Chiropractic & Manual Therapies 2014 (Apr 1); 22 (1): 15 ~ FULL TEXT
Cynthia K Peterson, Daniel Mühlemann, Barry Kim Humphreys
Department of Chiropractic Medicine,
Orthopaedic University Hospital Balgrist,
University of Zürich,
BACKGROUND: Low back pain in pregnancy is common and research evidence on the response to chiropractic treatment is limited. The purposes of this study are 1) to report outcomes in pregnant patients receiving chiropractic treatment; 2) to compare outcomes from subgroups; 3) to assess predictors of outcome.
METHODS: Pregnant patients with low back or pelvic pain, no contraindications to manipulative therapy and no manual therapy in the prior 3 months were recruited.Baseline numerical rating scale (NRS) and Oswestry questionnaire data were collected. Duration of complaint, number of previous LBP episodes, LBP during a previous pregnancy, and category of pain location were recorded.The patient's global impression of change (PGIC) (primary outcome), NRS, and Oswestry data (secondary outcomes) were collected at 1 week, 1 and 3 months after the first treatment. At 6 months and 1 year the PGIC and NRS scores were collected. PGIC responses of 'better or 'much better' were categorized as 'improved'.The proportion of patients 'improved' at each time point was calculated. Chi-squared test compared subgroups with 'improvement'. Baseline and follow-up NRS and Oswestry scores were compared using the paired t-test. The unpaired t-test compared NRS and Oswestry scores in patients with and without a history of LBP and with and without LBP during a previous pregnancy. Anova compared baseline and follow-up NRS and Oswestry scores by pain location category and category of number of previous LBP episodes. Logistic regression analysis also was also performed.
RESULTS: 52% of 115 recruited patients 'improved' at 1 week, 70% at 1 month, 85% at 3 months, 90% at 6 months and 88% at 1 year. There were significant reductions in NRS and Oswestry scores (p < 0.0005). Category of previous LBP episodes number at one year (p = 0.02) was related to 'improvement' when analyzed alone, but was not strongly predictive in logistic regression. Patients with more prior LBP episodes had higher 1 year NRS scores (p = 0.013).
CONCLUSIONS: Most pregnant patients undergoing chiropractic treatment reported clinically relevant improvement at all time points. No single variable was strongly predictive of 'improvement' in the logistic regression model.
From the Full-Text Article:
Low back and pelvic pain in pregnant women is such a common phenomenon that it is often
considered a normal part of the pregnancy [1-3]. However, the high prevalence of this
problem (50-80% of women) and the impact that this may have on their quality of life, as
well as the fact that back pain during pregnancy is commonly linked to low back pain
persisting after pregnancy, mandates that it be taken seriously by health care practitioners [1-6].
Many of these patients rate their back pain as moderate to severe with a small percentage
claiming to be significantly disabled by the pain [6-8].
Pregnancy-related low back pain is most often divided into 3 categories based on location.
These are: lumbar spine pain (LP), posterior pelvic pain (PPP), or a combination of these two
[1, 2, 9], with posterior pelvic pain reported to be the most common presentation [1, 10] and the
location most specific for pregnant patients . However, other authors have used 4
categories for pelvic only pain, including anterior pain at the pubic symphysis
(symphysiolysis) but excluding lumbar spine pain .
Although the etiology of low back pain associated with pregnancy is not definitively known,
the predominate theories include biomechanical changes due to the enlarging uterus resulting
in an increasing lumbar lordosis and the influence of the hormone relaxin on stabilizing
ligaments leading to hypermobility of joints [12-14].
The treatment of pregnancy-related low back pain has often been a ‘watch and wait’
approach, as medication use in pregnancy is strongly discouraged in many cases  and it is
assumed that the pain will disappear after delivery. Two recent systematic reviews of the
literature looked specifically at the evidence for chiropractic treatment of pregnancy-related
low back pain and both reviews concluded that there is research evidence demonstrating that
chiropractic care is associated with improved outcomes, but that the evidence is limited due
to the low to moderate quality of the studies [4, 6]. A prospective cohort outcomes study on
pregnant patients with low back pain receiving chiropractic treatment from a single
practitioner published since the systematic reviews evaluated data from 78 patients .
Seventy three percent of that cohort reported ‘good’ or ‘excellent’ out comes from
chiropractic treatment performed by a single chiropractor and his physical therapist.
However, the outcomes varied depending upon the specific location of the pain.
Finally a prospective randomized trial was published in 2013 which compared routine
obstetrical care for pregnant patients suffering from low back pain with chiropractic treatment
consisting of manual therapy, stabilization exercises and patient education . The
chiropractic treatment group reported statistically and clinically significant improvement
compared to patients in the routine obstetrical care group. However, outcome data was only
collected between 5 and 9 weeks after the baseline data and prior to delivery of the baby.
Additional research is therefore needed from a larger number of chiropractors to assess
outcomes as would be obtained in routine chiropractic practice and to follow the patients for
a longer time period. Furthermore, it is desirable to see if factors associated with
improvement or failure to improve identified in previous studies will also be found in this
current study . Thus, the purposes of this study are 1) to report out comes at various time
points up to 1 year in pregnant patients undergoing chiropractic treatment for low back and
pelvic pain; 2) to compare outcomes from various subgroups of patients; and 3 to investigate
the various demographic factors as predictors out outcome.
This is a prospective, cohort, outcomes study. Patients with baseline and 1 year data are
included in the study. Cantonal ethics approval was obtained prior to the start of the study
and all patients signed informed consent.
Pregnant patients over the age of 18 with low back pain, pelvic pain, or both of any duration
who have not undergone chiropractic or manual therapy in the prior 3 months were recruited
from chiropractic practices in Switzerland. All chiropractors in the German and French
speaking regions of the country were invited to submit patients but 2 multi-clinician practices
in particular that receive a high number of referrals from gyaecologists were targeted
specifically. These two practices were asked to recruit all consenting pregnant patients.
Patients with specific pathologies of the lumbar spine that are contraindications to
chiropractic manipulative treatment, such as tumors, infections, inflammatory spondylarthropathies,
acute fractures, Paget’s disease and severe osteoporosis, were excluded.
Chiropractic treatment was not standardized to any specific treatment methods or frequencies
and was left to the discretion of the treating clinician. However, it is known from the Swiss
job analysis study that the Diversified method of high velocity, low amplitude spinal
manipulative therapy (SMT) is the most common SMT method used in this country .
Baseline data and outcome measures
The numerical rating scale (NRS) for pain, where 0 = no pain and 10 = the worst pain
imaginable, and the Oswestry questionnaire, which has been validated in German and French
[19, 20] were administered to the patient immediately prior to the first treatment by the office
staff of the practice. Additional information provided by the treating chiropractor at the initial
consultation included: patient age, gestational week, number of previous pregnancies, work
status, whether or not the patient smokes, duration of current complaint, number of previous
LBP episodes, LBP during a previous pregnancy (yes/no), location category of pain (lumbar
pain only (LP), pelvic pain only (PP), both areas) and exercise level (regular, occasional,
none). The number of previous episodes of LBP was further categorized into one of three
groups: None, 1 – 4 episodes, =5 episodes.
One week after the first consultation/treatment, data from the NRS, patient’s global
impression of change (PGIC) scale, and the Oswestry questionnaire were collected from the
patient via a short telephone interview. Similarly, these same data were collected at 1 month
and 3 months after the start of chiropractic treatment via telephoneinterviews. At 6 months
and 1 year after the first chiropractic treatment, the NRS and PGIC scores were collected, but
not the Oswestry data. These telephone interviews were conducted by trained research
assistants at the university, unknown to the patients or clinicians. The PGIC scale was a 7
point verbal scale, including the options ‘much worse’, ‘worse’, ‘slightly worse’, ‘no
change’, ‘slightly better’, ‘better’, and ‘much better’. Patients responding ‘better or ‘much
better’ were categorized as ‘improved’ and all other patients as ‘not improved.’ This was
considered the primary outcome measure. Additionally, one question was included on the 1
year follow-up data collection concerning the patient satisfaction with their treatment. The
options included: ‘very happy’, ‘happy’, ‘neutral’, ‘unhappy’ and ‘very unhappy’.
The time frame within which each data collection telephone interview was allowed was
narrow. If a patient could not be reached within the window of time allowed, that data
collection time point was missed but the patient remained in the study. However, if 3
consecutive data collection telephone interviews were missed, the patient was deleted from
Descriptive statistics were calculated. The proportion (%) of patients improved at each data
collection time point was calculated. Subgroup analysis was carried out using ‘improved’ or
‘not improved’ as categorical variables. The chi-squared test was used to compare the
presence/absence of LBP during a previous pregnancy, category of the number of previous
episodes of LBP, and the category of the location of LBP with ‘improvement’. The scores on
the baseline and follow-up NRS for pain and Oswestry questionnaire were compared using
the paired t-test. The unpaired t-test was used to compare NRS and Oswestry scores in
patients with and without a prior history of LBP and for patients with and without LBP
during a previous pregnancy. Anova was used to assess for differences in baseline and
follow-up NRS and Oswestry scores by location category of the LBP and category of the
number of previous episodes of LBP. NRS and Oswestry change scores were also calculated
for each follow-up time period compared to the baseline scores.
Logistic regression analysis was also performed to determine statistically significant
predictors of improvement using the 10 baseline variables (age, number of previous
pregnancies, chronicity category, history of LBP, LBP during a previous pregnancy,
gestational week, location category for LBP, work status, exercise level category, smoking
status) at 1 month, 3 months, 6 months and 1 year after start of treatment. The full model
containing all predictors was also assessed for statistical significance and ability to
distinguish between patients who improved or did not improve as well as the proportion of
correctly classified cases.
Baseline and 1 year data were available on 115 patients. In order to obtain 1 year outcomes
data on these 115 patients, 143 were enrolled with baseline data. Seven of these 143 patients
requested to drop out of the study prior to the 1 year data collection time point and 28 other
patients were not able to be contacted for 3 consecutive telephone data collection time
periods. Thus they were deleted from the study. The patients came from a total of 15 different
chiropractors. One hundred of the 115 patients came from the 2 practices specifically
targeted. One of these sites has 4 chiropractors and the other 3 and all referred pregnant
patients to the study.
The mean patient age was 32.96 (SD = 4.64) years and the mean gestational week was 26.21
(SD = 6.98). Table 1 shows the results of the various baseline demographic factors. A slight
majority of patients (53.1%) were in their 3rd trimester of pregnancy (Table 1) and thus would
have delivered their babies by the 3 month follow-up time point. There was a fairly even
distribution in the percentage of patients complaining of lumbar pain only, pelvic pain
only or a combination of the two areas. Of the 53 patients who had at least one previous pregnancy,
31 (58%) reported having experienced back pain during the previous pregnancies.
Over half of the patients reported clinically relevant ‘improvement’ at 1 week, with the vast
majority ‘improved’ at all subsequent data collection time points (Table 2). Statistically
significant reductions in NRS and Oswestry scores (p < 0.0005) at all follow-up time points
compared to the baseline scores was also noted (Table 2). Comparing the category of the
number of previous episodes of LBP with ‘improvement’ found a significant relationship at 1
week (p = 0.035) and especially at 1 year (p = 0.02). Patients who ‘improve’ have fewer
episodes of prior LBP. Patients with more previous episodes (=5, n = 29) of LBP also had
significantly higher 1 year NRS scores with a mean of 2.16 (SD = 2.36) compared to a score
of 0.60 (SD = 1.07) for patients with no prior LBP history (n = 30) (p = 0.013). Patients who
reported having LBP in a previous pregnancy had significantly lower baseline NRS scores
(5.22, SD = 2.10) compared to those who did not have LBP in a previous pregnancy (6.35,
SD = 1.84) (p = 0.01). However, there was no significant difference in the NRS scores
between these two groups at any follow-up time point. There was no significant link between
the category of location of LBP (i.e. low back pain only, pelvic pain only, or both) and
‘improvement’ at any of the follow-up time points.
Percentage of Patients with the
various baseline demographic factors
Baseline and outcome data for all
patients at the various time points
At 1 year, 85.2% of patients (n = 98) were ‘very happy’ or ‘happy’ with their chiropractic
treatment and 6% (n = 7) were ‘unhappy’.
Logistic regression analysis using the 10 independent variables (Table 1) compared to the
primary outcome of ‚improvement‘ showed that the full model was statistically significant,
X2 (5, N = 115) = 40.71, p < 0.009 at 1 month, indicating that the model could distinguish
between patients ‘improved’ and ‘not improved’. Between 55.7% and 79.0% of the variability
is explained by this set of variables at 1 month after start of treatment. However,
no single independent variable made a unique statistically significant contribution to the
model. Additionally, at 3 months, 6 months and 1 year the model was not statistically
significant as the vast majority of patients were ‘improved’.
The results of this current study which showed that a high proportion of pregnant patients
with LBP undergoing chiropractic treatment reported clinically relevant ‘improvement’
support those published in a recent cohort study as well as the recent randomized clinical trial
(RCT) looking at chiropractic treatment for pregnant patients with low back or pelvic pain
[16, 17]. The most recent systematic reviews of the literature for interventions for preventing
and treating pelvic and back pain in pregnancy  and more specifically chiropractic
treatment for these patients [4, 6] unanimously concluded that the available research evidence
at that time was low to moderate quality at best. However, these reviews were published prior
to the cohort study by Murphy et al published in 2009  and the excellent RCT by George
et al published in 2013 .
In the RCT by George et al. one treatment arm of the trial on pregnant women suffering from
LB, PP or both included treatment by a chiropractor. The results clearly showed a statistically
and clinically significant greater level of improvement for the patients who received the
additional chiropractic treatment . However, outcomes in that RCT were only measured
at one time point between 5 and 9 weeks after the start of treatment and while the patients
were still pregnant whereas this current study measured outcomes at 5 different and
consistent time points during the pregnancy and after delivery. Comparing the baseline scores
between this current cohort study with the baseline scores for the patients in the RCT who
were treated with chiropractic shows that they were nearly identical, including the standard
deviations (5.8 +/- 2.2 in the RCT, 6.07 +/- 1.91 in this current study). Additionally, the mean
gestational weeks were also nearly identical in the two studies. Comparing the 1 month NRS
pain scores in this current study with the NRS scores in the RCT measured between 5 and 9
weeks after the start of treatment for those patients in the treatment arm that received
chiropractic treatment also shows that they are nearly identical. The NRS change score in the
RCT was 2.9 and in this cohort study it was 3.06 . When looking at the mean NRS score
at 3 months after the first treatment in this current study it is less than 1/3 of the original
baseline score. However, approximately half of the patients would have delivered their babies
by this 3 month data collection time point and this likely had a positive impact on this
outcome. Therefore, although this cohort study is not a randomized clinic al trial and thus the
outcomes cannot be attributed to the chiropractic treatment, the strong similarity between
these results and those from the recently published RCT supports their validity.
Comparing the outcomes from this study on Swiss patients with those from a very similarly
designed outcomes study on patients in the United States (US) , shows that they are also
quite similar. At 1 month after the start of treatment 70% of the patients in this current study
reported clinically relevant improvement of ‘much better’ or ‘better’ compared to 73% of
patients in the Murphy et al  study. However, the precise time of their outcome data
collection is not specified. It was done at the end of active treatment, and this time frame
varied between patients. By 3 months after the start of treatment 85% of the patients in this
current study reported being clinically significantly improved. It is important to point out that
the option ‘slightly better’ on the PGIC scale was not considered clinically relevant
improvement in this current study and these patients were classified as unchanged.
Unfortunately it is not possible to compare disability scores or other quality of life factors
between these two studies because the Murphy et al paper used the Bournemouth
questionnaire  whereas our current study used the Oswestry pain and disability
questionnaire. The Bournemouth questionnaire would have been a better choice as an
outcome measure for these types of patients as it measures more relevant domains, including
psychosocial factors, compared to the Oswestry questionnaire. However, at the time that this
current study was conducted the Bournemouth questionnaire was not yet translated and
validated into German so could not be used whereas the Oswestry questionnaire had been
translated and validated into both German and French.
Another relevant, although perhaps not surprising finding from this current cohort study
includes the fact that patients who reported a higher number of previous LBP episodes
(=5) were less likely to report clinically relevant improvement, particularly at 1 year after the first
treatment. However, this factor was not predictive in the logistic regression model. This is
consistent with other studies that show that back pain is commonly recurrent [21-23].
However, the location category of the LBP (LB, PP, both) in this current study was not linked
with the likelihood of improvement at any data collection time point nor in the logistic
regression model. This is different from what Murphy et al  found. They reported that
patients with pain in both areas were significantly less likely to report clinically significant
improvement in disability, at least in the short-term, compared to the other two groups.
Furthermore, the majority of patients in the Murphy et al  study had posterior pelvic pain
(58.3%) whereas the location of the LBP in this current Swiss study was quite evenly
distributed between the three locations, with approximately 1/3 of the patients reporting
pelvic pain. Another difference between the Murphy et al  study and this current one is
that Swiss patients with a history of LBP during a previous pregnancy did not have worse
outcomes compared to patients without LBP in a prior pregnancy whereas US patients
without LBP in a previous pregnancy were more likely to report improvement compared to
US patients with LBP in a previous pregnancy. Reasons for the differences in these outcomes
between US and Swiss patients can only be speculated upon. Obesity is much more common
in the US than in Switzerland and this may result in a higher proportion of women
experiencing both LBP and pelvic pain during pregnancy as this could further increase the
lumbar lordosis and place additional stresses on the pelvic joints .
The literature states that 94% of women who have LBP in a previous pregnancy have
recurrent pain with subsequent pregnancies . However, in this current cohort study only
58% of the patients who had experienced a previous pregnancy reported that they had
suffered from back pain at that time. The reason for this discrepancy in proportions is
unclear. It is also somewhat surprising that patients with more episodes of previous LBP have
worse outcomes at the 1 week and 1 year time points but not at the 1, 3 and 6 month time
points. Obviously at the 1 year data collection point all patients would have delivered their
babies several months before and would likely then fall into the category of ‘usual’ low back
pain patients where recurrence is not unusual.
No serious adverse events were reported in this study and over 85% of the patients were
happy or very happy with their chiropractic treatment. Adverse events from spinal
manipulation to pregnant women or those in the early post-partum period are very rare with
only 7 cases found in the literature . All seemed to be related to treating the cervical spine
rather than the low back however, and the practitioners involved included chiropractors, a
physiotherapist, and a general medical practitioner. A recent qualitative study evaluating the
treatment experience of pregnant women under chiropractic care reported that chiropractors’
approach to these patients is patient-centered rather than symptom centered . This may
explain why such a high percentage of the patients in this current study were happy with their
Some of the limitations to this study have been alluded to above. Because this is a cohort
study without a control group or other treatment group for comparison, the outcomes reported
cannot be assumed to arise from the treatment. Additionally, the patients in this study were
treated primarily at two practice sites but by different chiropractors and the details of the
types of treatments and treatment dosage are not known. No attempt was made to compare outcomes
by practitioner or style of treatment. This would be interesting for future studies.
As previously stated, the use of the Oswestry questionnaire was not the best choice for this
patient population, but was the best available that was translated and validated in both
German and French. Additionally, the assessment of symphysis pubis pain in these pregnant
patients was not specifically assessed as it was desired to use those same categories of low
back pain in pregnancy that previous papers used in order to make direct comparisons.
A large proportion of pregnant patients with LBP or pelvic pain under going chiropractic
treatment report clinically relevant improvement in their symptoms at all time points up to 1
year. There is a relationship between the number of prior episodes of LBP and ‘improvement’
with patients reporting more episodes being less likely to improve. However, this was not a
strong predictor of ‚improvement‘ when placed into a logistic regression model.
LBP: Low back pain;
LP: Lumbar spine pain;
NRS: Numeric rating scale for pain; PGIC: Patient’s global impression of change;
PPP: Posterior pelvic pain;
SD: Standard deviation;
SMT: Spinal manipulative therapy
The authors declare that they have no competing interests.
CP: Ethics approval submission, Literature search, data entry, ana lysis and interpretation of
data, drafting and revising the manuscript, final approval of the manuscript. DM: Patient
recruitment, baseline data collection, patient treatment, final approval of the manuscript.
BKH: Concept and design of the study, manuscript preparation and final approval of the
manuscript. All authors read and approved the final manuscript.
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