What if You're Pregnant?

Chiropractic and Pregnancy 

By Sanford Skolnik, D.C. 

There are several changes that take place to the woman's musculoskeletal system in pregnancy. 
The more observable of these involves posture. 

There are primarily four (4) postural changes that occur in pregnancy. First, there is an increasing lumbar lordosis (the normal, gentle curve to the low back) and shifting of the center of gravity towards the back over the lower legs. Secondly, the sacrum (the bone between the hips) angle of attachment becomes increased. There is an increased mobility of the sacroiliac, sacrococcygeal, and pubic joints that therefore lead to an alteration of gait. There is an alteration in the feet, including turning outward, flattening of the arches, and a shift of weight bearing toward the heel 
leading to muscle imbalance, weakness, and compromised coordination. 

In a pregnant patient, the Sacro-Iliac joint becomes very unstable. Some of the findings associated with this instability are: pain and tenderness to palpation along the sacroiliac joint; most often unilateral, but may be bilateral. This may be accompanied by palpable swelling and fluid distention of the joint between the hips. There is a decreased lumbar range of motion. There is tenderness at the lateral aspect of the posterior superior iliac spine (PSIS) at the attachment of the piriformis muscle. This is the same muscle that becomes sore and tender with excessive exercise like a stair master. 

Pain and tenderness along the iliac crest at the attachment of the gluteus maximus muscle is common. Tenderness is also common at the greater trochanter at the insertion of the gluteal muscles, and in the belly of the piriformis muscle (this is along the buttocks and to the back of the thigh). 

There is spasm of the erector spinae of the side of the posterior ilium. Spasm, or decreased tone, or involvement of the posas muscle on the side of the gluteal irritation. Commonly, there are symptoms such as pain when rising from seated position, pain and spasm while turning over in bed, inability to place weight on the lower extremity on the side of sacroiliac involvement, etc.  Additionally, there is irritation, sensitization or frank inflammation of the sciatic nerve as it passes under or through the piriformis. 

What happens to the lumbar spine during pregnancy and how does it present? 

As the pregnancy progresses, there is increasing weight added to the anterior of the pelvis. In order to maintain more stable and evenly distributed weight bearing structure, the lumbar spine becomes ever increasingly more lordotic.  This, however, places an ever increasing load of weight bearing on the posterior elements (facets) of the spine. This imbalance combined with the stretching of the abdominal muscles sets the stage for lumbar strain and a bilaterally, anteriorly, rotated pelvis. 

What happens to the thoracic spine during pregnancy and how does it present? 

The weight of the breasts, widening of the angle that the ribs attach and pressure on the lower four to five ribs, viscero-somatic reflex from stressed organs such as the stomach, liver and pancreas, and thereby responsively increasing the lumbar lordosis. 

The psychological changes that occur with pregnancy are either due to normal or biomechanical changes. The changes that occur due to progesterone or a decrease in smooth muscle and vascular tone, increase in fat storage, temperature, and development of the breasts for nursing.  Changes in estrogen levels cause significant alterations in the connective tissue, control and function of the uterus, growth and regulation of the fetus. 

There are primarily three neurological conditions that are associated with pregnancy. 

1.    Meralgia parasthetica: Compression of the lateral, femoral, cutaneous nerve as it passes 
        beneath the inguinal ligament. Pain and most often paresthesia are seen in the lateral aspect 
        of the upper thigh. 
2.    Sciatic neuralgia: Compression of the lumbar plexus resulting in pain in the pelvic region 
        and/or pain radiating down the leg. 
3.    Traumatic neuritis: Motor and sensory deficits of L5, S1 and S2 nerve roots after labor. 
        It may be a result of one or more of the following: 
            disc protrusion at IVD 
            traction of lumbosacral trunk (forceps) 
            compression of lumbosacral trunk by fetal head 
            compression of popliteal nerve due to positioning 

What types of techniques would work well on a pregnant patient? 

I think that the more gentle, low force techniques (i.e. S.O.T., Activator, Biophysics and Diversified) would be of greatest value to these patients because of the ligamentous laxity induced by all of the hormonal and biomechanical changes that the patient is experiencing. Lack of proper equipment for the comfort of the pregnant patient are my primary concerns.