Obstet Gynecol Surv 2009 (Jun); 64 (6): 416–427 ~ FULL TEXT
Raheleh Khorsan, MA, Cheryl Hawk, DC, PhD, Anthony J. Lisi, DC,
and Anupama Kizhakkeveettil, BAMS, MAOM
Military Medical Research and Integrative Medicine,
Corona del Mar,
California 92625, USA
Objective: The objective of this review is to evaluate the evidence on the effects of Spinal Manipulative Therapy (SMT) on back pain and other related symptoms during pregnancy.
Data sources: A literature search was conducted using Pubmed, Manual, Alternative and Natural Therapy Index System, Cumulated Index to Nursing and Allied Health, Index to Chiropractic Literature, the Cochrane Library, and Google Scholar. In addition hand searches and reference tracking were also performed, and the citation list was assessed for comprehensiveness by content experts.
Methods of study selection : This review was limited to peer-reviewed manuscripts published in English from 1966 until September 2008. The initial search strategy yielded 140 citations of which 12 studies were reviewed for quality.
Tabulation, integration, and results: The methodological quality of the included studies was assessed independently using quality checklists of the Scottish Intercollegiate Guidelines Network and Council on Chiropractic Guidelines and Practice Parameters. The review indicates that the use of SMT during pregnancy to reduce back pain and other related symptoms is supported by limited evidence.
Conclusion: Overall, this body of evidence is best described as emergent. However, since effective treatments for pregnancy-related back pain are limited, clinicians may want to consider SMT as a treatment option, if no contraindications are present.
Target audience: Obstetricians & Gynecologists, Family Physicians
Learning objectives: After completion of this article, the reader should be able to describe the concepts of spinal manipulative therapy and types of symptoms for which it might be considered in pregnancy, explain the quality of available research on the use of spinal manipulative therapy, and plan to discuss this therapy with interested pregnant patients.
From the Full-Text Article:
It is estimated that 50% to 80% of women experience
some form of musculoskeletal pain or related
symptom during their pregnancy, which in some
cases may become chronic. [1–3] Skaggs et al identified
pregnancy-related pain at 3 major sites: low
back pain, pelvic girdle pain, and mid-back pain.
About two-thirds of all pregnant women report back
pain sometime during their pregnancy. Pregnancyrelated
pain is linked to sleep disturbance and negatively
influences the patient’s quality of life. 
The structural, postural, and hormonal changes that
occur during pregnancy may contribute to pregnancyrelated
back and pelvic girdle pain. These changes
include postural adaptations as the pregnancy
progresses and the production of the hormone relaxin,
which causes joints and ligaments to be more
pliant. Previous history of back pain or injury may
increase the risk of developing back and pelvic girdle
pain during pregnancy. However, most studies have
not been able to identify any single risk factor, etiology,
or pathogenesis for developing any kind of
back or pelvic girdle pain in pregnancy. 
Treatment options for back pain, pelvic girdle pain,
and related symptoms during pregnancy are limited.
Many medications used to treat pain are not recommended
for use during pregnancy. Some patients are
instructed to limit weight gain, exercise to strengthen
the back muscles, maintain correct posture, and wear
comfortable shoes. In one survey of underserved
pregnant women in the United States, 85% perceived
that they had not been offered treatment for their
musculoskeletal disorders, and the care that they
were provided was not satisfactory.  Alternative or
complementary treatments such as massage or spinal
manipulation may also provide some relief.
SPINAL MANIPULATION AS A THERAPEUTIC INTERVENTION
Spinal Manipulative Therapy (SMT), also referred
to as Osteopathic Manipulative Therapy (OMT) or
chiropractic adjustment, is the application of biomechanical
force to synovial joints in the spinal column.
Manipulation is usually characterized as a localized
force of high velocity and low amplitude directed at
a spinal segment. Mobilization uses low velocity
passive movement techniques, within the spine’s
normal range of movement.  In the United States,
SMT is most commonly performed by chiropractors,
osteopathic physicians, and physical therapists. Chiropractors
perform about 94% of SMT in the United
SMT is a widely used treatment option for musculoskeletal
pain, especially back pain, in the general
population. [8, 9] The annual use of chiropractic by
the general public is between 8% and 12% (reported
for 2002–2003) [10, 11] Generally the majority of
patients seek chiropractic care for spine-related pain,
particularly of the low back [12, 13] Severe adverse
effects of SMT are rare, especially related to the
lumbar spine. [14–16]
There are no definitive data for the use of SMT
among pregnant women, although it is estimated that
76% of chiropractors practicing in the United States
provide SMT to pregnant women. [17, 18] A survey
by Allaire et al found that about 53% of North
Carolina Certified Nurse-Midwives recommended
chiropractic to their pregnant patients.  Another
survey on the use, recommendation, and referral of
complementary and alternative medicine (CAM) by
Texas midwives reported that the most popular treatments
for pregnancy-related musculoskeletal/back
pain was chiropractic care. 
OSTEOPATHIC MANIPULATIVE TREATMENT AND CHIROPRACTIC ADJUSTMENT
Literature on the application of OMT in prenatal
care dates to the first half of the 20th century. 
These older articles were mainly commentaries describing
specific OMT techniques or case reports
reporting improved pregnancy outcomes. [22–27] By
mid-century there was an increase in publications on
the application of OMT in prenatal care. These studies
had larger samples sizes, more complex research
designs, and were empirically oriented,
reflecting current osteopathic obstetric standards. [21, 28, 29] The articles on OMT in obstetrics published in the second half of the 20th century had a
general theme of pain reduction during pregnancy
and labor, especially lower back and pelvic pain.
Chiropractic, like osteopathy, is a comprehensive
form of therapy including a treatment plan based on
the patient’s individual needs. Such a plan may include
spinal manipulation, soft tissue therapy, prescription of
exercises, and health and lifestyle counseling.
There is substantial evidence from randomized
controlled trials (RCTs) and systematic reviews supporting
the effectiveness and safety of spinal manipulation
for low back pain and neck pain. [8, 9, 30] The purpose of this review is to evaluate the evidence on
the treatment effects of SMT and/or mobilization
(including both chiropractic and osteopathic approaches) on back pain, pelvic girdle pain, and other related symptoms during pregnancy and labor. Because RCTs and other higher levels of evidence are often lacking for CAM therapies such as spinal manipulation, we included lower levels of evidence in
this review, rather than restricting it only to higher
levels, as is usually done in systematic reviews. A
recent Cochrane review of CAM therapies for low
back pain in pregnant women did not address spinal
manipulation at all, because it considered only RCTs
and other higher levels of evidence. Thus, clinicians
are provided with no guidance with respect to this
very commonly-used therapy. Eliminating lower level
studies from even being considered is not in keeping
with the practice of evidence-based decision-making,
which relies on the best available scientific evidence — if
higher level evidence is lacking, then it is important
to consider the evidence that is available, while being
mindful of its limitations.
The relevant studies were identified using the following
databases: PubMed, an index to Medline
(1966-September 2008), Manual, Alternative and Natural
Therapy Index System (1966-September 2008), the
Cochrane Library, Cumulated Index to Nursing and
Allied Health (1982-September 2008), and Index to
Chiropractic Literature (inception-September 2008),
Google Scholar. In addition hand searches and reference
tracking were also performed, and the citation
list was assessed for comprehensiveness by content
experts (Fig. 1).
The initial search was done by a librarian experienced
in literature retrieval. Initial search terms were
"chiropractic" AND "pregnant*"; "manipulation" AND
"pregnant*." A second search strategy was done to
ascertain retrieval of relevant articles because manipulation
is a term related to both chiropractic and
osteopathic medicine. The second search strategy
consisted of MeSH or key terms related to the therapy
(ie, manipulation) and population (pregnant
women) such as Chiropractic "OR" Manipulation,
Chiropractic OR Manipulation, Osteopathic OR Osteopathic
Medicine "AND" Pregnancy OR Labor,
Obstetric. We checked reference lists of relevant
studies to identify cited articles not captured by electronic
searches and contacted authors of primary
studies who had e-mail addresses available.
Three reviewers (C.H., R.K., and A.L.) independently
screened titles and abstracts for relevance and
2 reviewers (C.H. and R.K.) made an independent
selection of studies for inclusion in this review. To
avoid any misinterpretation, we excluded articles in
languages other than English.
Articles were included if they met the following
(1) published in a peer-reviewed journal (journals were considered peer-reviewed if they stated as such on their editorial page);
(2) English language;
(3) involved human subjects;
(4) addressed aspects of pregnancy, labor and/or childbirth; and
(5) addressed SMT or OMT.
Articles were excluded if they:
(1) did not present original data or an analysis of original data (ie, commentaries, editorials, or expert opinion pieces);
(2) were published in other media or in incomplete formats
(ie, abstracts, conference proceedings, posters, or web postings);
(3) did not address treatment outcomes;
(4) addressed exclusively nonmanual procedures (ie, exercise treatment, electrotherapy, use of a sacroiliac belt);
(5) addressed soft tissue treatment only (eg, massage); and
(6) addressed only sequelae of pregnancy and childbirth (ie, postpartum low back pain).
This systematic review did not involve human
or nonhuman experimentation and was exempt from
Institutional Review Board approval.
The methodological quality of the included studies
was assessed independently by the reviewers (C.H.,
R.K., and A.L.). Each article was evaluated by type
of study design and quality, with the exception of
case reports, narrative reviews and descriptive surveys,
which were NOT evaluated for quality (Table 1).
RCTs, systematic reviews, cohort studies, case-control
studies, and controlled clinical trials (ie, nonrandomized,
pilot, single group, and other small studies)
were evaluated for quality using the Scottish Intercollegiate
Guidelines Network (SIGN) checklists. [31, 32] The SIGN checklist rates studies as high quality (+) (indicates that the study met most or all
criteria for that study design), low quality (–) (indicates
that the study design was weak with few or no
criteria fulfilled), or neutral (n) (indicates that, while
it did not meet the majority of the criteria, the study
had a neither exceptionally strong [ie, PLUS score]
nor exceptionally weak design [ie, MINUS score])
(Table 2). For case series study design, we used an
evaluation checklist developed and in use by the
scientific commission of the Council on Chiropractic
Guidelines and Practice Parameters. 
Case series have traditionally been excluded from most systematic
reviews as they represent the lowest level of
study evidence in most simple hierarchies of study
design.  However, in emergent fields like CAM
research, we felt that the inclusion of case series
could assist clinicians in gaining a better perspective
on the utility of SMT, as well as informing the design
of future controlled studies. 
Three coauthors independently rated each article.
Differences in ratings were resolved by reconciliation,
discussion, and consensus. Safety evaluation
and adverse events reporting in all the clinical studies
was assessed by 2 review members (C.H. and R.K.) and
checked for consistency. All assessments were based on
information provided in the published manuscript.
The search strategy yielded a total of 140 citations (no
overlapping citations between databases) of which 32 [18–20,36–63] met our inclusion criteria. Of these,
1 was a RCT ,
2 systematic review [41, 64],
2 case-control studies [43, 48],
1 small nonrandomized static-group comparison study (preexperimental
4 narrative reviews [38, 40, 47, 62],
6 case series [18, 42, 45, 50–52],
9 descriptive surveys [19, 20, 37, 53, 55, 56, 58, 60, 63], and
6 case reports (of 1–2 cases) [36, 44, 49, 57, 59, 61].
Quality Assessment and Trial Homogeneity
Thirteen (13) studies were reviewed for quality, as
summarized in Table 3; the descriptive surveys, narrative reviews, and case reports were not rated for
quality. Only 2 studies (1 case series and 1 case
control) [18, 21] were classified as (+) meeting all or most of the measures of study design quality; 6
studies (4 were case series, [42, 45, 50, 52] and 2 were
systematic reviews) [41, 64] scored (n) with neither exceptionally strong nor exceptionally weak design;
and 5 remaining studies (1 cohort study , 1 case
control , 1 other study design , 1 RCT ,
1 case series , and scored as weak (–) indicating exceptionally weak study designs) (Table 3). Most studies had methodological limitations.
There were no RCTs or controlled clinical trials on
the efficacy of SMT (including both chiropractic and
osteopathic approaches) on back pain, pelvic girdle
pain, and other related symptoms during pregnancy.
For labor and delivery, one RCT (n = 15) measured
the application of pressure via SMT to the lumbar
area versus pressure applied to the thoracic area (as a
placebo control) to inhibit back pain during labor and
effectively reduce the need for analgesic medication
during delivery. Because of the lack of clinical trials,
study heterogeneity, small sample size, and poor
design quality of the articles identified during the
review phase we were unable to conduct a metaanalysis
and total effect size. We did however, include
methods for combining both qualitative and
quantitative research in this systematic review by
globally classifying the included studies as high quality,
neutral, or low quality.
Overall the studies varied in inclusion criteria,
treatment protocols and definitions of outcomes. The
primary outcome in the majority of studies was patient
reported pain relief. In the studies addressing
back pain during labor, the use of pain medication
was also used as an outcome measure; secondary
outcomes included length of labor and mode of delivery
(Table 3). Although the majority of the medical literature
retrieved in the review involved chiropractic treatment
almost one-third involved osteopathic treatment.
Case reports and narrative reviews were included
in Table 4 to describe the nature and severity of
reported adverse events related to SMT or OMT
during pregnancy. The majority of studies, including
case reports, did not include reporting of adverse
effects in their manuscript (Tables 3, 4). Two narrative
reviews discussed possible contraindications to
SMT during pregnancy and 3 clinical studies formally
reported that no adverse events occurred.
Clinical Studies on Pregnancy, Labor, and Delivery
For labor and delivery, one RCT (n = 15) measured
the application of pressure via SMT to the
lumbar area versus pressure applied to the thoracic
area (as a placebo control) to inhibit back pain during
labor and effectively reduce the need for analgesic
medication during delivery. The lumbar pressure was
applied by the patient’s husband/coach or nurse.
Lumbar pressure for back pain during labor had no
significant effect on the length of labor. However, it
significantly decreased pain medication use (P <
0.05). This RCT had a score of (–) using the SIGN
methodology checklist for RCTs. The study design
was weak and lacked an appropriate and clearly
address question. The trial neither addressed randomization
nor sample homogeneity. Of the clinical studies,
only 1 case series  and 1 case-control study 
were scored as (+) — adequately designed and methodologically
sound. Both studies addressed the effect of SMT on pregnant women with low back pain.
A retrospective case series reported that 16 of the
17 cases demonstrated clinically important improvement
in pain intensity throughout the course of treatment.
The overall group average Numeric Rating
Scale pain score decreased from 5.9 (range, 2–10) at
initial presentation to 1.5 (range, 0–5) at termination
of care. The average time to initial clinically important
pain relief was 4.5 (range, 0–13) days after initial
presentation, and the average number of visits undergone
up to that point was 1.8 (range, 1–5). 
Similarly, a second study (retrospective case control)
to test the effectiveness of OMT during pregnancy
found beneficial effects on the outcomes of pregnancy,
labor, and delivery.
The medical records of
160 women from 4 cities who received prenatal OMT
were reviewed for the occurrence of meconium-stained
amniotic fluid, preterm delivery, use of forceps, and
cesarean delivery. The randomly selected records of
161 women who were from the same cities, but who
did not receive prenatal OMT were reviewed for the
same outcomes. Prenatal OMT was significantly associated
with decreased meconium-stained amniotic
fluid (Z = 13.20, P < 0.001) and preterm delivery
(Z = 9.91; P < 0.01), while the use of forceps was
found to be marginally significant (Z = 3.28; P =
0.07). Overall, the results suggested improved outcomes
in labor and delivery for women who received
prenatal OMT, compared with women who did not. 
Other clinical studies also found that SMT during
pregnancy successfully reduced back pain (Table 3).
In 2001, a systematic review  on clinical studies
and case reports of chiropractic technique procedures
including SMT for specific low back conditions reviewed
143 articles. This review included only 2 case
series [42, 52] involving pregnant women. This review
was scored as (n) because it adequately addressed
methodological issues, but failed to identify
all relevant studies.
In 2008, a systematic review reported on chiropractic
treatment of pregnancy-related low back pain.  All peer-reviewed articles were considered except
single case reports, narrative reviews, and qualitative
designs. Conference abstracts and proceedings
were deemed acceptable for inclusion. Their electronic
searches identified 55 citations (including
overlapping citations between databases). The full
text of 15 articles was obtained after screening the
titles and/or abstracts to determine if they met the
review’s inclusion criteria of which 6 articles met all
of the inclusion/exclusion criteria of the review (3
abstracts, 1 retrospective cross-sectional survey ,
1 retrospective case series , and 1 case series.  Although this review adequately addressed
methodological issues and identified most of the
relevant studies, we scored it as "n" because the
evaluation instrument, a modified Downs and Black
scale, is not appropriate for studies that describe
outcomes in designs such as case series or survey.
Checklist items regarding the allocation mechanism,
random assignment, and blinding do not relate to
case series. [34, 65]
Case Reports and Surveys
This systematic review reviewed 9 descriptive surveys [19, 20, 37, 53, 55, 56, 58, 60, 63] and 6 case reports
(of 1–2 cases) [36, 44, 49, 57, 59, 61] of which 3 dealt
with a chiropractic technique called the Webster
Technique used to correct Breech presentation by
manipulation of the sacrum (not involving external
version of the fetus) [36, 55, 61], 3 addressed pelvic
girdle pain during pregnancy [37, 53, 59], 2 case reports
described SMT in the treatment of recurring
lower back pain during pregnancy [44, 49], and 1 case
report presented a case of an odontoid fracture occurring
after SMT; the patient was found to have had
a preexisting aneurysmal bone cyst  (Table 4). Of
the remaining surveys, 1 surveyed the chiropractors’
opinions of the safety of SMT during pregnancy  and 5 surveys addressed CAM (including
SMT) referrals from prenatal health care providers
and prevalence recall of CAM use (including
SMT) by pregnant women for back pain and
breech presentation. [19, 20, 56, 58, 63]
This review provides healthcare professionals and
the scientific community with a comprehensive evaluation
of scientific literature on the treatment effects
of SMT on back pain, pelvic girdle pain, and other
related symptoms during pregnancy and labor.
This review was limited to peer-reviewed manuscripts
published in English and published from 1966
until September 2008. However, its chief limitation
was the paucity of literature. Our search indicated
that a number of systematic and narrative reviews on
CAM and pregnancy failed to include SMT as a
treatment option (66–70). Furthermore, the reviews
we identified omitted some relevant SMT studies. [38, 40, 41, 47, 62]
The 5 clinical studies — RCT , cohort study , 2 case-control studies [43, 48], and small nonrandomized
static-group comparison study (preexperimental
design)  evaluated did not permit this
review to draw any definitive conclusions with respect
to the effectiveness of SMT versus other treatments
used on back pain and other related symptoms
Most clinical studies reviewed contained design
flaws such as a small sample size, duration of followup,
control of cointerventions, the absence of a placebo
control group, lack of blinding, proper analysis
of dropouts, and a lack of description for the manipulative
procedure. Furthermore, most of the clinical
studies lacked sufficient description of their methodology,
thus making it difficult for the reader to assess
their validity and diminishing the ability to generalize
the results to clinical practice. Although several
clinical studies reported on sacroiliac joint pain, we
were unable to find clinical studies that employed
clear operational definitions to address pelvic girdle
pain during pregnancy that met our inclusion criteria.
The case series included in this review suggest that
SMT may be helpful to pregnant women with low
back pain; however, this design does, of course, lack
causal force. The 2 systematic reviews, focusing on
RCTs, conclude that due to the small number and
relatively low quality of the experimental studies
available, this procedure needs further evaluation.
The treatment options for low back pain in pregnancy
are limited. Although minimizing the use of
medications during pregnancy is commonly accepted,
no nonpharmacologic means is supported by
strong evidence of safety and effectiveness.  Because
there is evidence supporting the safety and
effectiveness of manipulative therapies for low back
pain in the general population , it appears reasonable
to consider a trial of manipulative therapies for
back pain in uncomplicated pregnancy, despite the
small body of evidence focusing on the role of SMT
for the special population of pregnant women. Current
understanding of the biomechanics of manipulative
therapies suggests that the transmitted loads
are within physiological ranges [72, 73], and are thus
not likely to be contraindicated in uncomplicated
In summary, the use of manipulative therapies
(SMT or OMT) during pregnancy to reduce back
pain and other related symptoms are supported by
limited evidence; the evidence for the effects of
manipulative therapies on labor and delivery is even
more limited. Overall, this body of evidence is best
described as emergent. Definitive evidence supporting
its effectiveness has not yet been developed;
however, definitive evidence supporting a lack of
effectiveness is also lacking. Therefore, high quality
clinical trials on safety and effectiveness should be a
priority. However, until they are available, because
safe and effective treatments for pregnancy-related
back pain are limited, clinicians may want to consider
SMT as a treatment option for patients who
have a preference for this approach if no contraindications
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