Pregnancy should be a time

Chiropractic Evaiuation and Management of the Pregnant Patient: An Update from Recent Literature by Lindsey Zerdecki and Steven Passmore P regnancy...
Author: Frank Burns
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Chiropractic Evaiuation and Management of the Pregnant Patient:

An Update from Recent Literature by Lindsey Zerdecki and Steven Passmore

P

regnancy should be a time of joy for the expectant mother. However, it's also a virtually unparalleled period of rapid change in one's morphology. The stresses placed on a human's anatomy and physiology result in compensatory altered biomechanics and gait to perform even the 'ák^M^M\ n^ost basic activities of daily living. These | | _ 0 _ ^ changes to an individual often result in the onset of a myriad of musculoskeletal issues that can develop during pregnancy. This article details the current explanations of these changes as well as the potential role of chiropractic therapy for the pregnant woman. Low Back Pain and Physiologic Changes in the Pregnant Patient

Low back pain is a common complaint of the pregnant woman (Ritchie 2003). Research has demonstrated that between 50% and 80% ofpregnant patients report low back pain (Skaggs et al. 2004), the majority when the mother is between 20 and 40 weeks pregnant (Kristiansson, Svärdsudd and von Schoultz 1996). An estimated 25% of women with low back pain during pregnancy have a severity of pain categorized as temporarily disabling (Borg-Stein, Dugan and Gruber 2005). A portion of this back pain can be attributed to the release ofthe hormones progesterone, estrogen and relaxin during the beginning stages ofpregnancy (Borg-Stein, Dugan and Gruber 2005). These hormones primarily cause decreased muscle tone, changes in connective tissue integrity, retention of water and laxity of ligaments. Ligamentous laxity (looseness ofthe ligaments) in the pelvis can cause hypermobility ofthe pubic symphysis or the sacroiliac joints, thus affecting lumbar spine stability (Bogduk 1997). This laxity, along with changes in posture, may be the main components of low back pain in the pregnant population. Postural changes in the pregnant patient include: increased lumbar lordosis (leading to shortened lumbar musculature), increased sacral base angle, increased extremity pronation, possible transient rever-

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sal ofthe cervical lordosis, a shift ofthe plumb it will pull the pelvis toward it (Anonyline posteriorly and a change in the sacro- mous 2003). coccygeal angle (Benizzi DiMarco 2003). These changes in posture cause an increased Beyond Low Back Pain—the Role of load on the posterior aspects ofthe vertebral the Chiropractor in the Evaluation column including the zygapophyseal joints; and Management of the intervertebral discs; supraspinous, intraspiPregnant Patient nous and intertransverse ligaments along Besides low back pain, other conditions with the ligamentum flavum and muscles that occur during pregnancy are within including the deep spinal muscles; the erec- a chiropractic scope of practice for mantors; the psoas and the muscles ofthe pelvis. agement or evaluation. These include peri(Editor's Note: For a better understanding of pheral nerve entrapments, headaches, tranthe psoas in relation to pregnancy, see "Birth- sient osteoporosis or osteonecrosis and pubic ing Fear: The Iliopsoas Muscle," Midwifery Today, pain. Common nerve entrapments at the Issue 74.) In addition, anterior structures are carpal tunnel (median nerve) and the inguinal not spared; stretching of the anterior longi- region (lateral femoral cutaneous nerve) lead tudinal ligament also occurs, yielding spinal to carpal tunnel symptoms or meralgia paresinstability (Ibid). thetica (numbness in the outer thigh) respecAlthough lumbar disc herniations are tively (Borg-Stein, Dugan and Gruber 2005). uncommon in pregnant women, they do Nerve entrapments during pregnancy can be appear in approximately one of 10,000 attributed to hormonal changes causing poscases of lumbosacral pain during preg- sible edema around a nerve, compression or nancy (LaBan et al. 1995). Weight gain, traction to the nerve itself Edema around the coupled with the previously mentioned extensor pollicus brevis and abductor pollicus hormonal and postural changes, alters bio- longus can cause DeQuervain's syndrome mechanics, which may contribute to disc (stenosing tenosynovitis) (Ibid). herniations. Weight gain further increases The pregnant patient also may present loads on the joints ofthe lumbar spine. A with headache. Melhado, Macial and Guerweight gain of 20%, which is adequate, reiro (2007) found that the majority ofwomen increases the load on the zygapophyseal with headaches during pregnancy presented joints by as much as 100% (Ritchie 2003). with migraine headaches, which the women The morphology and biomechanical strain had prior to conception. Most disappeared on a pregnant woman are not unlike that by the second or third trimester (Melhado, of the man with a pendulous protuber- Macial and Guerreiro 2007). ant abdomen or "beer belly." Differences Although rare, transient osteoporosis between the two would be, most notably, of the femoroacetabular joint can develop the slow onset of weight in males and the during pregnancy. This condition presents lack of hormonally-induced ligamentous with weight-bearing hip pain, usually in laxity. An empirical comparison of these the third trimester (Borg-Stein, Dugan and populations in terms of lordosis, stability Gruber 2005). The etiology for this condition and response to intervention needs fur- is unknown (Ritchie 2003). A possibility of ther study. osteonecrosis ofthe femoral head also exists. Another contribution to low back pain Causes for the condition are unknown, but in pregnant women is anterior pelvic rota- some theorize that the higher cortisol levels tion and subsequent muscle hypertonicity, combined with increased stress of the joint because pelvic rotation leads to increased from weight gain may be responsible (Cheng, lumbar lordosis (Borg-Stein, Dugan and Burssens and Mulier 1982). Another hypothGruber 2005). Asymmetrically taut ham- esis is that the higher levels of estrogen and strings may also affect pelvic rotation. If progesterone along with increased intraosone side is more hypertonic than the other seous pressure may contribute to the devel-

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opment of osteonecrosis of the femoral head (Hungerford and Lennox 1985). Pubic pain also is commonly seen in pregnant women. Various conditions may be the cause of this pubic pain including: increased motion due to ligamentous laxity, osteitis pubis or a rupture of the symphysis pubis. All of these conditions are considered self-limiting, with rare exceptions, in which case care may be warranted (BorgStein, Dugan and Gruber 2005). One must consider the totality of symptoms to determine whether causality may be temporally, anatomically or physiologically attributed to pregnancy, because a patient's complaint may not be related to tbe pregnancy at all, but from a previous co-morbid condition (Anonymous 2003). Thorough evaluation and frequent re-evaluation of a patient is essential to avoid failing to diagnose and manage a patient appropriately.

for women who want a natural birth, and it increases the risk for both mother and baby of other complications from pain-relieving drugs and instruments. Pregnant women who are clinically depressed in the early parts of pregnancy also have an increased risk of developing preeclampsia (Kurki et al. 2000). In addition, the risk of bleeding during gestation, prematurity(< 37 weeks), low Apgar scores, neonatal unit admissions, neonatal growth retardation, elevated fetal heart rate and low birth weight (