Adverse events from spinal manipulation in the pregnant and postpartum periods: A critical review of the literature

Division of Graduate Education and Research, Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, ON M2H 3J1, Canada. .
Chiropractic and Manual Therapies 03/2012; 20(1):8. DOI: 10.1186/2045-709X-20-8
Source: PubMed


The safety of spinal manipulation during pregnancy and the postpartum periods has been a matter of debate among manual therapists. Spinal manipulative therapy during these periods is a commonly performed intervention as musculoskeletal pain is common in these patients. To date there has not been an evaluation of the literature on this topic exclusively.
A literature search was conducted on PubMed, CINAHL and the Index to Chiropractic Literature along with reference searching for articles published in English and French in the peer-reviewed literature that documented adverse effects of spinal manipulation during either pregnancy or postpartum. Case reports, case series, and any other clinical study designs were deemed acceptable for inclusion, as were systematic reviews. The appropriate Scottish Intercollegiate Guidelines Network (SIGN) tools were used to rate included articles for quality when applicable.
Five articles identifying adverse events in seven subjects following spinal manipulation were included in this review, along with two systematic reviews. The articles were published between 1978 and 2009. Two articles describing adverse effects from spinal manipulation on two postpartum patients were included, while the remaining three articles on five patients with adverse effects following spinal manipulation were on pregnant patients. Injury severity ranged from minor injury such as increasing pain after treatment that resolved within a few days to more severe injuries including fracture, stroke, and epidural hematoma. SIGN scores of the prospective observational cohort study and systematic reviews indicated acceptable quality.
There are only a few reported cases of adverse events following spinal manipulation during pregnancy and the postpartum period identified in the literature. While improved reporting of such events is required in the future, it may be that such injuries are relatively rare.

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    • "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 [25]. 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. "
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    ABSTRACT: 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. 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. 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 [single low-9 quotation mark]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). Most pregnant patients undergoing chiropractic treatment reported clinically relevant improvement at all time points. No single variable was strongly predictive of[single low-9 quotation mark] improvement' in the logistic regression model.
    Full-text · Article · Apr 2014 · Chiropractic and Manual Therapies
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    • "Chiropractic care may include spinal manipulative therapy (SMT), mobilizations and soft tissue therapy, as well as exercise prescription [3]. Previous studies and systematic reviews of the literature have indicated the relative safety and effectiveness of chiropractic treatment for LBP during pregnancy [3,5-7]. "
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    ABSTRACT: Background Chiropractors regularly treat pregnant patients for low back pain during their pregnancy. An increasing amount of literature on this topic supports this form of treatment; however the experience of the pregnant patient with low back pain and their chiropractor has not yet been explored. The objective of this study is to explore the experience of chiropractic treatment for pregnant women with low back pain, and their chiropractors. Methods This qualitative study employed semi-structured interviews of pregnant patients in their second or third trimester, with low back pain during their pregnancy, and their treating chiropractors in separate interviews. Participants consisted of 11 patients and 12 chiropractors. The interviews consisted of 10 open-ended questions for patients, and eight open-ended questions for chiropractors, asking about their treatment experience or impressions of treating pregnant patients with LBP, respectively. All interviews were audio-recorded, transcribed verbatim, and reviewed independently by the investigators to develop codes, super-codes and themes. Thematic saturation was reached after the eleventh chiropractor and ninth patient interviews. All interviews were analyzed using the qualitative analysis software N-Vivo 9. Results Five themes emerged out of the chiropractor and patient interviews. The themes consisted of Treatment and Effectiveness; Chiropractor-Patient Communication; Pregnant Patient Presentation and the Chiropractic Approach to Pregnancy Care; Safety Considerations; and Self-Care. Conclusions Chiropractors approach pregnant patients with low back pain from a patient-centered standpoint, and the pregnant patients interviewed in this study who sought chiropractic care appeared to find this approach helpful for managing their back pain symptoms.
    Full-text · Article · Oct 2012 · Chiropractic and Manual Therapies
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    ABSTRACT: A case of internal carotid artery dissection in a pregnant woman with Systemic Lupus Erythematosus (SLE) immediately following chiropractic treatment is presented. The literature regarding complications of neck manipulation during pregnancy, spontaneous dissection of craniocervical arteries in pregnancy and the postpartum period, and dissection of craniocervical arteries in SLE are reviewed. To the best of the author's knowledge, this is the first case of carotid artery dissection following chiropractic treatment in a pregnant woman published in the literature.
    Full-text · Article · Dec 2012 · Chiropractic and Manual Therapies
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