J Clinical Chiropractic Pediatrics 2010 (Dec); 11 (2): 771–774 ~ FULL TEXT
Elisabeth Aas-Jakobsen, BS, DC, MSc and Joyce E. Miller, BS, DC, DABCO
Musculoskeletal (MSK) problems in pregnancy constitute
a tremendous cost to society, both in regards to
sick leave and chronic pain, and are a major public health
concern. (In Norway one-third of all pregnant women are
on sick leave at any given time, and many of these because
of back pain). There is little agreement on the best treatment
for the various MSK problems in pregnancy and very
little is known about the efficacy of chiropractic treatment
in pregnancy. However, chiropractic care has been shown
to be both popular with patients during pregnancy, as well
as being considered safe and appropriate by chiropractors.
The purpose of this paper is to describe a survey which
investigated the characteristics of pregnant women who
sought chiropractic care in Norway
The design of this study was a cross-sectional survey
which was designed to collect demographic data from the
first 100 pregnant women who presented in consecutive
order within a specific time frame to a chiropractic clinic
in Oslo, Norway. The data were abstracted from patient
records of new patients who were pregnant and consulted
the clinic from September 2007 to December 2008. Only
the data from treatments during pregnancy were used;
treatments after the end of pregnancy were not included.
Only the data that systematically had been recorded in all
the files were used. Inclusion criteria were that the patients
were pregnant on presentation to the clinic, that they spoke
Norwegian and received more than one treatment. If they
had sought other treatment earlier in the same pregnancy,
they were still included. Exclusion criteria were receiving
only one treatment (to avoid patients travelling through
the area, and to avoid any assumptions of patients potentially
not returning after the first treatment where it was
impossible to re-interview or re-examine the patient). Only
treatments during pregnancy were included. Episode of
care was throughout the pregnancy, and did not extend
All data were held completely confidentially and no
patient was identifiable. All patient data were coded without
use of names or identifying features. Patient’s files on
the computer were transcribed to an Excel spreadsheet.
Descriptive statistics were used to analyze the data.
This study was approved by the Anglo-European College
of Chiropractic Research Ethics Sub-Committe for
postgraduate research in accordance with the Declaration
of Helsinki. No further approval was required in Norway.
There were no funding issues or conflicts of interest.
The mean age of the patients presenting to the chiropractor
was 32.5 years (range 25-42). Forty percent
(n=40/100) were in the group 29-32 years old, 40% were
in the group 33-36 years old and 20% were under age 28,
or 37 or above. About half of the patients (47%) were in
their first pregnancy, the other half (49%) in their second
pregnancy, and only a few (4%) in their third pregnancy.
For 32% of the patients, the contact in this office was the
first time they had ever received any care for any musculoskeletal
problems in the health care system regardless
of pregnancy status. Thirty eight percent had been to a
chiropractor before, either before they were pregnant,
or in a previous pregnancy. Thirty percent had been to a
physiotherapist previously, either in the present pregnancy
or an earlier pregnancy, or for any condition before they
In this clinic 44% were referred to the clinic by friends
or family and 48% referred by other health professionals,
23% received advice from their midwife to contact the
clinic, 15% from their medical doctor, and 10% from their
About 90% of the women had pelvic pain as the main
reason why they had contacted the clinic during pregnancy.
Six out of 10 had back pain, and 6 out of 10 had specific
thoracic pain. Three out 10 had neck pain, 29% had symphysis
pubis pain, 15% experienced headaches and 2%
migraines. Overall, 82% experienced a combination of
Fifty-five percent of the patients received care in the
pelvic/lumbar, thoracic and cervical areas. Forty-one percent
received pelvic/lumbar and thoracic treatment and
4% in the pelvic/sacrum areas only.
When looking at the 82% who experienced a combination
of pain sites, it was most common to have a combination
of 3 sites, then 2, 4 or a combination of 5 or more.
In this study, 44% had experienced some form of back
pain prior to this pregnancy. Twenty-one percent had experienced
pain in an earlier pregnancy. Thirty-five percent
had no previous experience with back pain.
The average gestational age was 26.5 weeks. The mode
was 26 weeks.
Fifty-two percent of the patients were in their second
trimester (eleven percent in gestational week 26), 43%
were in their third trimester (nine percent in gestational
week 32 and ten percent in week 35) and 5% were in their
Thirty-six percent of the patients noted that their pain
had started at what they defined as the “beginning” of the
pregnancy. Sixteen percent had had pain for 1-2 weeks,
10% 3-4 weeks, 8% 5-7 weeks and 20% had had pain for
more than 2 months duration before clinical prensentation.
Those with the greatest number of pain sites had experienced
it for the longest duration (Figure 1).
The most common number of treatments was 8.5
(range 2-19). Forty-seven percent received between 7-12
treatments, 34% received 2-6 treatments and 19% received
more than 13 treatments. Many of the patients received
care after birth; however these were not included. Number
of treatments generally increased with the number of pain
sites (Figure 2).
The patients who had had no previous experience with
back or pelvic pain sought care on average after 4.5 weeks
of pain. The patients who had had previous back pain not
related to pregnancy waited on average 12.5 weeks before
seeking care. Those women who had experienced back or
pelvic pain in a previous pregnancy waited on average 14
weeks before consulting a chiropractor.
When studying the patients who waited the longest
before seeking care (more than 20 weeks), it was found
that only the women who had had earlier back pain waited
that long before seeking care, 10 with a previous back pain
history and 3 with pain in an earlier pregnancy. When
looking at those patients who sought care within 1-3 weeks
of pain, it was found that none of these 12 had had any
previous experience with back pain. When looking at the
trimester when the patients presented as well as how long
they had had pain before they sought care, it was found
that in the first trimester the patients had had pain for an
average of 5.4 weeks, in the second trimester an average of
9.6 weeks and in the last trimester the patients had pain
for an average of 12.7 weeks.
It was found that those who had never received any
previous care waited 7.3 weeks on the average, those who
had been to a chiropractor previously waited 11.6 weeks,
and those who had been to a physiotherapist earlier waited
the longest at 13 weeks.
In this survey, just over one-third (36%) of the patients
claimed to have experienced pain since the “beginning of
the pregnancy.” They presented in their second or third
trimester (52% and 43%, respectively). Most commonly,
they presented at 26 weeks of pregnancy and on average,
had waited 11 weeks before they sought care. This puts a
large number of the patients into a category of what would
classically be termed chronic pain. Research has shown
that over half of people with 3 or more months of pain,
continue to have clinically significant back pain at 1 year. 
Pregnancy itself is regarded as a risk factor for chronic back
pain in women.  The length of time of pain before seeking
care may perhaps have an influence on the course of
the pain experienced after pregnancy. Many clinicians and
patients accept back and pelvic pain as a normal side effect
of pregnancy. Skaggs et al.  found that only 15% of the
women with pregnancy related lumbo-pelvic pain received
any care, only 10% of those were satisfied with the care
given and most of the women in this study were not given
any advice regarding available treatment options. Some
women complained because they didn’t know there were
options for treatment. A statement by a patient presenting
to my office follows:
“Why didn’t anyone refer me here earlier? It is just by
chance I ended up here in this office. Had I known
what I now know, I would have come much earlier.”
We need to know whether encouraging women to seek
care early significantly decreases the length of pain episode
and chronicity. Further long-term research is required to
answer those questions.
Those patients who never had back pain previously
waited the shortest amount of time before seeking treatment
(average 4.5 weeks) and those with previous pelvic or
back pain in pregnancy waited the longest (14 weeks). A
reason why first time pain patients sought care earlier may
have been that the pain was terrifying and they needed to
know what was wrong with them, or it may reflect a changing
attitude of the younger generation who do not have
a “wait and see” approach to their problem. The authors
hypothesize that it may reflect a healthy attitude of these
women; they may want to know at an early stage what can
be done for their condition, and how to prevent a progression
of their problem.
Of those patients who had pain for more than 20 weeks
before presenting to the chiropractor, all had experienced
low back pain previously. The long wait could be due to
them being less afraid of the pain (having experienced
it before) and having learned to accept it, or having had
previous treatment during earlier pregnancies that they
perceived as being non-helpful. None of the patients whose
first experience with back pain in her current pregnancy
waited more than 20 weeks before seeking care. To have
back pain for more than 20 weeks reflects the attitude of
women with chronic pain; they “get used” to it and learn
to live and deal with it and not complain about it.
Stevens  looked at “regular” chiropractic patients,
whose average pain onset was three weeks before visiting
the chiropractor was. This is two months earlier than this
study. He found that one of the biggest barriers to seeking
care was hope that the symptoms would go away. In the
pregnant patient this may be true as well, as this is exactly
what many patients in our study reported during their
pregnancy. They would have sought care earlier, but were
hoping that the pain would go away, only as the symptom
worsened did they realize this was not the case. Others
thought they could endure the pain because the end of
the pregnancy was perceived to be close, but as the quality
of life worsened they sought help for symptom relief.
The authors hypothesized that the pain usually gets worse
as the pregnancy progresses and the patient may, at some
point, become desperate and decide to seek care. Another
aspect of pregnancy pain is that it is often perceived as
a “positive” pain, something good will come soon (the
child) and there will probably be an end to the pain (the
pregnancy will end).
For almost one-third (30%) of the patients in this
study, chiropractic was their first choice of treatment, except
visits to their medical doctor for routine checks. This
may reflect a wider knowledge base of the patients, along
with perhaps reflecting the growing status and position of
chiropractic. In Norway perhaps this is a consequence of
the law changes and privileges that chiropractors in Norway
have been granted over the last few years. Chiropractors are
primary care givers, have the right to write sick leave notes
up to 12 weeks, have rights to prescribe physical therapy
paid for by the government, as well as any kind of special
testing such as radiographs, MRIs and further investigation
by other specialists.
When reviewing these findings it is important to keep
in mind the limitations of this particular study. As good
as surveys can be at finding trends and locating gaps in
information, the design of this study alone allows for many
gaps in information. Due to the relatively small number
of subjects (100 women) it is harder to draw conclusions
and find trends than it would be with a larger population
The patients presenting to this clinic may have unique
characteristics from patients in other clinics, because it is
a clinic specializing in pregnancy related problems. This
clinic may also give an over representation of pelvic related
pain, because the name of the clinic “bekken og barn”(pelvis
and children”) reflects a condition and implies a focus on
problems relating to the pelvic girdle. This could potentially
leave out patients, for example, who have migraines
in pregnancy as their chief complaint. The characteristics
of these patients may also have been influenced by the relatively
limited catchment area (limited geographic location)
also affecting the socio-demographic profile.
As for the treatment, it was carried out by only one
chiropractor, not giving room for differences from different
practitioners in regards to number of treatments given, the
areas of the spine treated, and the treatment schedules, even
though these are not directly discussed in detail here. Thus,
what is true for treatments given in this clinic may not reflect
the practitioners in clinics that are not specializing in
treating pregnant women. If there is indeed a difference in
those who seek care from specialists, especially in regards to
education and job satisfaction, this may also affect the sick
leave statistics. Further research might elucidate whether
those who seek specialized care are more satisfied with their
job, and would want to try “everything” so they can stay
working as long as possible. This may be especially true
because they have to pay for their care out of their own
pocket. In comparison, the most common alternative to
a chiropractor is a physiotherapist, whose treatment in
Norway is generally free of charge during pregnancy.
Some women seek chiropractic care during pregnancy
and in this study, half were sent by health care practitioners.
For one-third of the patients, chiropractic was their first
choice for treatment. All had pain relating to the pelvic
girdle or low back; however most of them had a combination
of two or more pain sites. This study found that the
longer the patient had pain before onset of care, the more
pain sites they experienced, the more areas of the spine
were treated and the more treatment they required. Future
studies should concentrate on efficacy of treatment (as
well as the initiation of early vs. delayed treatment), cost-effectiveness
and prevention of chronicity of back pain that
begins during pregnancy.
Dunn KM, Croft PR, Main CJ,Corf MV.
A prognostic approach to defining chronic pain: Replication in a UK primary care low back pain population.
Pain 2008; 135(1-2):48-54
Gutke A, Ostgaard HC, Oberg B.
Predicting Persistent Pregnancy Related Low Back Pain.
Spine 2008; 33(12):386-393
Skaggs CD, Prather H, Gross G, George JW, Thompson PA, Nelson DM.
Back and Pelvic Pain in an Underserved United States Pregnant Population: A Preliminary Descriptive Survey
J Manipulative Physiol Ther. 2007 (Feb); 30 (2): 130–134
Behavioural and Access Barriers to Seeking Chiropractic Care: A study of 3 New York Clinics.
J Manipulative Physiol Ther 2007; 30:566-572