Adjusting… Pregnancy Modifications for the Pregnant Patient

What causes subluxation? 3T’s – Thoughts – Trauma – Toxins Also consider hormonal and biomechanical factors

Hormonal Factors – Alteration of supporting structures Progesterone – decreases smooth muscle tone – This alters the vascular supply to the motor unit as well as the surrounding structures and all of the joints of the body Estrogen – relaxes the joint capsule – Allows for more “play” in the joints Relaxin – contributes to the “relaxation effect” allowing the pelvis to open (Fallon, 1994)

Biomechanical Changes Increased kyphosis Increased lordosis

What modifications should we make? Alteration of supporting structures; joint laxity – ? Changes in kyphosis/lordosis – ?

Cervical Spine Adjusting is handled in the same manner as non-pregnant women Remember to consider: laxity of ligamentous structure decrease in cervical lordosis (kypholordosis) – anterior head carriage, etc.

Thoracic Spine Stress on the thoracic kyphosis – breast enlargement – compensatory curve changes Flaring of the ribcage – Adjust the thoracic spine as well as ribs NOTE: intercostal neuralgia is common

Clinical Note Thoracic and abdominal compression will become more and more uncomfortable as the baby grows… Some DC’s like to use anterior adjusting – patient doesn’t have to be prone

Other Solutions Swing-away abdominal piece Crank pelvic piece Pregnancy pillow – gap for baby – protects the breasts – softens the table

Lumbar Spine Hyperlordosis ~> stress on facets – Spinous imbrication - facet “jams”

Pelvis Subluxations can occur in 3 separate places – R and L SI joints, symphysis pubis Most common area of involvement – Hormonal influences – Weight gain – Altered support structures – Joint capsules constantly stretched by pressure from the fetus

Chiropractic Assessment Observation Static Palpation Motion Palpation Instrumentation Radiography Adjustments

Observation – Pregnancy Normal postural changes of pregnancy must be differentiated from postural abnormalities that are clinically relevant. Lateral view Increased lumbar lordosis & sacral base angle – usually present by the 2 nd tri Exaggerated thoracic kyphosis Anterior translation of the head and cervical spine

Observation – Pregnancy The innominates may flare outward to compensate for the developing fetus May cause a compensatory gait alteration – “waddle” This does not indicate a bilateral “In” ilium fixation or a bilateral ilium adjustment

Clinical Note Pregnant patients may present the doctor with a more complex and difficult palpation assessment - constantly changing posture and biomechanical adaptation Subluxation vs. compensation? Compensation – may manifest as more symptomatic that the site of joint fixation

For example… SI joints may be – symptomatic – reveal tenderness upon static palpation – movement is normal Does not warrant adjustment! Similar findings may present in transitional regions (CO-C1, C7-T1, T12-L1)

Static Palpation – Pregnancy Digital palpation for tenderness and edema – Detected at both hypo and hypermobile* segments Also note suderiferous changes, tissue prominency, etc. *It is contraindicated to adjust a hypermobile articulation!

Motion Palpation – Pregnancy Intersegmental range of motion palpation – Passive – Patient assisted May be best done seated – Spine in a neutral position Modify your technique as the abdomen grows

Instrumentation – Pregnancy Dual Probe – break analysis – temperature patterns may vary more than the non- pregnant patient Compensations – may manifest as increased temperature differentials Subluxations – demonstrate a constant “break” Findings should be correlated with other exam findings.

Radiography – Pregnancy Usually not obtained on the pregnant female – Increased risk associated with fetal exposure Ursprung et al. Plain Film Radiography, Pregnancy, and Therapeutic Abortion Revisited. JMPT 2006; 29(1):83-87 In the case of trauma (cervical spine)… – may consider limited views Must discuss possible risks Use all safety precautions

Adustments – Pregnancy As stated before… Hormonal changes increase mobility If a motion segment is compensating for a lack of mobility at any level, then it may become more hypermobile Forces should not be introduced into joints that exhibit hypermobility!

– GONSTEAD – ACTIVATOR – LOGAN – THOMPSON – SOT – DIVERSIFIED – Any technique can be modified! Limitations: Patient comfort Patient size & mobility/flexibility Your creativity…

Remember Make sure she‘s comfortable 2. Keep her spine in a neutral position 3. Light thrusts! “...a rebound effect can occur if adjustments are too forceful during pregnancy.“ Larry Webster

Positioning her comfortably Give baby room but still support the abdomen – slight pressure on the abdomen will not harm the baby Work with your patient – her needs will change as the pregnancy progresses – let her tell you what feels best

Clinical Note In the last trimester, minimize time spent flat on her back – puts unnecesary pressure on abdominal aorta

Treatment Protocol (Fallon, 1994) How often should a pregnant woman be adjusted? Varies from patient to patient. 1x/month1 st trimester 2x/month2 nd trimester 1x/week leading up to & following birth 2x/month 1x/month (stabilizes)

References Anrig & Plaugher. Pediatric Chiropractic. Baltimore, MD: Lippincott Williams & Wilkins, Anrig-Howe C. Scientific Ramifications for Providing Pre-natal and Neonate Chiropractic Care. The American Chiropractor, 1993; May/June: Fallon. Textbook on Chiropractic and Pregnancy. Arlington, VA: International Chiropractors Association, Forrester J. Chiropractic Management of Third Trimester In-utero Constraint. Canadian Chiropractor, 1997; 2(3): Fysh. Chiropractic Care for the Pediatric Patient. Arlington VA: ICACCP, Kunau P. Application of the Webster In-utero Constraint Technique: A Case Series. Journal of Clinical Chiropractic Pediatrics, 1998; 3(1): McMullen M. Assessing upper Cervical Subluxations in Infants Under Six Months. ICA International Review of Chiropractic, 1990; March/April: Pistoles R. The Webster Technique: A Chiropractic Technique with Obstetric Implications. JMPT, 2002; 25(6). Webster L. Chiropractic Care During Pregnancy. Today’s Chiropractic, 1982; Sept/Oct: