Spinal manipulation and pregnancy (Full Version)

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ALICIAPT13 -> Spinal manipulation and pregnancy (July 19, 2006 9:55:00 AM)

I have recently learned a few lumbopelvic manipulations for treating patients with low back pain. The class I took did not have a clear answer on manipulating women who are pregnant. Articles I have found vary; some say never to manipulate as pregnancy is a contraindication. Some say that it is safe to manipulate up to a certain month, depending on if the mother is in her first pregnancy or not. Most of the trials done on the effects of manipulation on LBP use pregnancy as an exclusion criterion. What I am looking for is good evidence on this topic, whether it agrees or disagrees with manipulating these women. Anyone have any free full-text fitting this???

Thanks,
Alicia



emad/emad -> Re: Spinal manipulation and pregnancy (July 19, 2006 10:26:00 AM)

Hi Alicia :

First of all , i have NO article /research/evidence concerning safety of manipulation application in pregnancy .

But , i like to say manipulation here is gulity until other evidenced ,i mean why i am going to apply manipulation for back pain ,while just rest could give more better outcomes .
Another point ,you may find evidence support its application and others not .

Cheers
Emad



drbuddy -> Re: Spinal manipulation and pregnancy (July 19, 2006 10:30:00 AM)

FWIW, we were never taught that manipulation was a contraindication. Technique must be altered to avoid pressure on the abdomen, and you might want to use less forces as well.

Rest is as good as manipulation? I'm guessing you dont have too much experience with manipulation to make such an uninformed statement. Patient selection is important, and when used appropriately, manipulation will provide good outcomes.

Do you feel that rest is just as good as providing other therapeutic interventions?



emad/emad -> Re: Spinal manipulation and pregnancy (July 19, 2006 10:44:00 AM)

Hello Buddy :

Just my view regardless of uninformed or informed , or my experience with manipulation .

Let me put the manipulation debat aside ,we are just discussing its safety and appropriateness in pregnancy .
Personally , i think just fine ,relaxed ,gentle activities/motions within a rest period is enough .

Cheers
Emad



Alex Brenner PT MPT OCS -> Re: Spinal manipulation and pregnancy (July 19, 2006 10:52:00 AM)

Alicia,
To my knowledge there is no evidence for or against the use of manipulation on someone who is pregnant. I can anecdotally say that I have good results with it and it appears very safe. Unfortunately we live in a litigious society and so as a civilian therapist I would be very cautious on whom you manipulate. I personally feel that it is a very safe intervention and have done it many times even into the later trimester depending on the "belly" factor.

emad/emad,
Bed rest greater than one day, as shown in several studies, is actually a contraindication for low back pain so I am not sure where you received your information.



TMondale -> Re: Spinal manipulation and pregnancy (July 19, 2006 11:36:00 AM)

Alicia,

Excellent question, not much out there to guide us on it however. I tend to agree with those who say it is mostly safe and effective in this population when selected properly. I do however avoid manipulation in the first trimester, just due to the chance of problems (particularly spontaneous abortion) within that time, tends to be higher. I don't know if manipulation would have any affect on the rate of spontaneous abortions, but I would not like to have any reason to be associated with it.

Tim



drbuddy -> Re: Spinal manipulation and pregnancy (July 19, 2006 11:38:00 AM)

Have you all heard of the Webster technique? It is a technique used when the baby is in a breeched position. Preliminary studies show a 80% plus success rate in getting those babies to turn. That is performed well into the 3rd trimester. It involves trigger point therapy to an anterior pelvic muslce/ligament (I dont do it so I forget), and adjusting the sacrum.

I'm curious to hear your concern with manipulation during pregancy. Are you worried about compressing the abdomen too much? Or are we just being extra careful because there is a cute little baby in there?

Don't get me wrong, I see your concern and desire to err on the safe side. I'll often do the same myself. If I do attempt to manipulate someone that is pregnant, I will use very light force.



dosrinc -> Re: Spinal manipulation and pregnancy (July 19, 2006 1:23:00 PM)

Buddy, I think the concern is this:
You do the manipulation, the pt. miscarries, now she very well may have miscarried anyway but....
Rick



drbuddy -> Re: Spinal manipulation and pregnancy (July 19, 2006 2:01:00 PM)

I see your point, but on the other hand, we can't tip toe around every patient just because they may blame us for something. I know, there is a fine line...



emad/emad -> Re: Spinal manipulation and pregnancy (July 20, 2006 6:29:00 AM)

Hello Alex and all :

Alex,correct long bed rest in pain is not indicated in recent studies , i do NOT recommend it more than what you said ,just i suggest gentle neurodynamics/neural mobilisations and physiological lumbar mobilisation ,,,only just gentle for few numbers just once daily and ordinary daily life activities .

My view is avoidance of aggressive /sudden technique to be safe from blaming and avoiding protective reflex .

Cheers
Emad



ALICIAPT13 -> Re: Spinal manipulation and pregnancy (July 20, 2006 9:29:00 AM)

Thanks for all of the responses. The effectiveness of manipulation and low back pain can be very high if the patients fit certain criteria (clinical prediction rule). The more criteria they fit, the better the chances they will improve with manipulation. I am not manipulating everyone wit LBP, just those that statistically should benefit from it.

I guess my concern with manipulating someone who is pregnant would be the idea of harm. Also, the ligamentous laxity associated with the hormone changes of pregnancy.

Alicia



valmarie -> Re: Spinal manipulation and pregnancy (July 20, 2006 3:13:00 PM)

Well coming from a pregnant woman herself....my ligaments and joints are lax enough and mobile enough and the last thing I would want to do is mobilize them more than they are already getting with just normal everyday activities. Granted, a simple mob technique may very well assist in obtaining correct spinal/vertebral body position that may have been lost due to positioning and ligamentous laxity in the first place...but personally, anything beyond one or two manipulations is looking only to add to the problem. Stability is needed during pregnancy over anything else to create support for the loosening joints.

But of course, this is just my opinion. I honestly lack quite a bit of experience treating both LBP as well as pregnant patients.



Alex Brenner PT MPT OCS -> Re: Spinal manipulation and pregnancy (July 21, 2006 3:38:00 AM)

Hi Val. I am certain that most in the manual therapy area of physical therapy agree that when we manipulate we are not realigning anything. Anyone that says they are realigning the spine or sacrum need to take a long hard look in the mirror. In fact, we are uncertain exactly what happens or what the mechanism is for spinal manipulation. Your statement about adding to the problem is purely anecdotal and I do not know of any studies that back your statement up. If you know of some, please share with me. I understand yours and Alicia's theory about the ligament laxity/hormone changes but I just don't buy it that manipulation would cause this to get worse.

In fact, there is a case study that is currently in press with Manual Therapy where some colleagues of mine performed manipulation on a patient who had clinical symptoms of lumbar instability. They were able to demonstrate utilizing RUSI (Rehabilitative Ultrasound Imaging) that manipulation improved Transversus Abdominis muscle activation directly following lumbosacral manipulation. Following manipulation the hypermobile patient was able to more fully contract the TrA and was better able to perform their lumbar stabilization exercises and ultimately had improvement in low back pain symptoms. Now granted a case study is very low level of evidence, but it appears from this study that manipulation improves muscle inhibition even in patients with lumbosacral instability. So with this theory, backed with at least a case study, we have some evidence to show that a hypermobile pregnant woman may benefit from lumbosacral manipulation along with a lumbar stabilization program.

Alex



PTupdate.com -> Re: Spinal manipulation and pregnancy (July 21, 2006 5:23:00 AM)

Something to consider: Almost every day there are commercials on TV asking if YOU have some birth defect or other issue related to birth, and if so, WE CAN GET MONEY FOR YOU!!!

If you manipulate the lumbar spine, or even thoracic spine of a pregnant person, and god forbid there is a miscarriage, be prepared to defend yourself, because someone is going to look for a place to point a finger.

Here in Pennsylvania, lawsuits against physicians are wayyyyy out of control, and OB/GYN are at the top of the "most sued" list. Having watched a PT I know go through a lawsuit, that was completely groundless, trust me when I tell you it gets ugly and mean, and good attorney's can pick a PT apart.

John Duffy, PT OCS

Alex: Race you to 1000 posts? Also check your hotmail email, as I never heard back from you



ALICIAPT13 -> Re: Spinal manipulation and pregnancy (July 21, 2006 6:18:00 AM)

Alex - do you have a lead author name on that case study?

Thanks for all the responses!

Alicia



Alex Brenner PT MPT OCS -> Re: Spinal manipulation and pregnancy (July 21, 2006 6:26:00 AM)

John,
You make a great point. I feel very comfortable and somewhat protected because I am in the military. I am certain that if I was a civilian therapist I would be a lot more selective on which pregnant patients that I choose to manipulate even though there are no data that I know of to suggest that manipulation can cause a miscarriage. It goes back to the litigious society that we live in.

John,
I sent you a private message.

Alex



valmarie -> Re: Spinal manipulation and pregnancy (July 21, 2006 9:23:00 AM)

Alex,

Of course it was anecdotal, what'd ya expect from someone lacking experience in this area? ;)

That case study sounds interesting, it really changes my current perspective on things. It just seems to me that when you are mobilizing a joint you are placing some kind of pressure on the surrounding supporting ligaments....and if they are already lax to begin with I can't see the benefit of a gentle low grade mob. Then you get up to levels 4 and 5 (did I remember that right?) and it *seems* it could risk stressing the ligaments further than they already are and in a pregnant woman, with the relaxin, it just *seems* counterproductive.

I have much to learn though. I'll keep my eyes/ears open for further research in this area now that my interest is peeked.



Alex Brenner PT MPT OCS -> Re: Spinal manipulation and pregnancy (July 21, 2006 11:51:00 AM)

Alicia,
Here is the citation for that case study that is in press with Manual Therapy:

Gill NW, Teyhen DS, Lee IE. Improved contraction of the transversus abdominis immediately following lumbopelvic manipulation: a case study using real-time ultrasound imaging. Manual Therapy (in press).

I am the lead author with Skip Gill on another case study on a gentleman that demonstrated improved contraction of the lumbar mulitifidus following spinal manipulation. There was a thread on this a few weeks ago. That one should be going to JOSPT really soon.



Alex Brenner PT MPT OCS -> Re: Spinal manipulation and pregnancy (July 21, 2006 12:05:00 PM)

Val,
I see your rationale and I understand where you are coming from. Graded mobs and manipulation do seem to be counterintuitive but the truth of the matter is that we just don't know. Do you remember when aggressive eccentric exercises seemed counterintuitive for chronic Achilles tendonitis? The evidence now actually shows that this intervention results in improvement for this condition. We just don't know until we have some quality studies to back up our interventions. Even to this day, despite quality published research, many therapists ignore the benefits of spinal manipulation for certain subgroups of patients with acute low back pain. Doesn't it seem counterproductive to manipulate an acute low back? Well, research shows that manipulation actually results in DRAMATIC improvement; the opposite of what *seems* right.

I am not attacking you, just trying to make you more aware. Good luck and I am glad you are seeking evidence based care. You will be a much, much better therapist for that.

Check out this website when you get a chance.

[URL=http://www.evidenceinmotion.com]www.evidenceinmotion.com[/URL]



SJBird55 -> Re: Spinal manipulation and pregnancy (July 21, 2006 6:43:00 PM)

Brenner... too bad Duffy can't reply to you... you need to do some deleting.



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