENT OF PREGNANCY-RELATED LOW BACK PAIN: A SYSTEMATIC REVIEW OF THE EVIDENCE.Journal of Manipulative and Physiological Therapeutics. 31 (6), 447-454.

Hall. M et al. (2011). The Heart During Pregnancy. Rev Esp Cardiol.. 64 (11), 1045-1050.

Haas. J et al. (2004). Changes in the Health Status of Women During and After Pregnancy. J GEN INTERN MED . 20 (1), 45-51.

Mørkved. S et al. (2003). Pelvic Floor Muscle Training During Pregnancy to Prevent Urinary Incontinence: A Single-Blind Randomized Controlled Trial. The American College of Obstetricians and Gynecologists. 101 (2), 313-319.

Carlin and Alfirevic. (2008). Physiological changes of pregnancy and monitoring. Best Practice & Research Clinical Obstetrics and Gynaecology. 22 (5), 801-823.

Wadsworth. P. (2007). The Benefits of Exercise in Pregnancy. The Journal for Nurse Practitioners – JNP. 1 (1), 333-338.

Lisi. A. (2006). Chiropractic spinal manipulation for low back pain of pregnancy: a retrospective case series. . J Midwifery Womens Health. 51 (1), 7-10.

Stuber. K. (2007). The safety of chiropractic during pregnancy: A pilot e-mail survey of chiropractors’ opinions. Clinical Chiropractic. 10 (1), 24—35.

Guadagnino, Michael R.. (1999). Spinal manipulative therapy for 12 pregnant patients suffering from low back pain. Chiropractic Technique. 11 (1), 108 – 112.

Seth. S et al. (2003). A severe case of pubic symphysis diastasis in pregnancy. Abstract European Journal of Obstetrics & Gynecology and Reproductive Biology. 106 (1), 230-232.