J Clinical Chiropractic Pediatrics 2010 (Dec); 11 (2): 775—779 ~ FULL TEXT
Maria C. Browning, BSc, DC, MSc
Anglo-European College of Chiropractic, UK
Introduction: Low back and pelvic girdle pain are common and disabling conditions during pregnancy. Chiropractors are in a unique position to diagnose various pain syndromes with reliable clinical tests and offer a variety of treatments that are safe for both mother and fetus.
Objective: This paper explores the current evidence base on low back and pelvic girdle pain of pregnancy with recommendations for diagnosis and clinical management.
Discussion: Clinical tests used by chiropractors are reliable and a number of treatment techniques are available for the different low back and pelvic girdle pain syndromes of pregnancy.
Conclusion: Treating the pregnant patient can be challenging and it is realistic for the goal to be supportive care and keeping quality of life static due the constantly changing dynamics of pregnancy.
Key words: chiropractic, pelvic girdle pain, low back pain, symphysis pubis dysfunction
Pregnancy should be a joyful time but can quickly turn
into a miserable experience for women who have back or
pelvic girdle pain and their quality of life can be seriously
affected. This article will explore the validity of clinical tests,
manual therapy techniques and exercises for low back pain
(LBP) and pelvic girdle pain (PGP) in pregnancy in order
to maintain optimal function.
LBP is usually defined by pain between the 12th rib
and the gluteal fold, whilst pelvic girdle pain is defined as
pain experienced between the posterior iliac crest and the
gluteal fold, particularly in the vicinity of the sacroiliac
joints. The pain may radiate in the posterior thigh and can
also occur in conjunction with or separately in the symphysis.
The incidence of pelvic girdle pain in pregnancy is
about 20%. [1, 2] If low back pain is included, this figure rises
to 84%.  Pelvic girdle pain can be further subdivided into
pelvic girdle syndrome (daily pain in all three pelvic girdle
joints) which affects 29.7% of pregnant women with pelvic
girdle pain, symphysis pubis pain which affects 11.6%,
one-sided sacroiliac pain which affects 27.3% and bilateral
sacroiliac pain which affects 31.4%.  Significant risk
factors for developing low back pain or pelvic girdle pain
in pregnancy are previous low back pain or pelvic girdle
pain and/or previous trauma to the pelvis. [1, 2] Predictors for
having persistent pelvic girdle pain or combined pain after
delivery are low endurance of back flexors, older age, combined
pain in early pregnancy and work dissatisfaction. 
Pelvic girdle pain during pregnancy has a significant effect
on quality of life as the endurance capacity for standing,
walking, and sitting is diminished. This is particularly so in
the third trimester when the disability rating index (DRI)
is significantly higher compared with pregnant women
with low back pain only and pregnant women without
pain. The highest DRI is found in women with bilateral
posterior pelvic pain plus symphysis pubis pain Women
with pelvic pain in more than one location report more
frequent use of crutches. 
Why do so many women experience low back or pelvic
girdle pain during pregnancy? There has been much discussion
in the literature on the role of relaxin, previously
thought to be involved in the etiology of pregnancy-related
PGP. Early studies concluded that an increased concentration
of serum relaxin was a risk factor.  However, this correlation
has not been confirmed by subsequent studies. [7, 8]
The anatomy of the sacroiliac joint leads to the highest
coefficient of friction of diarthrodial human joints. This
friction can be altered according to the loading situation
along with nutation of the sacrum, resulting in functional
adaptations to stabilize the pelvic girdle. 
Therefore, it is likely that the postural adaptations of pregnancy result in
increased friction and loading on the sacroiliac joints.
Chiropractors have a range of clinical tests to assess low
back and pelvic girdle pain. Which tests are most optimal
for evaluating the various low back and pelvic girdle pain
syndromes of pregnancy? The following tests are recommended
by the European guidelines for the diagnosis of
pelvic girdle pain.  A description of these tests can be found in Appendix 1.
The most reliable tests to identify pain originating from the sacroiliac joints are:
- the posterior pelvic pain test (thigh thrust or P4),
- Patrick Faber test,
- tenderness on palpation of the long dorsal sacroiliac ligament
- Gaenslens test.
The most reliable tests to identify pain originating from the symphysis pubis are:
- tenderness on palpation of the symphysis pubis
- modified Trendelenberg test.
A reliable test for pelvic function and stability is the
active straight leg raise (ASLR). Women with pregnancy-related
low back and pelvic girdle pain use significantly
more effort during ASLR than pregnant women without
pain. At both 0cm and 20cm leg raise height they have
less hip flexion force and develop more muscle activity.
Therefore, the ASLR demonstrates disturbed load across
the sacroiliac joints in pregnant women with pregnancy-related
low back and pelvic girdle pain. 
The sensitivity and specificity of these tests are depicted
in Tables 1, 2 and 3. Worthy of note is that a bilateral
positive P4 corresponds to a higher DRI than a unilateral
or negative P4. Additionally, there is a significantly higher
DRI if the ASLR is more than 0. 
Pain provocation test of the sacroiliac joints
Pain provocation tests of the symphysis pubis
Functional tests of the pelvic girdle
What is the most effective treatment for reducing pain
and disability in pregnant patients with low back or pelvic
girdle pain? The following management techniques are
recommended by the European Guidelines for the treatment
of pelvic girdle pain. 
The use of spinal manipulative therapy during pregnancy
to reduce back pain and other related symptoms is
supported by limited evidence.  A systematic review of 6
studies concluded that chiropractic care is associated with
improved outcomes in pregnancy-related low back pain
and pelvic girdle pain. 
Specific stabilizing exercises
There is evidence that specific muscle strengthening
exercises (focusing specifically on stabilizing exercises for
control and stability), with advice on activities of daily living,
result in a significant reduction in pain. However, use
of a rigid or non-rigid pelvic support belt does not add to
the effects provided by exercise and advice. 
There is limited evidence that water aerobics diminishes
pregnancy related low back pain and sick leave due
to pregnancy-related low back pain more than a land-based
physical exercise program.  Nonetheless, regular
water aerobics can result in significantly fewer requests
for analgesia during labor and is a low risk exercise
during pregnancy. However, there is no influence on maternal
cardiovascular capacity, duration of labor or type
of delivery. 
There is some evidence that acupuncture, combined
with stabilizing exercises, results in less pelvic girdle pain
and may be a useful addition to a combined management
program.  However, it should be noted that although no
serious adverse events have been reported with the use of
acupuncture during pregnancy, there is a risk of mild adverse
events (painful treatment, headache and drowsiness,
rash, nausea with feeling faint, sweating and dizziness) on
the day of the treatment. 
Chiropractic care is safe during pregnancy although
there are some suggested modifications. Adjustments
should be low-force (remember that relaxin is present from
the first trimester to 3 months postpartum.) The patient
should experience no abdominal pressure. The practitioner
should make sure that the uterus is supported when the
patient is side-lying and flex the hip less than usual when
doing side posture techniques.
The author uses the following techniques with a good
rate of success in reducing pain and restoring optimal function
for the pregnant patient so that she can continue her
activities of daily living in comfort. However, it is realistic for
the goal to be supportive care and keeping quality of life static
due to the constantly shifting dynamics of pregnancy.
Treatment of Symphysis Pubis Dysfunction (SPD)
This can occur from the first trimester and ranges
from mildly to severely disabling. Some women have extreme
difficulty walking and need to use crutches. It can
have a detrimental effect on most activities of daily living.
Chiropractors can manage the pain but it often does not
resolve completely until after the birth. There are direct and
indirect treatment methods for SPD that the chiropractor
can utilise. Direct treatment includes use of the activator
on the inferior or superior pubic ramus. Indirect treatment
includes correction of any sacroiliac joint restrictions, symphysis
pubis mobilization and myofascial techniques.
The sacroiliac joints can be adjusted either in side
posture or with a prone drop whilst lying on a pregnancy
pillow. However, the author has found that utilizing the
drop piece with the patient supine and contacting the ASIS
gives good results too. It is also less alarming for the patient.
The patient is supine with knees bent and feet flat on the
couch. The chiropractor is at the foot of the table on the
side of SIJ restriction. Reassure the patient that no pressure
will be exerted on the baby but only on the side of the pelvis
and that this is a safe and gentle technique. Contact the
ASIS with the thenar eminence and the indifferent hand
contacts the patient’s posterior thigh on the same side. Lift
the hip into slight flexion and apply a drop over the ASIS
in an anterior to posterior with slight inferior to superior
direction. Repeat a further 1-2 times.
Symphysis pubis mobilization is as follows. The patient
is supine with both knees flexed and feet flat on the couch.
The chiropractor tests whether resisted hip abduction or
adduction causes pain over the symphysis pubis. If adduction
is the less painful of the two, the chiropractor places
the palms of both hands on the medial knees and asks the
patient to push her knees together against mild resistance.
The chiropractor then releases their hands. If abduction is
the less painful of the two, the chiropractor places the palms
of both hands on the lateral knees and asks the patient to
push her knees apart against mild resistance. The chiropractor
then releases their hands. The author has found that
abduction is more often the most painful.
Myofascial techniques should include the round ligament,
the long dorsal sacroiliac ligament, sacrotuberous
ligament, gluteal muscles and piriformis. The long dorsal
sacroiliac ligament has close anatomical relations with the
erector spinae muscle, the posterior layer of the thoracolumbar
fascia, and a specific part of the sacrotuberous
ligament. Functionally, it is an important link between legs,
spine, and arms. The ligament is tensed when the sacroiliac
joints are counternutated and slackened when nutated.
Slackening of the long dorsal sacroiliac ligament can be
counterbalanced by both the sacrotuberous ligament and
the erector muscle. 
Treatment of coccydynia
A couple of useful techniques for the chiropractor are
the gluteal squeeze and coccygeal pump. For the gluteal
squeeze, the patient lays prone and squeezes her buttocks together
tightly. The chiropractor resists by pushing outwards
with their hands in a cross-bilateral position then suddenly
releasing. This can also be given as a home exercise with the patient using their own hands to resist. The coccygeal
pump is done in the same way as the sacral pump but the
middle finger of the contact hand lies along the coccyx to
encourage flexion and extension.
For correction of coccygeal laterality, contact (with
activator or thumb) immediately lateral to the base of
the coccyx. The line of drive is lateral and superior. Avoid
direct contact with the coccygeal apex as it is exquisitely
Round ligament syndrome
This is characterised by a sudden, sharp pain in the
abdomen and/or groin. It occurs from sit to stand and
with hip extension. After the 5th month of pregnancy the
round ligament is palpable and is released by holding it
as a trigger point. Always check the SIJ’s and correct any
Other techniques used by the author for pelvic girdle
pain include the Webster technique, side-lying position,
standing sacral release and orthopedic blocking.
The Webster technique was developed by a chiropractor
particularly for the pregnant patient with a breech
presentation and to address intrauterine constraint. [18, 19] A
practice-based study in the USA reported that the Webster
technique is 69% effective with the greatest changes
observed in frank breech presentations.  It is a useful
technique but not in isolation. More satisfying results
are obtained when it is used in combination with other
Most pregnant patients find the side-lying position
very comfortable as a general stretching technique for the
pelvic girdle. The chiropractor stands in front of the patient
with legs against the couch at the level of the patient’s belly.
Contact over the lateral pelvis. Ask the patient to drop
the top leg off the bed and support the pelvis to resist any
forward roll of the body. Apply gentle pressure in a lateral
to medial direction.
The standing sacral release is indicated for the nutated
sacrum. The patient stands with both hands against the wall
as if they are going to be “frisked”. The chiropractor supports
the belly with the indifferent hand and slides the heel
of the other hand down the sacrum from superior to inferior.
If the sacrum is not nutated, the hand slides smoothly
down to towards the apex. However, if the hand ‘catches’
then the sacrum is in pronation. Apply a light pressure in a
superior to inferior and posterior to anterior direction until
the hand slides smoothly down the sacrum.
How often should the chiropractor treat a pregnant
patient? The author finds that twice a week for three weeks
then once a week for two to three weeks works well. It
depends on the gestation week on initial consultation and
whether they have pain in more than one location. Once
they reach 30 weeks, they are seen once or twice a week to
maintain optimal function until the birth.
There is evidence that low back and pelvic girdle pain
can be assessed with reliable clinical tests and treated with
a combination of manual therapy and specific exercises to
reduce pain and disability during pregnancy.
Adapted from the European guidelines for the
diagnosis and treatment of pelvic girdle pain. 2
Active straight leg raise test
The patient lies supine with straight legs and the
feet 20 cm apart. The test is performed after the instruction:
“Try to raise your legs, one after the other, above
the couch for 20 cm without bending the knee”. The
patient is asked to score any feeling of impairment (on
both sides separately) on a 6-point scale: not difficult
at all = 0; minimally difficult = 1; somewhat difficult =
2; fairly difficult = 3; very difficult = 4; unable to do =
5. The scores on both sides are added so that the sum
score can range from 0 to 10.
The patient, lying supine, flexes the hip/knee and
draws it towards the chest by clasping the flexed knee
with both hands. The patient is then shifted to the
side of the examination table so that the opposite leg
extends over the edge while the other leg remains flexed.
The examiner uses this manoeuvre to gently stress both
sacroiliac joints simultaneously. The test is positive if
the patient experiences pain (either local or referred)
on the provoked side.
Long dorsal sacroiliac ligament (LDL) test
The patient lies on her side with slight flexion in
both hip and knee joints. If the palpation causes pain
that persists for more than 5 seconds after removal of the
examiner’s hand it is recorded as pain. If the pain disappears
within 5 seconds it is recorded as tenderness.
Modified Trendelenburg’s test
The patient stands on one leg and flexes the hip and knee at 90 degrees. If pain is experienced in the
symphysis the test is considered positive.
Patrick’s Faber test
The patient lies supine: one leg is flexed, abducted,
and externally rotated so that the heel rests on the
opposite knee. The examiner presses gently on the
superior aspect of the tested knee joint. If pain is felt
in the sacroiliac joints or in the symphysis the test is
Posterior pelvic pain provocation test
The test is performed supine and the patient’s
hip flexed to an angle of 90 degrees on the side to
be examined: light manual pressure is applied to the
patient’s flexed knee along the longitudinal axis of the
femur while the pelvis is stabilized by the examiner’s
other hand resting on the patients contralateral superior
anterior iliac spine. The test is positive when the
patient feels a familiar well localized pain deep in the
gluteal area on the provoked side.
A similar test is described as the posterior shear or
“thigh thrust” test.
Symphysis pain palpation test
The patient lies supine. The entire front side of
the pubic symphysis is palpated gently. If the palpation
causes pain that persists for more than 5 seconds after
removal of the examiner’s hand, it is recorded as pain.
If the pain disappears within 5 seconds it is recorded
Albert H, Godskesen M, Westergaard J.
Incidence of four syndromes of pregnancy-related pelvic joint pain.
Vleeming A, Albert H, Ostgaard HC, Sturesson B, Stuge B.
European guidelines for the diagnosis and treatment of pelvic girdle pain.
Eur Spine J 2008;17:794-819
Bastiaanssen JM, de Bie RA, Bastiaenen CH,
Heuts A, Kroese ME, et al.
Etiology and prognosis of pregnancy-related pelvic girdle pain; design of a longitudinal study.
BMC Public Health 2005;5:1
Gutke A, Ostgaard HC, Oberg B.
Predicting persistent pregnancy-related low back pain.
Robinson HS, Mengshoel AM, Bjelland EK, Vollestad N.
Pelvic girdle pain, clinical tests and disability in late pregnancy.
Man Ther 2010;15:280-285
Kristiansson P, Svardsudd K, von Schoultz B.
Serum relaxin, symphyseal pain, and back pain during pregnancy.
Am J Obstet Gynecol 1996;175(5):1342-7
Hansen A, Jensen DV, Larsen E,
Wilken-Jensen C, Pedersen LK
Relaxin is not related to symptom-giving pelvic girdle relaxation in pregnant women.
Acta Obstet Gynecol Scand 1996;75:245-249
Albert H, Godskesen M, Westergaard JG, Chard T, Gunn L .
Circulating levels of relaxin are normal in pregnant women with pelvic pain.
Eur J Obstet Gynecol Reprod Bio 1997; 74:19-22
de Groot M, Pool-Goudzwaard AL, Spoor CW, Snijders CJ.
The active straight leg raising test (ASLR) in pregnant women: Differences in muscle activity and force between patients and healthy subjects.
Man Ther 2008;13:68-74
Khorsan R, Hawk C, Lisi AJ, Kizhakkeveettil A.
Manipulative therapy for pregnancy and related conditions: a systematic review.
Obstet Gynecol Surv 2009;64(6):416-27
Stuber KJ, Smith DL.
Chiropractic treatment of pregnancyrelated low back pain: a systematic review of the evidence.
Depledge J, McNair PJ, Keal-Smith C, Williams M.
Management of symphysis pubis dysfunction during pregnancy using exercise support belts.
Phys Ther 2005;85(12):1290-1300
Granath AB, Hellgren MS, Gunnarsson RK.
Water aerobics reduces sick leave due to low back pain during pregnancy.
Baciuk EP, Pereira RI, Cecatti JG, Braga AF, Cavalcante SR
Water aerobics in pregnancy: cardiovascular response, labor andneonatal outcomes.
Reprod Health 2008; 5:10
Elden H, Ladfors L, Olsen MF, Ostgaard HC, Hagberg H.
Effects of acupuncture and stabilising exercises as adjunct to standard treatment in pregnant women with pelvic girdle pain: randomised single blind controlled trial.
Elden H, Ostgaard HC, Fagevik-Olsen MF, Ladfors L, Hagberg H.
Treatments of pelvic girdle pain in pregnant women: adverse effects of standard treatment, acupuncture and stabilising exercises
on the pregnancy, mother, delivery and the fetus/neonate.
BMC Comp Altern Med 2008;8:34
Vleeming A, Pool-Goudzwaard AL, Hammudoghlu D,
Stoeckart R, Snijders CJ, Mens J M.
The Function of the Long Dorsal Sacroiliac Ligament: Its Implication for Understanding Low Back Pain.
Application of the Webster in-utero constraint technique: a case series.
J Clin Chiro Ped 1998;3:211-6
The Webster Technique: A Chiropractic Technique With Obstetric Implications
J Manipulative Physiol Ther 2002 (Jul); 26 (6): E1—9
Alcantara J, Ohm J.
“The Webster Technique: Results from a chiropractic practice-based research program”;
accepted for poster presentation at the
ACNM annual meeting in Boston, May 2008
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