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

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DOI: 10.1186/2045-709X-20-8 · Source: PubMed
Abstract
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.
SYST E M A T I C REV I E W Open Access
Adverse events from spinal manipulation in the
pregnant and postpartum periods: a critical
review of the literature
Kent Jason Stuber
1*
, Shari Wynd
2
and Carol Ann Weis
1
Abstract
Background: The safety of spinal manipulation during pregnancy and the postpartum periods has been a matter
of debate among manual therapists. Spin al 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.
Methods: 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.
Results: Five articles identifying adverse ev ents 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.
Conclusions: There are only a few reported cases of adverse events following spinal manipulation during
pregnancy and the post partum 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.
Keywords: Chiropractic, Spinal manipulative Therapy, Pregnancy, Postpartum, Adverse effects
Background
Musculoskeletal pain is a common occurrence during
pregnancy and the postpartum period. For example, low
back pain has been reported to occur as frequently as
50% to 85% of pregnant women [1-4] and at two to
three years postpartum, eight to 20% of these women
still report persistent symptoms [5,6]. Although low
back pain is often accepted as an unavoidable complaint
during pregnancy, for some women the pain can be
debilitating, interfering with sleep, work and normal
activities of daily living [7,8]. However, the etiology of
this pain is unknown [9]. It has been suggested that low
back pain experienced during pregnancy is multifactoral
in nature and some of the proposed mechanisms
include, but are not limited to, the influence of altered
circulating relaxin levels producing ligamentous laxity
[7,10], maternal weight gain and/or biomechanical
changes due to pregnancy [7].
In the non-pregnant population, low back pain is a
significant cause of pain and disabil ity as well, with 80%
* Correspondence: kstuber@cmcc.ca
1
Division of Graduate Education and Research, Canadian Memorial
Chiropractic College, 6100 Leslie Street, Toronto, ON M2H 3J1, Canada
Full list of author information is available at the end of the article
Stuber et al. Chiropractic & Manual Therapies 2012, 20:8
http://chiromt.com/content/20/1/8
CHIROPRACTIC & MANUAL THERAPIES
© 2012 Stuber et al; licensee BioMed Central Ltd. T his is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use , distribution, and reproduction in
any medium, provided the original work is properly cited.
of the population experiencing an episode during their
lifetime [7,11]. Neck pain [12,13] and headaches [14] are
also a substantial source of pain and disability in the
non-pregnant population [12]. One of the effective treat-
ment options used by manual practitioners for those
suffering from low back pain [15,16] cervical spine
[16,17] and some headache pain [18,19] is spinal manip-
ulative therapy (SMT). SMT is usually characterized as a
localized force of high vel ocity and low amplitude direc-
ted at a spinal segment [1]. Severe adve rse effects of
SMT are rare in the cervical spine [20-22] and lumbar
spine [23].
Manual treatment options for pregnancy-induced pain,
such as back pain, have been repor ted to be limited [1].
However, chiropractors report seeing pregnant patients
frequently, and surveys of chiropractors reflect an opi-
nion that SMT is safe for pregnant patients [1,24].
While the safety of SMT for adult and pediatric popula-
tions has undergone scrutiny in both public and scienti-
fic domains [13,22,25], the safety of SMT in sub-groups
of the population including pr egnant and postpartum
patients has received little attention. This lack of evi-
dence is surprising given the obvious importance of the
welfare of the expectant and new mother. Given the
hormonal and the coagulability status of perip artum and
postpartum individuals, it is possible that SMT is a con-
traindication t o the musculoskeletal complaints asso-
ciated with pregnancy.
It is accepted that females are more susceptible to
increases in joint laxity than men [26-28]. Hormonal
causes have been postulated as a pote ntial source for
this increase in female joint laxity [29-32]. Relaxin, a
polypeptide that is produced by the corpus luteum dur-
ing pregnancy [32], is one of the implicated hormones.
In the pregnant female, relaxin is essential in order to
secure the passage of the fetus during parturition in sev-
eral animal species [33]; it has been associated with a
decrease in soft tissue tension especially in preparing
thefemalebodyfordeliveryincludingrelaxingthepel-
vic ligaments, inhibiting spontaneous uterine contrac-
tions, ripening of the uterine cervix, and stimulat ing the
mammar y gl ands [34]. Although relaxin increases laxity
in the symphysis pubis in preparation fo r birth, it s
effects are not solely limited to that joint. In addition,
women immediately postpartum are thought to also
have this hormone-mediated ligament laxity that might
reduce the protective stability of the intervertebral
articulations [35].
Hypercoaguable disorders that promote thrombosis
have been categorized as thrombophilias [36]. During
pregnancy a nd the postpartum state the risk of throm-
bophilia increases compared to the non-pregnant state
[36,37]. Thromboem bolism or pulmonary embolism has
been identified as the leading cause of maternal death in
the United States [36,37]. These h ypercoaguab le disor-
ders during pregnancy can be a result of venous stasis,
changes in the vessel wall and changes in the composi-
tion of blood; also known as Virchows triad [36].
In the absence of a prospective study of the safety of
SMT during the antepartum and postpartum periods, it
woul d be beneficial to survey the s cientific literature for
the number and types of injuries sustained by pregnant
and postpartum patients following spinal manipulation.
While systematic reviews of the literature on the use of
SMT for pregnancy and related condition s have been
conducted [1,11], an exploration of the literature specifi-
cally for adverse events associated with SMT and preg-
nancy has not yet been undertaken. Accordingly, the
aim of this study is to critically review the l iterature for
reported cases of iatrogenic injuries following spinal
manipulative therapy during the pregnancy and postpar-
tum periods.
Methods
Objective
To collect and synthesize available evidence on adverse
events associated with SMT during the pregnancy and
postpartum periods.
Search strategy
A literature search was conducted in three different
electronic databases: PubMed (including MEDLINE),
CINAHL, and the Index to Chiropractic Literatu re. The
date ranges applied were from the beginning of each
respective database t o October 2011. The following
search terms were employed: adverse effects, adverse
rea ctions, adverse events, harm, pregnancy, postpartum,
chiropractic, spinal manipulative therapy, spinal manipu-
lation, and manual therapy. These search terms were
categorized and combined using Boolean terms (please
see Additional file 1: Appendix 1 for the complete
search stra tegy). Reference searching of relevant articles
retrieved from the electronic literature search was also
undertaken, as was a search of each of the authors per-
sonal collections. Specific inclusion criteria for this
review were:
Study designs
All clinical study designs published in peer-reviewed
journals. Conference proceedings, cross-sectional and
other descriptive designs and narrative reviews were
excluded.
Population
Female patients who are either pregnant o r postpartum
(defined as the period between the delivery of the child
and six weeks after the birth) [38].
Intervention
Spinal Manipulative Therapy (SMT) (defined as a man-
ual therapy technique that uses a high velocity low
Stuber et al. Chiropractic & Manual Therapies 2012, 20:8
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amplitude thrust applied at a spinal motion segment
[39] to any region of the spine.
Comparison
Not relevant.
Outcomes
Any adverse events associated with SMT.
Language
Articles in either English or French were considered for
inclusion.
Study selection
Two of the authors (KS and SW) independently
reviewed the titles and abstracts of the electronic data-
base searches for any that appeared to match the inclu-
sion criteria. The full text versions of any potentially
relevant articles were obtained and reviewed by the
same two authors using the in clusion criteria described
above. Each of the authors compiled a list o f articles to
include that was compare d, and any disagreements were
resolved through discussion.
Data collection and rating process
A data extraction sheet was compiled by one of the
aut hors (KS) and relev ant data from each included arti-
cle was entered into the sheet. The appropriate Scottish
Intercollegiate Guidelines Network (SIGN) tools were
used to rate included articles for quality, although any
case reports included in the review were not rated for
quality as there is no applicable SIGN tool for case
reports. The overall assessment of a paper using a SIGN
tool is given one of three scores: ++ indicates the
highest level of methodological quality for that study
type, fulfilling all or most of the internal validity criteria
for that particular study type, + indicates some criteria
were fulfilled, and - indicates that few or none of the
criteria were satisfied. Two of the authors (KS and SW)
rated the articles using the applicable SIGN tool. One of
the authors (KS) was an author on one of the systematic
reviews and thus that article was rated by the other two
authors ( SW and CAW) t o avoid potential bias. Where
reviewers disagreed, consensus was achieved by
discussion.
Analysis
Meta-analysis could not be conducted as only case
reports and an observatio nal cohort study we re identi-
fied; data are summarized in text (percentages).
Results
Figure 1 depicts the flow of articles through the review
process [40]. One full text article was excluded because
it did not use HVLA s pinal manipulation [41]. Five
articles that identified possible adverse events in seven
subjects following spinal manipulation of a pregnant or
post-partum subject were identified from the literature
search, along with two relevant systematic reviews
[1,11] (the full list of included articles appears in Addi-
tional file 2: Appendix 2). The five articles consisted of
four case reports [20,21,35,42] and one prospecti ve
observational cohort study [43]. The four case rep orts
all detailed adverse ev ents following cervical manipula-
tion, whereas the prospective observational cohort
study described three adverse events following lumbar
manipulation. The articles were published between
1978 and 2009. Figure 2 describes the four case reports
included, while (Additional file 3: Table S1) provides
additional details on those case reports. One case
report [42] was identified by reference searching. A
systematic review of manipulative therapy during preg-
nancy [1] was identified from the authors personal
collections.
Murphy et al published an observational cohort study in
2009, which evaluated a diagnosis-based decision rule
for pregnancy-related lumbopelvic pain [43]. One hun-
dred and fifteen patien ts began the study and complete
data was obtained on 78 subjects. In terms of adverse
effects three subjects (3.8%) reported increased pain
after treatment; this was reported as resolving for two of
these patients in less than 48 hours and in one week for
the third patient. The treatments that each patient
received depended on their specific diagnosis and it is
unsure what diagnosis these patients were given. How-
ever nearly all patients (68/78) received some form of
manual therapy. No other c omplicatio ns were reported
in this study. The overall SIGN rating assigned to this
article was +, indicating acceptable quality although it
was limited by a lack of blinding and possible
confounders.
Records screened
N=219
Full text articles
excluded
N=1
Records excluded
N= 211
Full text articles assessed for
eligibility
N=8
Articles included in the review
N=7
Records identified through
database searching:
N=217
Additional records identified through other
sources:
N=2 (reference search, personal collection)
Figure 1 PRISMA Information Flow [40].
Stuber et al. Chiropractic & Manual Therapies 2012, 20:8
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The systematic revi ew by Stuber and Smith in 2008 o n
spinal manipulation for pregnancy-related lower back pain
indicated that no adverse effects were noted in any of the
papers that they reviewed, although only one of the articles
specifically commented on an absence of adverse events
[11]. The systematic review by Khorsan et al published in
2009 identified only the case report by Schmitz et al as
having an adverse event resulting from manipulative ther-
apy during pregnancy [1]. Most of the studies included in
that review did not report adverse effects at all, although it
was noted that three clinical studies indicated that there
were no adverse events during their trials. The overall
SIGN rating assign ed to both of these systematic reviews
was ++, indicating good quality.
Item / Citation Case description
Ng KPL, Doube A. Stroke
after neck manipulation in
the post partum period. J
NZ Med Assoc 2001;
114(1143): 498.
A 34 year old woman, 5 week post-partum with right sided neck
pain after delivery. She received a cervical manipulation by a
chiropractor and experienced memory loss within 30 minutes which
resolved, the following day she had poor coordination of her right
hand, difficulty with articulation, and unsteady gait. MRI
demonstrated a right cerebellar infarct with a wedge shaped area of
increased T2 signal in the right antero-superior cerebellar cortex.
She had a full recovery within one month.
Parkin PJ, Wallis WE,
Wilson JL. Vertebral
artery occlusion following
manipulation of the neck.
NZ Med J 1978; 88: 441-
443.
A 23 year old woman, 2 weeks post-partum with head and neck
pain. She saw a physiotherapist and underwent a provocative test
followed by vertical traction with lateral head rotation which
resulted in vertigo within seconds and discontinuation of the
procedure. Upon standing she became ataxic, and had dysarthria,
with right sided numbness of the body. Cerebral angiography
demonstrated total occlusion of the left vertebral artery, a small
right vertebral artery which filled normally, and a large thrombus in
the basilar artery. She was discharged after 2 months of moderate
improvement with some residual issues with coordination,
sensation, and ataxia, as well as left-sided paralysis of the palate
and tongue.
Schmitz A, Lutterbey G,
von Engelhardt L, von
Falkenhausen M, Stoffel
M. Pathological cervical
fracture after spinal
manipulation in a pregnant
patient. J Manipulative
Physiol Ther 2005; 28(8):
633-636.
A 37 year old woman, 15 weeks pregnant with neck pain. She saw
a general medicine practitioner 5 days prior and underwent a single
cervical manipulative treatment and paravertebral injections. She
had swelling and neck pain five days later and MRI showed a
pathological type II odontoid fracture with ventral displacement
producing spinal cord compression and paravertebral hematoma, a
tumor was identified in the C2 vertebral body. She was discharged
without neurological complications and the pregnancy was
undisturbed.
Heiner JD. Cervical
epidural hematoma after
chiropractic spinal
manipulation. Am J
Emerg Med 2009; 27:
1023.e1-1023.e2.
A 38 year old woman, 29 weeks pregnant with low back pain. She
received a cervical manipulation from a chiropractor and
experienced numbness and pain in the neck and arms during the
treatment followed by several seconds of transient upper extremity
paralysis and lower extremity numbness. MRI showed a right sided
epidural hematoma with associated mass effect on the spinal cord.
She was discharged 2 weeks later with minimal residual
paresthesias along the posterior aspect of the neck.
Figure 2 Case Report Descriptions.
Stuber et al. Chiropractic & Manual Therapies 2012, 20:8
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Discussion
To our knowledge, this is the first critical review of the
literature regarding adverse events from spinal manipu-
lation during pregnancy and postpartum and it provides
healthcare professionals with a comprehensive evalua-
tion of the available scientific literature. This review
revealed adverse affects during spinal manipulation in
three studies during pregnancy and two studies in the
postpartum period. Of the studies identified, four case
studies demonstrated adverse events following cervical
manipulation whereas the observational cohort study
demonstrated adverse events following lumbar manipu-
lation. The remaining two papers that were identified
were systematic reviews. As such reports of adverse
events following spinal manipulation in these popula-
tions are scarce in the literature.
Mild and transient adverse events were reported as a
result of lumbar spinal manipulation [43] whereas the
serious adverse events reported in the literature all
occurred following cervical spinal ma nipulation either
during pregnancy [20,21] or postpartum [35,42]. Mur-
phy and colleagues found that 3.4% of their pregnant
pop ulation incurred an injury following manual therapy
which resulted in a transient increase in pain after a sin-
gle session. They found this to be much lower than
other studies that have focused on manual therapy in
which the rate of injury was approximately one third of
the st udy group [43]. As such they suggest ed that SMT
of the lumbar spine is safe for this population, however
a larger sample size would be needed to detect rare
complications [43]. This review did not identify any
injuries or adverse events that could be associated speci-
fically with either being pregnant or in the postpartum
period (such as premature delivery or an abnormally dif-
ficult delivery, etc), t hat is to say that the adverse events
identified may have occurred in a non-pregnant patient.
In the non-pregnant population severe complications
after cervical spinal manipulation are rare [13,22]. How-
ever rare, reported complications include vertebral
artery dissection, cord or root injury, epidural hema-
toma, cervical disc rupture and vertebral fracture [21].
Pregnant and postpartum populations are not immune
to this possibility and given the hormonal and coagul-
ability status of pregnant and postpartum patients it is
possible that SMT is contraindicated in pregnant and
postpartum patients with musculoskeletal complaints.
However, this may depend on the spinal regions and
complaints being treated as different consideration may
need to be given to manipulation of the cervical spine
versus the thoracic or lumbopelvic regions.
Most contraindications to spinal manipulation are evi-
dent during a careful history and physical exam [21].
Clinicians who use SMT as part of the plan of
management for pregnant patients should consider pro-
thrombotic and joint laxity risk factors when deciding
whether to undertake such a therapy in order to mini-
mize the risks of potentially dange rous neurological
complications [35]. Patients at higher risk for c omplica-
tions, such as those in a post-thrombotic state and pos-
sibly those with lax joints, should be treated with
additional care and consideration. There is an increased
importance to counsel this patient with respect to the
risks of SMT [20,35] and these patien ts should be made
aware of the signs and symptoms of possible neu rovas-
cular complications [20,35]. However, based on the lit-
erature reviewed, it cannot be ascertained as to what
role those factors may have actually played in the etiol-
ogy of the adverse events documented, if any.
Although this study has resulted in very few papers to
review, it had strengths including the thorough search
of the literature to help reduce bias in the review. The
authors searched multiple relevant electronic databases
over all possible y ears represented in those databases,
employed a number of broad search terms, performed
reference and hand-searching, examined personal
libraries, and used multiple authors to determine articles
for inclusion in the review and to evaluate and rate the
literature.
The major limitation of this critical review was the
number of studies available and the hierarchy of evi-
dence that the studies available yielded. The papers
identified for t his review were case studies and a pro-
spective observational cohort study, both of which are
lowe r levels of evidence. Given the levels and paucity of
evidence identified, the pos sible level of risk to pregnant
and postpartum patients undergoing spinal manipulative
therapy cannot be measured or stated definitively, nor
can it be determined if any such risk level is higher or
lower than in the non-pregnant or postpartum popula-
tions. However, this does allow for hypothesis genera-
tion and should help drive future directions for
research. There is a need to design and execute larger
and higher quality observational and randomized con-
trolled studies investigating the potential benefits of the
use o f spinal manipulation as a treatment during preg-
nancy or postpartum particularly for those with low
back pain. Such studies should ensure that any possible
adverse events are tracked throughout. One possible
option for an observati onal study design may be a case-
crossover study as adverse events from spinal manipula-
tive therapy may be rare in these populat ions [44,45].
The previous systematic reviews on spinal manipulation
as a tr eatment during pregnancy have highlighted the
lower levels of evidence available thus far on the topic
[1,11]. Another limitation of this review was including
only articles published in English and French.
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Conclusions
There are only a handful of reported cases of adverse
events following spinal manipulation during pregnancy
and the postpartum period in the literature with the
severity ranging fro m mild increases in pain that
resolved quickly to significant life-threatening injuries.
While improved reporting of such events is required in
the future, it may be that such injuries are relatively
rare. Clearly future research into efficacy of this treat-
ment for these populations and the rates of occurrence
of adverse events is necessary to deter mine whether or
not this is true.
Additional material
Additional file 1: Appendix 1. Search strategy.
Additional file 2: Appendix 2. List of included articles.
Additional file 3: Table S1. Case report details.
Author details
1
Division of Graduate Education and Research, Canadian Memorial
Chiropractic College, 6100 Leslie Street, Toronto, ON M2H 3J1, Canada.
2
Texas Chiropractic College, 5912 Spencer Highway, Pasadena, TX 77505-
1699, USA.
Authors contributions
KJS conceived the study, participated in its design and coordination,
conducted the literature search, screened the literature search results,
analyzed and interpreted the data, and drafted the manuscript. SW
conceived the study, participated in its design, screened the literature search
results, and analyzed and interpreted the data. CAW analyzed and
interpreted the data and drafted the manuscript. All authors read and
approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 17 November 2011 Accepted: 28 March 2012
Published: 28 March 2012
References
1. Khorsan R, Hawk C, Lisi AJ, Kizhakkeveettil A: Manipulative therapy for
pregnancy and related conditions: a systematic review. Obstet Gynecol
Survey 2009, 64 :416-427.
2. Skaggs C, Prather H, Gross G, George J, Thompson P, Nelson D: Back and
pelvis pain in an underserved United States pregnant population: A
preliminary descriptive survey. J Manipulative Physiol Ther 2007,
30:130-134.
3. Stapleton D, MacLennan A, Kristiansson P: The prevalence of recalled low
back pain during and after pregnancy: a South Australian population
survey. Aust N Z J Obstet Gynaecol 2002, 42:482-485.
4. Wu H, Meijer O, Uegaki K, Mens J, van Dieen J, Wuisman P, Ostgaard H:
Pregnancy-related pelvic girdle pain (PPP) I: Terminology, clinical
presentation and prevalence. Eur Spine J 2004, 13:575-589.
5. Olsen MF, Gutke A, Elden H, Nordenman C, Fabrisius L, Gravesen M, Lind A,
Kjellby-Wendt G: Self-administered tests as a screening procedure for
pregnancy-related pelvic girdle pain. Eur Spine J 2009, 18:1121-1129.
6. Mogren IM: Physical activity and persistent low back pain and pelvic
pain post partum. BMC Public Health 2008, 8:417-421.
7. Pennick VE, Young G: Interventions for preventing and treating pelvic
and back pain in pregnancy. Cochrane Database of Syst Rev 2007, 2:
CD001139, DOI:10.1002/14651858.CD001139.pub2.
8. Mogren IM, Pohjanen AI: Low back pain and pelvic pain during
pregnancy: Prevalence and risk factors. Spine 2005, 30:983-991.
9. Lisi A: Chiropractic spinal manipulation for low back pain of pregnancy;
A retrospective case series. J Midwifery Women Health 2005, 51:e7-e10.
10. Kristiansson P, Savardsudd K, von Schoultz B: Back pain during pregnancy.
A prospective study. Spine 1996, 2:702-709.
11. Stuber KJ, Smith DL: Chiropractic treatment of pregnancy-related low
back pain: a systematic review of the evidence. J Manipulative Physiol
Ther 2008, 31:447-454.
12. Natvig B, Ihlebaek C, Grotle M, Brage S, Bruugsgaard D: Neck pain is often
a part of widespread pain and is associated with reduced functioning.
Spine 2010, 35:E1285-E1289.
13. Haldeman S, Carroll L, Cassidy JD: Findings from The Bone and Joint
Decade 2000 to 2010 Task Force on Neck Pain and Its Associated
Disorders. J Occup Environ Med 2010, 52:424-427.
14. Coulter ID, Hurwitz EL, Adams AH: Patients using chiropractors in North
America: who are they, and why are they in chiropractic care? Spine
2002, 27
:291-296.
15.
Bishop PB, Quon JA, Fisher CG, Dvorak MF: The Chiropractic Hospital-
based Interventions Research Outcomes (CHIRO) study: a randomized
controlled trial on the effectiveness of clinical practice guidelines in the
medical and chiropractic management of patients with acute
mechanical low back pain. Spine J 2010, 10:1055-64.
16. McMorland G, Suter E: Chiropractic management of mechanical neck and
low -back pain: a retrospective, outcome-based analysis. J Manipulative
Physiol Ther 2000, 23:307-11.
17. Shekelle PG, Coulter I: Cervical spine manipulatiion: summary report of a
systemic review of the literature and multidisciplinary expert panel. J
Spin Disord 1997, 10 :223-8.
18. Nelson C: Principles of effective headache management. Topics Clin Chiro
1998, 5:55-61.
19. Bryans R, Descarreaux M, Duranleau M, Marcoux H, Potter B, Ruegg R,
Shaw L, Watkin R, White E: Evidence-based guidelines for the chiropractic
treatment of adults with headache. J Manipulative Physiol Ther 2011,
34:274-89.
20. Heiner JD: Cervical epidural hematoma after chiropractic spinal
manipulation. Am J Emerg Med 2009, 27:1023. e1-1023.e2.
21. Schmitz A, Lutterbey G, von Engelhardt L, von Falkenhausen M, Stoffel M:
Pathological cervical fracture after spinal manipulation in a pregnant
patient. J Manipulative Physiol Ther 2005, 28:633-636.
22. Cassidy JD, Boyle E, Côté P, He Y, Hogg-Johnson S, Silver FL, Bondy SJ: Risk
of vertebrobasilar stroke and chiropractic care: results of a population-
based case-control and case-crossover study. J Manipulative Physiol Ther
2009, 32(Suppl 2):S201-8.
23. Oliphant D: Safety of spinal manipulation in the treatment of lumbar
disc herniations: a systematic review and risk assessment. J Manipulative
Physiol Ther 2004, 27:197-210.
24. Stuber K: The safety of chiropractic during pregnancy: a pilot e-mail
survey of chiropractors opinions. Clin Chiro 2007, 10:24-35.
25. Humphreys BK: Possible adverse events in children treated by manual
therapy: a review. Chiropr Osteopat 2010, 18:12.
26. Juul-Kristensen B, Rogind H, Jensen DV, Remvig L: Inter-examiner
reproducibility of tests and criteria for generalized hypermobility and
benign joint hypermobility syndrome. Rheumatol 2007, 46:1835-1841.
27. Beighton P, Solomon L, Soskolne CL: Articular mobility in an African
population. Ann Rheum Dis 1973, 32:413-418.
28. Carter C, Wilkinson J: Persistent joint laxity and congenital dislocation. J
Bone Joint Surg 1964,
46B:40-45.
29.
Marnach ML, Ramin KD, Ramsey PS, Song SW, Stensland JJ, An KN:
Characterization of the relationship between joint laxity and maternal
hormones in pregnancy. Am Coll Obstet Gynecol 2003, 101:331-335.
30. Björklund K, Nordström ML, Odlind V: Combined oral contraceptives do
not increase the risk of back and pelvic pain during pregnancy or after
delivery. Acta Obstet Gynecol Scand 2000, 79:979-83.
31. Calguneri M, Bird HA, Wright AV: Changes in joint laxity occurring during
pregnancy. Ann Rheum Dis 1982, 41:126-128.
32. Dragoo JL, Lee RS, Benhaim P, Finerman GA, Hame SL: Relaxin receptors in
the human female anterior cruciate ligament. Am J Sports Med 2003,
31:577-84.
Stuber et al. Chiropractic & Manual Therapies 2012, 20:8
http://chiromt.com/content/20/1/8
Page 6 of 7
33. Hansen A, Jensen DV, Larsen E, Wilken-Jensen C, Petersen K: Relaxin is not
related to symptom-giving pelvic relaxation in pregnant women. Acta
Obstet Gynecol Scand 1996, 75 :245-249.
34. Skott O, Carter AM: Relaxin is a vasodilator hormone. Am J Physiol
Regularory Integrative Comp Care 2002, 283:R347-R348.
35. Ng KPL, Doube A: Stroke after neck manipulation in the post partum
period. J NZ Med Assoc 2001, 114:498.
36. Stella CL, Sibai BM: Thrombophilia and adverse maternal-perinatal
outcome. Clin Obstet Gynecol 2006, 49:850-860.
37. Drife J: Thromboembolism. Br Med Bull 2003, 67:177-190.
38. Maternal and Newborn Health/Safe Motherhood Unit, World Health
Organization: Postpartum Care of the Mother and Newborn: A Practical Guide.
Geneva 1998.
39. Bergmann T, Peterson D: Chiropractic Technique: Principles and Procedures. 3
edition. St. Louis: Elsevier; 2011.
40. Moher D, Liberati A, Tetzlaff J, Altman DG: Preferred reporting items for
systematic reviews 368 and meta-analyses: the PRISMA statement. J Clin
Epidemiol 2009, 62:1006-1012.
41. McPartland JM: Craniosacral iatriogenesis - side-effects from cranial sacral
treatment: case reports and commentary. J Bodywork Movement Ther
1996, 1:2-5.
42. Parkin PJ, Wallis WE, Wilson JL: Vertebral artery occlusion following
manipulation of the neck. NZ Med J 1978, 88:441-443.
43. Murphy DR, Hurwitz EL, McGovern EE: Outcome of pregnancy-related
lumbopelvic pain treated according to a diagnosis-based decision rule: a
prospective observational cohort study. J Manipulative Physiol Ther 2009,
32:616-624.
44. Redelmeier DA, Tibshirani RJ: Interpretation and bias in case-crossover
studies. J Clin Epidemiol 1997, 50:1281-7.
45. Smeeth L, Donnan PT, Cook DG: The use of primary care databases: case-
control and case-only designs. Fam Pract 2006, 23:597-604.
doi:10.1186/2045-709X-20-8
Cite this article as: Stuber et al.: Adverse events from spinal
manipulation in the pregnant and postpartum periods: a critical review
of the literature. Chiropractic & Manual Therapies 2012 20:8.
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Stuber et al. Chiropractic & Manual Therapies 2012, 20:8
http://chiromt.com/content/20/1/8
Page 7 of 7
    • "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 . "
    [Show abstract] [Hide abstract] 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
    • "No new or additional studies were found for the following conditions: coccydynia, dysmenorrhoea, premenstrual syndrome. Adverse events Seven systematic reviews [24,25,28,29,210211212213 and seven primary studies214215216217218219220 were identified specifically concerning adverse events of manual therapy . Mild-to-moderate adverse events of transient nature (e.g., worsening symptoms, increased pain, soreness , headache, dizziness, tiredness, nausea, vomiting) were relatively frequent. "
    [Show abstract] [Hide abstract] ABSTRACT: This systematic review updated and extended the "UK evidence report" by Bronfort et al. (Chiropr Osteopath 18:3, 2010) with respect to conditions / interventions that received an 'inconclusive' or 'negative' evidence rating or were not covered in the report. A literature search of more than 10 general medical and specialised databases was conducted in August 2011 and updated in March 2013. Systematic reviews, primary comparative studies and qualitative studies of patients with musculoskeletal or non-musculoskeletal conditions treated with manual therapy and reporting clinical outcomes were included. Study quality was assessed using standardised instruments, studies were summarised, and the results were compared against the evidence ratings of Bronfort. These were either confirmed, updated, or new categories not assessed by Bronfort were added. 25,539 records were found; 178 new and additional studies were identified, of which 72 were systematic reviews, 96 were RCTs, and 10 were non-randomised primary studies. Most 'inconclusive' or 'moderate' evidence ratings of the UK evidence report were confirmed. Evidence ratings changed in a positive direction from inconclusive to moderate evidence ratings in only three cases (manipulation / mobilisation [with exercise] for rotator cuff disorder; spinal mobilisation for cervicogenic headache; and mobilisation for miscellaneous headache). In addition, evidence was identified on a large number of non-musculoskeletal conditions not previously considered; most of this evidence was rated as inconclusive. Overall, there was limited high quality evidence for the effectiveness of manual therapy. Most reviewed evidence was of low to moderate quality and inconsistent due to substantial methodological and clinical diversity. Areas requiring further research are highlighted.
    Full-text · Article · Mar 2014
    • "Vasculitis leading to chronic inflammation increasing vessel wall fragility has also been proposed as a contributing factor [6]. Migraine was shown to be associated with a two-fold increase risk of cervical artery dissection in a recent meta-analysis [7]. Stuber et al recently published an critical review of the literature regarding adverse effects from spinal manipulation in the pregnant and postpartum periods [8]. They identified adverse events in five pregnant women, and two postpartum women. "
    [Show abstract] [Hide abstract] 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
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