The chiropractic care of pregnant women: a scoping review of the literature

doi:10.21203/rs.3.rs-2454751/v1

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The chiropractic care of pregnant women: a scoping review of the literature

https://doi.org/10.21203/rs.3.rs-2454751/v1

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Background

Of the various practitioner-based alternative therapies, chiropractic is highly utilized by pregnant women to address mainly pregnancy related pelvic girdle pain and low back pain. Despite its popularity among pregnant women, no consolidation of the peer-reviewed literature on pregnancy chiropractic care has been performed. To address this deficit, we performed a scoping review to inform chiropractors and other healthcare professionals involved in perinatal care.

Methods

The literature review was conducted from 1978 to 2022 using PubMed, AMED, EMBASE, CINAHL, MANTIS and Index to Chiropractic Literature. The search terms were chiropractic, chiropractic care, chiropractic manipulation, pregnancy or pregnant or prenatal or antenatal or perinatal or maternal and related words. Inclusion criteria for our review were manuscripts: (1) involving pregnancy care within the scope of practice of chiropractic (i.e., spinal manipulative therapy (SMT) and/or adjunctive therapies) and (2) published in a peer-reviewed journal. Exclusion criteria were: (1) abstracts from conference proceedings, (2) dissertations for a Master or PhD degree, (3) letters to the Editor, (4) chapters in textbooks and (5) non-English language manuscripts. Natural Language Processing and K-means cluster analysis was applied to the eligible manuscripts to identify themes and deficits of the existing literature.

Results

A total of 127 manuscripts from 733 titles met inclusion criteria for review consisting of three randomized controlled trials, 18 cohort studies, one case control, 49 case reports, 13 case series, one qualitative study, 33 commentaries, 8 systematic reviews, and one best practice recommendations document. Four clusters were identified with manuscripts describing care of pregnant women with complex MSK presentations (Cluster 1), the care of pregnant women with simple MSK presentations (Cluster 2), the use of the Webster Technique (Cluster 3) and papers characterized by advocacy for the chiropractic care of pregnant women (Cluster 4).

Conclusions

Overall, there is a deficit in the literature on chiropractic pregnancy care. Studies characterizing the practitioner and patient perspective are lacking. We encourage continued research efforts on chiropractic pregnancy care to inform prenatal research, practice, education, and policy.

chiropractic

pregnancy

scoping review

spinal manipulation

Utilization studies continue to document the growing popularity of complementary and alternative medicine (CAM) in the general population [1]. For women in pregnancy and the postpartum period, Barnes et al. [2] identified two over-arching motives for CAM use: 1) to protect themselves or their babies from adverse events, and 2) to facilitate the normal physiological processes of pregnancy, birth and lactation. Bowman et al. [3] found similarly in that women used CAM to support their sense of self-determination, to pursue a natural and safe childbirth, and because they resonate with the philosophical underpinnings of the CAM therapies used.

Of the various practitioner-based CAM therapies, chiropractic is highly utilized [4–8] and well established with chiropractors practicing in 100 countries worldwide [4]. Chiropractors have been caring for pregnant women since chiropractic’s inception [9]. With a holistic and vitalistic approach to patient care [10], chiropractic supports a woman’s need for a safe and natural childbirth [11–12] and provide relief of their musculoskeletal (MSK) complaints (i.e., low back pain (LBP) and/or pelvic girdle pain (PGP)) [13–15].

In the past 10 years, we noted from within chiropractic, a growing interest in pregnancy care among chiropractors based on the growing professional membership in the International Chiropractic Pediatric Association (ICPA) that advocate for and provide postgraduate training in chiropractic perinatal care [16], published textbooks on chiropractic prenatal care [17, 18] and the overall popularity of CAM therapies during pregnancy [2, 3]. However, to date, no comprehensive assessment and consolidation of the peer-reviewed literature on the chiropractic care (i.e., the use of the spinal adjustments and adjunctive therapy) of pregnant women has been performed. To inform clinical practice and research, health care consumers and policy makers, we performed a scoping review of the literature on the chiropractic care of pregnant women to determine the types and sources of literature, identify key themes and gaps/deficits in the existing literature.

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-ScR) guidelines [19] with the following steps: (1) formulate the research question, (2) identify and select the relevant literature, (3) charting or extracting relevant data, and (4) collating, summarizing, and reporting the results.

STEP 1: Formulating the research question

Our scoping review was guided by the following questions:

What are the aims/purpose, types and sources of literature?

What is clinically relevant information (i.e., presenting complaints, management protocols) provided by the manuscripts?

What are the patterns or themes of the reviewed manuscripts?

What are the gaps/deficits in the existing literature?

STEP 2: Identifying and selecting the relevant literature

Our literature search utilized PubMed, Allied and Complementary Medicine (AMED), Excerpta Medica Database (EMBASE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Manual, Alternative and Natural Therapy Index System (MANTIS) and Index to Chiropractic Literature. The search terms were “chiropractic or chiropractic care or chiropractic manipulation AND pregnancy or pregnant or prenatal or antenatal or perinatal or maternal” utilizing the “apply related words” function from January 1, 1978 to November 20, 2022. Inclusion criteria for our review were manuscripts: (1) involving pregnancy care within the scope of practice of chiropractic (i.e., spinal manipulative therapy (SMT) and/or adjunctive therapies) and (2) published in a peer-reviewed journal. Exclusion criteria were: (1) abstracts from conference proceedings, (2) dissertations for a Master or PhD degree, (3) letters to the Editor, (4) chapters in textbooks and (5) non-English language manuscripts.

The principal author (JA) doubly screened the search results for their eligibility and confirmed by the co-authors (SPM, EE, SG) with disagreements resolved by consensus. The principal author also examined the references of the reviewed manuscripts for eligible literature not previously identified.

STEP 3

Charting or extracting relevant data

The principal author (JA) extracted the following data from the relevant studies using an Excel spreadsheet: (1) study description (i.e., study design, year of publication, country of origin); (2) aim or study purpose (3) clinical management information (i.e., diagnosis/assessment procedure(s), chiropractic technique and adjunctive therapies and (4) summary of findings.

The extracted data was confirmed by a second review author (EE, SG and SPM) to minimize error. Disagreements were addressed by consensus among the authors.

STEP 4: Collating, summarizing, and reporting the results

To integrate disparate literature of varied designs/methodologies, aims, clinical scenarios etc., we utilized data-based convergent synthesis [20] where both qualitative and quantitative data are complementary and analyzed together. In this way, a narrative synthesis of the literature, augmented with summary tables, defined themes of the literature to provide a framework/theory for future research [21] and identify gaps/deficits of the literature. The analysis involved a three-step process that involved (1) data transformation (text from various study designs were assigned a numerical value), (2) integration (i.e., the process of integrating disparate study designs), and (3) the creation of patterns, themes or trends from the text of the reviewed manuscripts. Data transformation utilized Natural Language Processing (NLP) [22] to quantify text from all the reviewed manuscripts to allow for statistical analysis. Integration of the transformed text utilized the statistical technique of K-means cluster analysis [23] to identify similar groups or clusters of text. In this way, an exploratory analysis of the literature allowed for deeper and more useful insights into the text patterns, themes and trends of the reviewed literature. Analysis of variance (ANOVA) determined statistical difference in ≥3 group means. The statistical software R was used for analysis [24] with statistical significance was set at p < 0.05. Details of this three-step process (i.e., NLP and K-means cluster analysis) is provided in Appendix 1.

Search Outcomes

A total of 733 titles were initially screened resulting in the removal of 164 duplicate titles. An additional 435 titles were eliminated based on the inclusion/exclusion criteria with 133 manuscripts remaining. An additional article was found in a reference list that met inclusion criteria resulting in 134 papers for review.

Study characteristics

Of the 134 manuscripts reviewed, 129 met inclusion criteria: three were randomized controlled trials (RCTs) [25–27], seven prospective cohort studies [11, 28–33], one case control [34], 11 cross-sectional studies [35–45], 51 case reports [46–96], 13 case series [97–109], and one qualitative study [110]. An additional 42 manuscripts met our inclusion criteria consisting of 33 commentaries [9, 15, 111–141], eight systematic reviews (SRs) [12, 142–148], and one best practice recommendations consensus paper [149]. Five articles were excluded, with two involving post-partum care [150–151] and three involving non-chiropractic care [152–154] (see Fig. 1). The extracted data based on study design are summarized in Tables 1–4.

Table 1

Summary findings of clinical trials, cohort studies, case control and qualitative studies involving chiropractic care for pregnant women.
Reference/yr/ country	Study aim(s) or purpose	Study design	Clinical presentation or study of Interest	Management protocol	Summary of findings
Peterson et al. [25]/ 2012/USA	A pilot study to comparative effectiveness study of three interventions (i.e., exercise, SMT and NET) to mitigating pregnancy related LBP.	RCT	Fifty-seven pregnant women (mean age = 29.7 years; SD = 5.0) with a singleton fetus suffering from pregnancy-related LBP	neuro-emotional technique, exercises and HVLA SMT	No clinical or statistically significant differences between the three groups.
George et al. [26]/ 2013/ USA	To determine if the addition of manual therapy to standard obstetric care was superior in reducing pain, impairment, and disability in pregnant women.	RCT	Pregnant women 15–45 years old with a single fetus at 24–28 weeks’ gestation were assessed for LBP and/or PGP	Manual therapy - chiropractic SMT with exercise and patient education. Obstetrics Care - rest, aerobic exercise, heating pad application, use of acetaminophen or narcotics	Addition of manual therapy to obstetric care resulted in significant reductions in pain and disability.
Gausel et al. [27]/ 2017/ Norway	To determine the effectiveness of spinal manipulation (SM) and adjunctive therapies versus conventional medical care in pregnant women with dominating one-sided pelvic girdle pain (PGP).	RCT	Forty-eight women with dominating one-sided PGP randomized to chiropractic care versus conventional medical care.	Chiropractic Care -spinal manipulation, mobilization, soft tissue treatment, exercises, and patient advice Conventional primary health care – not described	No statistically significant difference in measured outcomes (i.e., new occurrence of full time and/or graded sick leave due to PGP and/or LBP) between the two groups during and after pregnancy.
McCoy et al. [28]/2009/ USA	To determine a number of outcomes (fetal correction, pain NRS and SF-36) in pregnant women with a course of chiropractic care.	Prospective cohort	Twenty-five pregnant women ranging in weeks of gestation from 23 to 39 weeks with an average age of 30.56 were followed prospectively for their response to care using clinical outcomes (pain NRS) and the SF-36	Diversified Technique and the Webster Technique	At time of reporting, the study was ongoing with no reported SF-36 outcomes. Eight of 25 pregnant women delivered with five delivering vaginally and 3 delivered via Caesarean. Of 4 fetal malpresentations, two of turned to vertex, one was unable to turn, and one was not known. Delivery of the fetuses were one vaginal birth, one unknown, and two Caesareans, with one an emergency Caesarean.
Murphy et al. [29]/2009/ USA	To determine the effectiveness of a diagnosis-based clinical decision rule as an approach to care for pregnancy-related lumbopelvic pain using a	Prospective cohort	One-hundred fifteen pregnant women (mean age = 29.9; SD = 4.8; mean weeks of gestation = 25.2; SD = 7.4) suffering from LBP and/or PGP	Care provided by a chiropractor/physical therapist team following a diagnosis-based clinical decision rule based on a diagnostic process that considers differential diagnostic factors, pain-generating tissues and perpetuating factors.	At end of treatment (n = 83) and 11 months follow-up (n = 61), the mean patient-rated improvement was 61.5% and 83.2%, disability improved by 39% and 68%, change in pain NRS was 2.9 and 3.5 points and the FABQ-Act was 0.54 and 2.6, respectively.
Alcantara et al. [30]/ 2012/ USA	To determine the success of the Webster Technique in correcting fetal malposition/ malpresentation in women attending care in a PBRN.	Prospective Cohort	Sixty-three pregnant women with fetal malposition/ malpresentations (i.e., brow (n = 1); complete breech (n = 12), footling breech (n = 7), facial (n = 2) frank breech (n = 27) oblique (n = 6), posterior (n = 10), transverse lie (n = 16) assessed at a mean of 31.8 weeks of gestation.	The Webster Technique	Seventy percent (n = 44) success rate towards vertex position among 63 pregnancies with fetal malposition/malpresentation.
Peterson and Peterson [31]/ 2012/ USA	To determine if manual muscle testing (MMT) could predict fetal sex in-utero beyond chance.	Prospective cohort	Twenty-seven women that did not know the sex of their baby were study participants.	Manual muscle testing (MMT)	The use of MMT was found to be incapable of predicting fetal sex in-utero beyond chance.
Peterson et al. [32]/ 2014/ Switzerland	To examine the effectiveness of chiropractic care in women with pregnancy related LBP and/or PGP.	Prospective Cohort	One hundred and fifteen women with LBP and/or PGP were followed longitudinally over a 1-year period commensurate with chiropractic care	Non-standardized chiropractic care	After one week of care, 52% indicated their pain as “improved. After one month − 70%), at three months − 85%, at six months − 90%, and one year − 85%. There was significant reduction in pain NRS and Oswestry Disability Index scores with a course of care.
Haavik et al. [33]/ 2016/ New Zealand	To examine changes in levator hiatal area following a single session of HVLA SMT in pregnant and non-pregnant women.	Prospective Cohort	Eleven pregnant and 15 nonpregnant women were assessed for their hiatal areas and anterior-posterior and lateral diameters at rest, on maximum pelvic floor muscles contraction, and during maximum Valsalva, before and following chiropractic SMT using 3-/4-dimensional (3D/4D) transperineal ultrasonography	Chiropractic SMT – HVLA SMT	Levator hiatal area at rest increased significantly after spinal manipulation in the pregnant cohort but not in the control group
Alcantara et al. [11]/ 2018/ USA	To measure the quality of life (using PROMIS-29) and visit-specific patient satisfaction (using VSQ-9) of pregnant women in a PBRN.	Prospective Cohort	Three hundred forty-three pregnant women (average age = 30.96 years) with non-described clinical presentations were assessed for their quality of life and patient satisfaction.	Chiropractic care – various chiropractic techniques with/without the use of adjunctive therapies within a practice-based research network.	In addition to high patient satisfaction, significant improvements were observed in fatigue, pain interference, pain intensity, and sleep disturbance, while significant increase in satisfaction with social roles. was observed. Anxiety and depression did not change.
Phillips et al. [34], 1995 USA	To determine if obstetric interventions during labor and delivery were affected with the addition of chiropractic care to standard obstetric care.	Case Control	Thirty-five pregnant women between 18 and 35 years of age receiving chiropractic care were matched with 35 non-chiropractic women to determine differences in obstetrics intervention.	Diversified, Thompson, Logan, and/or Webster Techniques and Upledger craniosacral therapy. Adjunctive therapies consisted of general prenatal health education including nutritional advice, exercise recommendations and birth education.	No statistically significant differences were identified in the level of intervention of labor (i.e., synthetic oxytocin [Pitocin] induction or stimulation) was not affected with the addition of chiropractic care to usual obstetrics care.
Laufer [35]/ 1987/ Canada	Retrospective file review to characterize (i.e., age, occupation, number of children and major complaints) women presenting for pregnancy chiropractic care.	Cross-sectional retrospective survey	To characterize 126 pregnant women presenting for chiropractic care.	Non-intervention study	The average age was 29.8 years, most were career oriented and presented commonly with LBP.
Diakow [36]/ 1991/ Canada	To determine the association of LBP in pregnancy and delivery and if SMT affected the outcome of low back pain during labor.	Cross-sectional Survey	One hundred seventy women were interviewed about their pregnancies (n = 400) with respect to their complaints and its severity.	Non-intervention study	There was a significant association between LBP during pregnancy and during labor.
Andrew and Pedersen [37]/ 2003/ United Kingdom	To investigate the use of chiropractic care and to provide useful information on the management of women with SPD	Cross-sectional Survey	Retrospective survey of 16 women experiencing SPD in the perinatal period along with 7 chiropractors providing care for SPD.	Non-intervention study	Response to care resulted in 10 women with moderate recovery, 4 women with complete recovery and two women with slight improvement. Seven chiropractors indicated using spinal adjustments for care, six used sacro-occipital technique (SOT) blocks, five with exercises, two with cryotherapy, three with soft-tissue work.
Rubin [38]/2007/ USA	To illustrate the use of triage skills in a single practitioner chiropractic practice.	Cross-sectional retrospective survey	Pregnant women were triaged as P1/red/emergency (i.e., needs immediate referral); P2/yellow/cautionary (i.e., warrants additional attention and follow-up), or P3/ green (i.e., limited concern).	Non-intervention study	Seven (87.5%) of eight new pregnant women were assessed at the P3 level of triage with limited concern. One (12.5%) was assessed at P2 level (12.5%) (i.e., warranted follow-up) due to significant vomiting and LBP and groin pain in third trimester.
Aas-Jakobsen et al./ [39] / 2010/ Norway	Retrospective file review of 100 consecutive pregnant women attending care at a chiropractic clinic in a one-year period to characterize their age and presenting complaint	Cross-sectional Survey	The mean age of the presenting women was 32.5 years (range 25–42) with MSK complaints.	Non-intervention study	Approximately 90% suffered from pelvic pain as the motivator for care. Six out of 10 had LBP, and 6 out of 10 had specific thoracic pain. Three out 10 had neck pain, 29% had symphysis pubis pain, 15% experienced headaches and 2% migraines. Overall, 82% experienced a combination of pain sites.
Alcantara et al. [40]/ 2012/ USA	To characterize (i.e., age, WOG, presenting complaints) the chiropractic care of pregnant patients attending care in a PBRN.	Cross-sectional Survey	One hundred and twenty-six pregnant patients provided socio-demographics (i.e., age, gender, level of education), weeks of gestation, presenting complaints triaged as primary (1⁰), secondary (2⁰), and tertiary (3⁰) and perceived effectiveness of care.	Non-intervention study	Their average age was 30.56 years and presented at a mean of 29.42 gestational age. Approximately 25% presented for “wellness care.” Presenting complaints were mostly MSK pain. The majority (98%) reported a high perceived effectiveness of the care with specific outcomes categorized as “decreased pain”, “improved function and “other.”
Pistolese [41]/ 2002/ USA	To survey chiropractor members of the International Chiropractic Association on their use of the Webster Technique and its outcome(s).	Cross-sectional Survey	Surveys were sent to 1047 members of the ICPA. Of 187 responders, 112 surveys comprised the data.	Webster Technique	Of 112 surveys, 102 (92%) chiropractors indicated success with the correction of a breech fetal presentation, while 10 (9%) indicated the fetus positioning as remaining unaffected with the Webster Technique.
Stuber [42]/ 2007/ Canada	To explore the experience of chiropractors, and pregnant women having chiropractic care for LBP.	Cross-sectional Survey	Eighteen chiropractors were surveyed on their perceived safety of chiropractic care for pregnant women, their care protocols and referral patterns with other healthcare professionals.	Non-intervention study	The majority indicated that SMT was appropriate for LBP, mid-back pain, neck pain, headaches, and benign vertigo, Common adjunctive therapies include soft-tissue therapy and exercise for women with multiple pregnancies, gestational diabetes, hypertension, pre-eclampsia, ectopic pregnancy and blood clotting disorders.
Yuen et al. [43]/ 2013 Canada	To determine the most common therapeutic interventions provided by Greater Toronto Area chiropractors to pregnant women.	Cross-sectional Survey	One hundred and forty-three (39% females and 61% males) chiropractors from 630 successfully delivered invitations comprised the study (24% response rate).	Non-intervention study	Majority of respondents (90%) reported using Diversified Technique; soft tissue therapy (62%) and Activator Methods (42%). Most common referral was to a massage therapist (90%). Most indicated recommending stretching exercises (92%), multivitamins (84%) or folic acid (81%).
Weis et al. [44]/ 2019/ Canada	To determine a cohort of Ontario chiropractors’ knowledge on current guidelines for exercise during pregnancy.	Cross-sectional Survey	Eighty-six chiropractors (41 female; 45 males) out of 456 invited comprised the study population. The majority (30%) were 30–40 years of age or 41–50 years of age with the majority (53.5%) with practice experience of 0–15 years.	Non-intervention study	The mean knowledge score was 0.52 (i.e., maximum score = 10) with great variability among the respondents to a 10-item questionnaire
Kawchuck et al. [45]/ 2020/ Canada	To assess chiropractors’ compliance with specific health and pregnancy related conditions as well as claims of immunity during the COVID-19 pandemic in British Columbia, Canada.	Cross Sectional	Approximately 750 websites and 650 social media pages of approximately 1250 CCBC registrants were reviewed with a customized internet search tool resulting in 250 potentially inappropriate communications	Non-intervention study	The internet search tool identified 636 potential cases involving pregnancy-related conditions from 1350 websites. Further evaluation classified 83 cases as inappropriate.
Sadr et al. [110]/ 2012/ Canada	To explore the experience of chiropractors, and pregnant women having chiropractic care for LBP.	Qualitative study	Pregnant patients in their second or third trimester, with LBP during pregnancy, and their treating chiropractors in separate interviews.	Semi-structured interviews	From both sets of interviews, five themes emerged consisting of clinical presentations, the care provided and its effectiveness, chiropractor-patient communication; safety considerations; and self-care.
CCBC = College of Chiropractors of British Columbia; COVID = corona virus disease; HVLA = high velocity, low amplitude NET = Neuro Emotional Technique; LBP = low back pain; PGP = pelvic girdle pain; MSK = musculoskeletal; PRO = patient reported outcome; PRO = patient reported outcome; PBRN = practice-based research network PROMIS = Patient Reported Outcomes Measurement Information System; RCT = randomized controlled trial; SD = standard deviation; SF-36 = Short Form 36; SMT = spinal manipulative therapy; SOT = Sacro-Occipital Technique; SPD = symphysis pubis dysfunction; VSQ = visit-specific questionnaire; ICPA = International Chiropractic Pediatric Association; 1⁰ = primary; 2⁰ = secondary; 3⁰ = tertiary

Table 2

Summary findings of case reports and case series involving the chiropractic care of pregnant women.
Reference/yr/ Country	Study aim(s) or purpose	Clinical Presentation or Study of Interest	Management Protocol	Summary of Findings
Fallon [46]/ 1996/ USA	To describe the care of a 23-year-old at 10 WOG.	The woman was referred by her obstetrician with complaints of right-sided mid-back pain radiating from the spine to the sternum.	The patient received chiropractic HVLA SMT directed at the T6 vertebral level. The patient received care similarly on subsequent visits	The patient attended a total of 5 visits and then released from care.
Ducar et al. [47]/ 2005/ USA	To describe the care of a 32-year-old woman at 20 WOG.	The woman presented with groin pain, pain with forward bending and a positive long dorsal ligament test. She had a Quebec Task and Force Disability Scale questionnaire score of 122 and rated her pain as an 8/10 on a visual analog scale	Active Release Technique, home relaxation exercises, patient education, and ergonomic training were provided over approximately 3 weeks (3 treatments).	The woman’s Quebec disability score decreased to 62 from 122 and her pain NRS from 8/10 to 0/10.
Skaggs et al. [48]/ 2006/ USA	To describe the care of a 22-year-old at 16 WOG.	The woman presented with LBP, bilateral anterolateral thigh paresthesia and groin pain of one month duration.	Treatment was provided at 6 visits over a 6-week period where the patient underwent manual intervention, and exercise prescription. Active Release Technique (ART) was performed to the SIJ, quadratus lumborum muscles and iliopsoas muscles.	After 6 visits, the patient reported complete resolution of LBP and left lower extremity symptoms and a 90% improvement in the right thigh symptoms. At her one-year follow-up, the woman reported no further complications and the absence of pain.
Kruse et al. [49]/ 2007/ USA	To describe the chiropractic treatment of a 26-year-old woman in her second trimester of pregnancy	The woman suffered from severe LBP that radiated to her hips bilaterally and to her right leg. She reported tingling down her right lower leg to the dorsum of her foot.	Treatment consisted of manual traction in the side-lying position using Cox flexion-distraction decompression modified for pregnancy.	Relief was noted after the first visit, and complete resolution of her complaints after 8 visits.
Alcantara and Hamel [50]/ 2008/ USA	To describe the chiropractic care of a 29-year-old woman	The woman presented with LBP	The patient was cared for with the Webster Technique, employing a drop-piece mechanism for the sacral adjustment.	The patient’s LBP resolved along with a successful vaginal birth at 40th week of gestation.
Thomas [51]/ 2008/ USA	A 28-year-old at 37 WOG.	The woman presented with a breeched fetus as determined via Leopold’s maneuver by her midwife.	Webster Technique	After 3 visits, the fetus assumed a breech to vertex position based on Leopold’s maneuver as performed by her midwife
Alcantara and Cossette [52]/ 2009/ USA	To describe the care of a 24-year-old female at 32 WOG.	The woman presented with long-standing medically diagnosed migraine headaches	Chiropractic care involved SMT and adjunctive therapies and the use of the Webster Technique.	The results of care were symptom improvement and independence from medication.
Alcantara et al. [53]/ 2009/ USA	To report on the successful collaboration of chiropractors and midwives in the care of a 26-yr-old in home birth delivery with 3 midwives and her chiropractor.	The woman experienced difficulty with her labor.	With lack of cervical dilation, descent and diminished uterine contractions along with decreased fetal heart tones at 23 hours of labor, the chiropractor applied the Webster Technique resulting in stronger and more frequent contractions with stabilized fetal heart tones. At 28 hours, the fetus was determined to be asynclitic. At 34 hours of labor, the attending chiropractor performed the psoas release followed by complete cervical dilation.	The labor progressed rapidly after the psoas release and a healthy baby girl was born.
Drobbin and Welsh [54]/ 2009/ USA	To describe the care of a 41-year-old at 36 WOG.	The woman presented with ultrasound confirmed breech fetus with recommended Caesarean.	Webster Technique	After 5 visits, the fetus turned from a longitudinal fetal lie to a longitudinal fetal lie and vertex presentation.
Hwang [55]/ 2009/ USA	To describe the care of a 28-year-at 32 WOG.	The woman presented with sharp, stabbing pain starting at the left sacroiliac joint and radiating into her posterior left thigh.	Chiropractic SMT using drop table	The patient experienced 50% relief from the frequency and intensity of pain within two weeks of care; a 90% improvement in function and decrease in pain by the 6th week,
Stone-McCoy and Sliwka [56]/ 2010/ USA	A 37-year -old woman pregnant 35 WOG	The woman presented with ultrasound confirmed frank breech fetus	The woman received care with the Webster Technique, effleurage and home exercises.	After five Webster Technique adjustments, the fetus turned from a breech position to a vertex, head-down position.
Dashtkian and Whittle-Davis [57]/ 2011/ USA	A 25-year-old woman sought chiropractic care at 31 WOG	The woman sought care to avoid a Cesarean section due to breech presentation as confirmed by her Ob/Gyn.	Webster Technique	The woman’s baby shifted from the breech position to transverse after the first visit. After the second visit, the fetus shifted from transverse to vertex. The patient continued care thereafter due to pregnancy related low back pain.
Abbot [58]/ 2012/ USA	To describe the care of a 30-year-old woman in her 34 WOG.	The woman presented with a breech fetus as confirmed by ultrasound. Previous pregnancy was Caesarean section.	Webster Technique was applied using an Activator Adjusting Instrument). Trigger point therapy was also performed according to Webster protocol.	After three visits, the fetus moved from a breech position to a normal vertex or head down position.
Ferguson and Kulesza [59]/ 2012/ USA	A 35-yr-old 30th week WOG	Doula confirmed transverse breech	Webster Technique	After 4 visits and receiving care with the Webster/drop table, the fetus turned to vertex.
Heagy and Wrubel [60]/ 2012/ USA	A 28-year-old with twin pregnancies presenting at 30 WOG.	The woman presented with a breech presentation as determined by her obstetrician	Gonstead and Webster Technique	The woman attended five visits over three weeks. Her obstetrician confirmed that the involved twin was in cephalic lie.
Morton [61]/ 2012/ USA	A 31-year-old woman, pregnant at 16 WOG. The woman had a history of Systemic Lupus Erythematosus.	Presented to a chiropractor for treatment of occipital headache. Immediately after receiving treatment the subject noted severe right sided anterior neck pain, and rapidly developed ipsilateral Horner’s syndrome. Magnetic resonance imaging (MRI) revealed extensive dissection of the right internal carotid artery. The subject was treated with intravenous heparin and subsequently low-molecular weight heparin.	Not described	Four days after the onset of neurological symptoms intrauterine foetal de- mise was noted. The patient was subsequently anticoagulated with warfarin for six months. Follow-up MRI six months later revealed a focal false aneurysm of the right internal carotid artery. The Horner’s syndrome persists one year after the initial presentation.
Peterson [62]/ 2012/ USA	A 32-year-old woman who was 24 WOG.	The woman presented with persistent heartburn that was treated with Zantac® and Tums®, daily.	Neuro Emotional Technique (NET)	At her final evaluation, the woman was symptom free and free of medications to control her heartburn. The heartburn did not return for the remainder of her pregnancy.
Herring and Mullin [63]/ 2012/ USA	To present the care of 38-year-old multi-gravid woman and review the atypical presentation of deep vein thrombosis (DVT) in pregnancy.	The woman complained of radicular leg pain imitating sciatic neuropathy.	No treatment provided. The patient was immediately referred to a local vascular diagnostic center to rule out thrombosis. A diagnosis of thrombus of the right lower extremity, including possible acute deep vein thrombosis from the common femoral vein into the calf veins was made.	The patient was immediately admitted into the hospital for emergency intervention. The patient went on to have a successful delivery without complications at 40 WOG.
Stone-McCoy et al. [64]/ 2012/ USA	To describe the care of a 33-year-old expectant mother at 8 months WOG	The woman presented with a breech presentation as noted by her midwife.	Webster Technique	The woman’s progress was monitored by her midwife. The fetus was no longer breech after nine visits and the mother delivered a healthy baby.
Rocker [65]/ 2013/ USA	A 23-year-old primigravida woman at G	The woman presented with a breech presentation and sacroiliac pain.	Webster Technique	The woman attended a total of 7 visits over a 3 1/2-week period. The patient’s sacroiliac pain NRS reduced from 8/10 to 3/10. However, her breech presentation remained unchanged. At 37 WOG, her midwife detected vaginal bleeding and reduced fundal height resulting in hospitalization and a diagnosis of oligohydramnios. The woman delivered by emergency Cesarean.
Clark and Alcantara [66]/ 2013/ USA	To describe the chiropractic care of a 24-year-old at 37 WOG.	The woman presented with a chief complaint of LBP and left leg pain and the desire for a natural childbirth. The breech fetus was diagnosed at 36 WOG via ultrasound imaging.	Chiropractic care administered over 2 visits utilized the Webster Technique resulting in the baby assuming the vertex position as imaged by ultrasound.	The woman continued care with the Webster Technique to address pelvic bowl dysfunctions over a total of 9 visits with positive outcomes.
Afshar [67]/ 2014/ USA	A 28-year-old female presented at 36 WOG	The woman presented with a transverse position fetus as confirmed with ultrasound by her Ob/Gyn.	Webster Technique	After one session with the Webster Technique, the fetus was confirmed to have moved from transverse position to vertex position via ultrasound.
Edwards and Alcantara [68]/ 2014/ USA	To describe the care of a 32-year-old at 32WOG	The patient presented with ultrasound imaging confirmed breech fetal positioning and placenta previa.	The patient was cared for with a combination of Diversified and Webster Techniques.	Comparative ultrasound imaging confirmed the breeched fetus assumed a vertex position with the placenta migrating to more than 3 cm away from the os of the cervix.
Drobbin and La Rosa [69]/ 2015/ USA	To describe the care of a 31-year-old at 30 WOG.	The woman presented with a transverse breech fetus as determined by her obstetrician.	Webster Technique	The patient’s care consisted of a total of 24 visits. After 7 visits over 3 weeks, the woman’s midwife confirmed a vertex presentation. The woman went on to have a natural home birth.
Edwards and Alcantara [70]/ 2015/ USA	To describe the chiropractic care of a 30-year- old at 34 WOG	The woman presented with her baby in a transverse lie malpresentation.	The patient was cared for over a 6-week period. She received care using Diversified and Thompson Techniques along with Webster Technique.	The woman’s baby converted to the vertex position and delivered naturally.
Edwards and Alcantara [71]/ 2015/ USA	To describe the care of a 28-year-old woman at 14 WOG	The woman presented with migraine headaches, hypothyroidism, and tachycardia along with a desire to have a natural childbirth.	The patient was cared for with the Gonstead Technique, Thompson Drop, and Webster Technique.	She attended care for a total of 33 visits over a 7-month period. The result was a successful trial of labor at 40 weeks plus 4 days and delivery of a healthy baby girl.
Edwards and Alcantara [72]/ 2015/ USA	To describe the chiropractic care of a 28-year- old at 33 WOG	The woman presented with complaints of tingling and numbness in the second through fourth fingers on her right hand, LBP, and swelling in her right leg and a history of endometriosis, ovarian cysts, and two miscarriages.	The patient was scheduled twice a week for 9 visits. Care consisted of HVLA SMT to sites of subluxations.	The patient’s presenting complaints resolved with a trial of care
Bernard and Tuchin [73]/ 2016/ Australia	To describe chiropractic care of a pregnant 35 year-old at 32 WOG.	The woman suffered from severe pregnancy-related lumbopelvic pain and leg pain.	The woman received spinal manipulation, soft tissue therapy, exercises, and ergonomic advice in 13 visits over 6 weeks.	The woman’s LBP reduced from 7 to 2 on a 0–10 numeric pain scale rating. Functional activities were reported such as walking, sitting, and traveling comfortably in a car had improved.
Edwards and Alcantara [74]/ 2015/ USA	To describe the care of a 24-yr-old woman at 26 WOG.	The woman presented with severe neck pain extending to both shoulders, migraine headaches, and diplopia.	The patient was cared for with multiple techniques (i.e., Ortho-Bionomy, flexion-extension distraction, Thompson and Diversified Drop Table Techniques, Gonstead and Logan basic Techniques.	The woman attended a total of 14 visits in 5 weeks and was scheduled for a Caesarean-section delivery at 37 weeks. Three days after her final visit, the patient’s water broke, and she successfully delivered vaginally at 30 WOG.
Cherry and Wilson [75]/ 2016/ USA	A 27-year-old female at 35 WOG	The woman presented with a breech fetal position and problems with pelvic alignment.	Webster and Logan Techniques	After 3 visits, the woman’s baby reverted to a vertex as confirmed via US by her obstetrician
Spear and Alcantara [76]/ 2016/ USA	To describe the care of a 37-year-old woman at 35 WOG.	The woman presented with right hip and pelvic pain with ultrasound imagining determined frank breech pregnancy.	The patient received care with the Webster Technique	Over three visits spanning five days, the fetus reverted to vertex and the woman gave birth vaginally.
Spear and Alcantara. [77]/ 2016/ USA	To describe the chiropractic care of a 28-year- at 29 WOG	The woman presented with complaints of chronic migraines, neck and LBP along with ultrasound confirmed placenta previa.	The patient was cared for with Diversified and Drop Table Technique.	Following a total of six visits over a six-week period, the patient’s presenting complaints resolved and had a successful VBAC.
Drobbin and McClain [78]/ 2017/ USA	A 35-year-old at 34 WOG.	The woman presented with a frank breech as determined via ultrasound imaging by her obstetrician.	The Webster and Diversified Techniques	The patient underwent four adjustments before reporting vertex positioning of the fetus as confirmed by her obstetrician via ultrasound.
Edwards and Alcantara [79]/ 2017/ USA	To describe the care of a 28-year-old at 21 WOG	The woman presented with pregnancy related MSK complaints (i.e., LBP) and a history of shoulder pain and neck pain secondary to scoliosis.	The patient received care using a combination of Gonstead, Diversified, and Webster Techniques utilizing drop table to correct the sacral malposition.	Each visit resulted in a reduction of her pain NRS by 2 points relative to her baseline rating. After completing 13 visits over 6 weeks of care, her pain NRS reduced from 6/10 to 2/10. Her PROMIS-29 quality of life measures improved in the prenatal period but not in the post-partum period compared to baseline measures.
Edwards and Alcantara [80]/ 2017/ USA	To describe the care of a 32-year-old woman.	The woman presented with triplets and complaints of LBP, lower extremity swelling and acid reflux.	The patient was cared for with Logan Basic, Diversified Technique and Webster Technique.	The patient was able to carry her pregnancy into her 3rd trimester with the babies born by Caesarean.
Falk and Stinson [81]/ 2017/ USA	A 26-year-old female in her 27 WOG with her second child.	The woman presented with LBP and ultrasound confirmed breech fetus.	Webster Technique	After 29 visits, the fetus moved from a breech position to a normal vertex position as confirmed by ultrasound at 39 weeks WOG. The woman had a natural vaginal birth with no complications.
Rashid et al. [82]/ 2017/ New Zealand	To the care of a 29-year-old at 32 WOG	The woman was medically diagnosed with placental insufficiency and fetal growth restriction	The woman attended care over a 3-week period, using Thompson Terminal Point Technique in combination with Diversified SMT.	Immediately following the initial visit there were improvements in placental resistance, with normalized FGR evident on Doppler ultrasound at 36 WOG.
Shtulman and Alcantara [83]/ 2017/ USA	A 38-year-old in her 30th WOG.	The patient presented with twins in a footling breech presentation.	Webster Technique and Activator Instrument	The attended care over a 2-week period consisting of 5 patient visits. Both fetuses innately turned to vertex, facilitating a successful vaginal birth.
Stone-McCoy and Speller [84]/ 2017/ USA	To review the care of a 39-year-old woman	The woman was seeking a vaginal birth after three Caesarean births (VBAC).	The woman received care using the Webster and Diversified Techniques.	A total of 14 visits over an 8-week period was scheduled prior to the patient giving birth. The patient made significant improvement and was able to have a vaginal birth (VBAC).
Vanderslice and Beachum [85]/ 2017/ USA	To describe the chiropractic care of 28-year-old female	The woman was under wellness care with her second pregnancy.	The patient was cared for with Diversified Technique and recommended to use, a pelvic compression belt.	The woman attended a total of 32 visits prior to the conception of her second child. Her second birth experience was both shorter and easier compared to her first birth.
Drobbin and Zink [86]/ 2018/ USA	A 33-year-old nulliparous female at 29 WOG.	The woman presented with a frank breech fetus as confirmed by ultrasound by her obstetrician.	Webster and Diversified Techniques.	The patient attended 9 visits before her obstetrician confirmed vertex positioning of her baby. The patient went on to have a successful, natural, vaginal birth with no reported complications.
Spear and Alcantara [87]/ 2018/ USA	A 34-year-old woman at 16 WOG.	The woman presented with twin girls and a chief complaint of left sacroiliac, left posterior hip and left buttock pain of 3 weeks duration. The woman also indicated a desire to have a natural childbirth since giving a Caesarean birth 2 years prior.	Network Spinal Analysis	The woman attended 18 visits over a period of 19 weeks. The woman’s presenting complaints abated and at almost 36 WOG, she successfully delivered via VBAC.
Porter and Alcantara [88]/ 2019/ USA	To discuss the chiropractic care of a 24 years old 10 WOG	The woman presented with complaints of LBP, upper back pain and disturbed sleep.	The patient was cared for with the Webster Technique and Thompson Technique.	The woman attended 16 visits over 3 months. The woman was able to return to work without pain and elected to continue her care throughout her pregnancy.
Shulman et al. [89]/ 2019/ USA	To describes the chiropractic care of a 28-year-old at 20 WOG	The woman presented with symphysis pubic dysfunction.	The patient received care consisting of the Activator Protocol to address subluxations at the coccyx and right inferior pubic bone, and toggle recoil to address a C1 subluxation and drop table (Webster Technique) to address a right sacral posteriority.	The patient attended 35 visits over a period of 8 months with positive outcomes.
Snyder and Alcantara. [90]/ 2019/ USA	To describe the care of a 28-year-old at 31 WOG	The woman presented with pain localized to the L5/S1 level and right sacroiliac joint	The woman received care with the Webster Technique scheduled at once a week for 3 weeks.	The woman’s LBP resolved with improved ROM.
Stone-McCoy and McNeill [91]/ 2019/ USA	To describe the care of a 28-year-old woman at 39 WOG.	The woman presented with a transverse lie fetus	Webster and Thompson Techniques	The patient experienced a natural VBAC with no complications. Ultrasounds imaging confirmed the fetus moved from a transverse lie to a vertex position.
Urban and Alcantara [92]/ 2019/ USA	To describe the care of a 24-year-old woman in her 12 WOG.	The woman had complaints of LBP concomitant with placenta previa.	Diversified and Webster technique were utilized to address vertebral subluxations over a four-week period.	After one week of care, her LBP had decreased significantly. By the end of the fourth week, the woman reported complete resolution of both LBP and placenta previa, as confirmed by ultrasound.
Marjerrison and Alcantara [93]/ 2019/ USA	To describe the care of a 36-year-old at 33-WOG	The woman had presented with hip pain and LBP along with escalating pubic pain following a fall.	The woman was cared for with Diversified Technique and Drop Table in conjunction with the Webster Technique.	The woman attended a total of 10 visits over a 4-week period. She experienced relief with care and delivered a healthy baby.
Stone-McCoy and White [94]/ 2020/ USA	A 33-year-old expectant mother presented for care at 8 months pregnant.	The woman presented with a breech fetus.	Webster Technique	After 9 sessions, the baby was determined to be in the vertex position. The position change was determined by the midwife after the 9th visit and the woman had a normal, vaginal delivery of her child.
Poirier and Loranger [95]/2022/USA	A 30-year-old woman presented for care at 39 weeks pregnant	The woman presented with a frank breech presentation	Webster Technique	Following the second visit, the woman noted movement with her baby with correction to vertex position as noted by ultrasound imaging by her obstetrician.
Swenson and Acevedo [96]/2022/USA	A 40-year-old women presented for care at 33 weeks gestation.	The woman presented for care with the desire to have a natural childbirth.	Webster Technique and Diversified Technique	The woman attended a total of 10 visits resulting in a natural childbirth after 2 Caesarean births.
Guadagnino [97]/ 1999/ USA	A retrospective file review of 12 pregnant women aged 14 to 34 years presenting for care over a 2-yr period.	All complained of low back pain attributed to their pregnancy.	Each patient was treated with SMT at a treatment frequency of 2–3 times per week until their delivery. Based upon their examination, a technique (Diversified, SOT, or Gonstead knee chest) was designated as the care approach. Prior to manipulation/mobilization, each patient received manual axial distraction and soft tissue trigger point therapy. Six patients also received “hot packs” to their low back pain area.	The overall group mean pain NRS score decreased from 7.58 at initial presentation to 3.71 immediately after care, 4.83 the following day and 4.25 under maintenance care.
Kunau [98]/ 1999/ USA	A case series of 14 pregnant women presenting with a variety of presenting complaints cared for with chiropractic	The pregnant women had an average age of 31.3 years (SD = 7.70) and presented at a mean of 17.2 WOG (SD = 12.8). The women presented with a variety of complaints consisting mostly of breech fetuses, pain complaints involving the spine and pelvis and extremities as well headaches, sexual abuse, and meralgia paresthetica	The women received care with the Webster Technique to address their breech presentations and the remainder received Diversified Technique and adjunctive therapies as appropriate.	This case series showcased the unique circumstances of each pregnant woman and the adaptation of chiropractic care provided with respect to the myriad of presenting complaints.
Lisi [99]/ 2006/ USA	A retrospective file review to examine the response to care in 17 pregnant women.	The files of 17 pregnant women presenting with LBP were reviewed with respect to their pain NRS ratings.	Active care consisted of reassurance and education, advice on body mechanics, and exercise instruction. Passive treatments were myofascial release, manual joint mobilization, and HVLA SMT.	The overall group mean pain NRS score decreased from 5.9 (range 2–10) at initial presentation to 1.5 (range 0–5) at termination of care. Sixteen of 17 (94.1%) cases demonstrated clinically important improvement. The average time to initial clinically important pain relief was 4.5 days (range 0 − 13) after initial presentation, and the average number of visits undergone up to that point was 1.8 (range 1–5). No adverse effects were reported in any of the 17 cases.
Andrews et al. [100]/ 2008/United Kingdom	To assess the usefulness of a validated survey instrument (i.e., Measure Your Own Medical Outcome Profile (MYMOP2)) and a non-validated survey instrument (i.e., Chiropractor’s Assessment and Treatment Tool (CATT)).	A retrospective file review of three women’s experiences with their chiropractic care with clinical presentations of pregnancy related PGP.	Sacro-occipital technique (SOT)	This pilot study demonstrated that the MYMOP2 and CATT demonstrated a consistency of response for recording and evaluating both women’s experiences and chiropractors’ findings.
Phillips [101]/ 2010/ USA	To examine benefits of a combination of techniques in pregnant women with musculoskeletal and radicular pain.	Three of the 4 women had a mean age of 34.33 years (SD = 2.52) with all women presenting at a mean of 30.25 WOG (SD = 5.06). All women presented with LBP with one also presented with neck stiffness, bilateral hip pain, thyroiditis and headaches	The women were cared for with a combination of techniques consisting of SMT, Craniosacral Therapy (CST) and Dynamic Body Balancing Techniques (DBB).	The women responded well to treatment with respect to their MSK and radicular complaints.
Rubin [102]/ 2012/ USA	To describe the chiropractic care of three pregnant women.	The only information provided were the women presented with breech fetuses.	The women were cared for with the Webster Technique utilizing Activator Methods to address the sacral subluxation.	With subject A, the baby turned after the 2nd session with Webster. Subject B responded successfully in 3 visits. Subject C required 4 sessions for correction of the breech fetus.
Kadin [103]/ 2010/ USA	A 49-year-old and a 28-year-old with twin pregnancies	Both women had twin breech fetuses.	Webster Technique, Diversified and Thompson Techniques.	Patient 1: both baby A and baby B assumed the vertex position as confirmed by ultrasound after 14 sessions over a 7 week period.. Patient 2: both babies were vertex after the 10th session over a 7-week period and confirmed by ultrasound. Both pregnancies remained vertex throughout their respective terms. Both women also stated improved function and decreased pain throughout the remainder of their pregnancies.
Van Loon [104]/ 2010/ USA	To describe the response to care in three pregnant women.	Three women presented with rib pain. The women presented at 33, 34 and 24 WOG. Age of the women was not provided.	The women received care described as Diversified Technique with soft tissue therapy, and the use of an external support involving an Ace wrap applied to the lower rib cage.	The use of the Ace wrap in conjunction with chiropractic care was an inexpensive solution to women presenting with rib pain.
Alcantara et al. [105]/ 2011/ USA	To describe the results with the Webster Technique in five women with breech presentations.	Four of the women presented at a mean WOG of 36.6 weeks (SD = 2.43). Two women were described as 21 years of age. Three women were described as presenting with breech fetuses, one as transverse breech and another as oblique right transverse breech.	Webster Technique	All women responded favorably with correction of their breech presentations.
Howell [106]/ 2012/ USA	To review the chiropractic and rehabilitative care of two pregnant women with Symphysis Pubis Dysfunction (SPD).	Patient one was a 35-year-old and at 30 WOG with severe left sided SPD and low back pain. Patient two was a 33-year-old female also 30 WOG presenting with right sided SPD and sacroiliac pain.	Care included soft tissue therapy, pregnancy support belt, side- lying mobilizations, pelvic SOT blocks and instrument-assisted pubic symphysis adjustments. Home advice included: ice, staying active, moving as a unit, stretching, use of a pillow between the knees while sleeping, regular breaks from sitting and pelvic floor (Kegel) exercises.	Both patients reported some relief with treatment and home care. Post-partum, rehabilitation exercises were prescribed to restore muscular endurance, control and pelvic stability. On long-term follow-up, the 35-year-old reported no pubic symphysis pain, but some low back pain secondary to a subsequent knee injury. The 33-year-old reported being mostly pain free with a rare exacerbation of her pubic symphysis.
Alcantara and Ohm [107]/ 2013/ USA	To assess the quality of life of six pregnant women (average age = 33.33 years) presenting at an average parity of 0.33 (range 0–1) and at a mean of 20 WOG 20.	The women indicated suffering from neck pain (N = 1), leg pain (N = 1), low back pain (N = 2), low back pain and upper extremity/shoulder pain (N = 1) and wellness care (N = 3).	Chiropractic care – non-descript.	In four of the six women, improvements in various domains of quality of life. Interestingly, pain interference was observed as the most common improvement in a majority of the patients along with fear and anxiety. Two patients demonstrated a decrement in a majority of quality of life domains.
Draper et al. [108]/ 2019/ USA	To describe the response to chiropractic care in two women suffering from LBP.	Two pregnant women presented with care for with two different clinical and varying presentations of pregnancy-related LBP.	Chiropractic SMT and a taping protocol	In both cases, the addition of taping applied to the lumbosacral and/or abdominal area decreased the pain NRS from 9–10 to 4 or less with 10 as maximum pain rating.
Mulcahy and Mayo [109]/ 2019/ USA	To describe the care of a 40-year-old woman at 36 WOG and a 30-year-old woman at 30 WOG.	Both women were diagnosed with OB confirmed breech fetus.	Both women received care with the Webster technique over a period of three weeks and the other with 6 visits.	Ultrasound confirmation at an OB’s office confirmed vertex fetal position for both women.
ART = active release technique; CATT = Chiropractor’s Assessment and Treatment Tool; CST = Craniosacral Therapy; DBB = Dynamic Body Balancing Techniques; DVT = deep vein thrombosis; HVLA = high velocity, low amplitude; LBP – low back pain; MRI = magnetic resonance imaging; MSK = musculoskeletal; MYMOP2 = Measure Your Own Medical Outcome Profile; NET = neuro emotional technique; NRS = numeric rating scale; Ob/Gyn = Obstetrics/Gynecology; PROMIS = Patient Reported Outcomes Measurement Information System; ROM = range of motion; SD = standard deviation; SOT = sacro occipital technique; SMT = spinal manipulative therapy; SIJ – sacro-iliac joint; US = ultrasound; USA = United States of America; VBAC = vaginal birth after Caesarean; WOG = weeks of gestation

Table 3

Summary findings of the commentaries
Reference/yr/ country	Study aim(s) or purpose	Commentaries
Wiles [111]/ 1980/ Canada	To review the neurological and pathophysiological aspects of pregnancy and the role of chiropractic.	Chiropractors should be aware that due to the close relationship of efferent and afferent fibers serving pelvic organs, vessels and glans may result in a number of reflexes (i.e., viscero-somatic reflexes) resulting in diverse and unpredictable effects that challenge the chiropractic examination and diagnosis. The intent of chiropractic care is to decrease extraneous MSK stress and to assist the body to cope with unavailable weight bearing stress. The chiropractor should be aware of contraindication to chiropractic care such as excessive vaginal bleeding (at any time during pregnancy), premature labor, placenta previa, placenta abruptio, ectopic pregnancy, and ruptured amniotic membranes without labor.
Gibbons et al. [9]/ 1982/ USA	A historical account on the practice of obstetrics by chiropractors.	Reports that the developer of chiropractic, Daniel David Palmer, may have been the first accoucheur and that chiropractors should be able to provide primary pregnancy care. Between 1930–1960 several schools (i.e., Carver College, Logan College, Western States College, and National College) taught obstetrics. By 1952, California, Oklahoma and Oregon allowed obstetrics as a chiropractic specialty but eventually lost these rights through adverse malpractice cases and negative rulings by the State Attorney General in those states. In 1980, Wiles [109] commented that chiropractic moved away from the practice of obstetrics for political reasons rather than a reflection of chiropractic’s limitations.
Fligg [112]/ 1986/ USA	A commentary to review the important treatment considerations associated with biomechanical changes in pregnancy.	In the first trimester, the main consideration is a history of miscarriage or spotting. By the fifth month of gestation, alternative patient positioning must be considered such as the knee chest and seated adjusting procedures. The psoas and piriformis deserve attention with stretching. For adjustments to the SIJ in a side posture position, the chiropractor should be cognizant of the fetus’ position; use less hip flexion; position the women further away from the chiropractor to allow for more abdominal support.
Penna [113]/ 1989/ USA	The author outlines the maternal changes that occur during pregnancy to educate patients and their medical providers on the safety and appropriateness of chiropractic care.	Cardiovascular changes include maternal blood volume, heart rate, stroke volume and cardiac output. Exercise can cause increase in cardiac output, heart rate and oxygen consumption and cause murmurs and accentuates heart sounds. Biomechanical changes occur as a result of weight gain and enlarged uterus that shifts the center of gravity with progressive lumbar lordosis. The result is MSK pain (LBP/PGP) along with tension headaches and a waddling gait attributed to relaxin and other hormones. The use of electrical stimulation and ultrasound may cause uterine contraction and contraindicated. If there’s spotting, its recommended to use non-force techniques such as SOT blocking. Avoid torquing the lumbopelvic and incorporate trigger point therapy, exercise and stretching. By the 3rd trimester, care should be provided to address MSK pain with appropriate modification of technique.
Esch and Zachman [114]/ 1991/ USA	To provide a commentary on spinal adjusting procedures for pregnant women.	Prior to significant weight gain, the aim of care for the pregnant woman is postural training, abdominal strengthening, and low back stabilization. With a growing fetus, there should be accommodation of the woman’s abdomen with the use of pillows or a drop piece. Spinal adjustments should apply less force using low force techniques such as the Logan Technique. Recommendations were made to address pubic symphysis dysfunction and sacral dysfunction as well as the use of spinal adjustments during labor and the use of trigger point therapy directed to the psoas muscles.
Troyanovich [115]/ 1993/ USA	To identify the most common postural displacements of pregnancy and provide a rational approach to strengthening the postural muscles.	Postural alterations in pregnancy are due to weight gain, increase in blood volume and maternal storage of fat and protein. Structural alterations include forward flexion of the pelvis on the heads of the femur and increase in the sacral base angle and hyperlordosis of the lumbar spine. The author recommends “mirror image” exercises for anterior translation and flexion of the skull relative to the thorax and the use of pelvic rock exercise, partial stomach crunches and squats to strengthen the quadriceps muscles.
Burton [116]/ 1997/ USA	Advocacy for the addition of the chiropractor in prenatal care	The chiropractor should assess the spine and provide advice on lifestyle changes along with the use laboratory analysis (i.e., blood typing) during the antenatal period. Following conception, the chiropractor can provide relief of LBP, monitor the woman and order routine laboratory tests and provide advice on exercise and nutrition.
Thompson [117]/ 1997/ USA	An outline of the benefits of chiropractic care during pregnancy.	In addition to alleviating pregnancy related LBP, the chiropractor can provide advice on the use of exercise, nutrition and perform standard pre-conception work-up (i.e., ergonomic and posture advice).
Cohen [118]/ 1997/ USA	A review of the changes that occur during pregnancy and the protocol to address common presenting complaints.	Structural changes include increased sacral base angle, hypermobility of the sacro-iliac joint (SIJ), sacrococcygeal and pubic joints, hyper pronation of the feet, shift in weight-bearing toward the heel, altered gait, muscle weakness and compromised coordination and compensatory changes in the thoracic spina and head and neck. Care approaches should address the compensatory tightening of the gluteus muscles due to relaxation of the ligaments supporting the SIJs. Posterior weight bearing results in antero-superior (AS) ilium subluxation. The thoracic spine is stressed, and a thoracic release technique involving low forces should be applied.
Bartol [119]/ 1997/ USA	To review the factors that must be considered in SMT during pregnancy.	The author advised that the chiropractor should ensure mobility of the SIJ in pregnant women in preparation for labor and delivery. Spinal adjustments should be “light” in force with modifications of the side-posture patient position with less flexion at the hip, positioning the chiropractor away from the patient and placing a small pillow between the abdomens to support the weight of the fetus. An alternative to mobilizing the SIJs is to position the patient in a side posture position and circumduction of the hips by adduction, extension, and flexion at the hip joint. The author also advised on how to correct an anterior listhesis, rotation of the fifth lumbar vertebrae, osteitis pubis and other spinal adjusting techniques.
Carlidge [120]/ 1997/ USA	To provide a perspective of a nurse-trained chiropractor on the McTimoney-Corley technique for pregnancy care.	Pregnancy care should maintain balance and structure during pregnancy. For example, the author advised to keep the pelvis balanced during delivery and provided general advice about lifting and holding the baby. The effects of relaxin were acknowledged and may affect skeletal structures with long term effects due to biomechanical compensations. The author promoted that McTimoney chiropractic provides a gentle approach to pregnancy care.
Krantz [121]/ 2016/ USA	Commentary to address the when, why and safety of pregnancy chiropractic care.	The author advocated that chiropractic care should begin prior to conception and continue to the postpartum period to allow for free nerve flow. In the 1st trimester – headaches and ligament pain are common. In the 2nd trimester, LBP begins which continues in the 3rd trimester along with sciatica and numbness of the hands and arms. The author recommended that a drop piece be used to accommodate the growing fetus and for patient comfort and Webster Technique applied to address breech presentations. Postpartum care was recommended to facilitate the spine and pelvis to return to its normal state.
Ohm [122]/ 2001/ USA	Advocacy for collaboration between chiropractors and midwives.	The author argued for collaboration between chiropractors and midwives. Both professions trust the inner wisdom of the body, support and commitment for non-invasive procedures and offer personal individualized care. The use of the Webster Technique by chiropractors provides a reason for midwives towards collaboration as the technique optimizes for natural delivery.
Andrew [123]/ 2002/ United Kingdom	Advocacy from midwife-chiropractor for chiropractic in pregnancy directed to midwives.	The author advocated on the benefits of chiropractic care during pregnancy based on the author’s clinical experience. For prolonged/delayed labor, SMT to the pelvis facilitates birth along with cranial work to ease the baby’s distress. Addressing pelvic dysfunction and restoration of pelvic alignment has an effect on fetal positioning with the Webster technique along with addressing LBP/PGP. The use of pillows and table drop-piece should be applied to accommodate the growing fetus and ensure the woman’s comfort. Use of gentle SMT and exercise /stretching were advised along with patient education on posture and activities of daily living as well as ergonomic advice at work and home. The author noted that chiropractors should be aware of possible contraindications on the use of SMT during pregnancy.
Phillips [124]/2003/USA	To advocate for the care of pregnant women	The author commented on technique adaptations to the care of pregnant women that included the use of proper tables to accommodate the growing fetus, the limitations of the use of electrical modalities, care approaches to the pelvic bowl and the lower extremities and the use of proper body mechanics when performing activities of daily living during pregnancy.
DiMarco [125]/ 2003/ USA	To educate chiropractors and other health care professionals with clinical knowledge to treat LBP of pregnant and postpartum patient with a review of the biomechanics and structural components involved in the development of postural changes and LBP and the clinically relevant anatomy, and neuromusculoskeletal disorders encountered during pregnancy.	According to the author, changes in hormonal (i.e., progesterone, estrogen, and relaxin) concentrations results in compromised structural integrity and alteration in posture (i.e., increased lumbar lordosis) and gait patterns. Changes in load distribution places excessive pressure on spinal structures. The pelvic girdle undergoes metamorphosis during the gravid state as the pubic symphysis relaxes and widens. Spinal adjustments should not compromise the health of the fetus and the patient's comfort. Prone patient positioning should be considered for the patient's comfort and the left lateral decubitus and seated position are recommended when applying SMT. Gentle non- force techniques are best. The author provided a list of contraindications to SMT.
Ohm [126]/ 2004/ USA	Advocacy for collaboration between chiropractors and midwives based on shared clinical and philosophical framework for pregnancy care.	Collaboration for both professions based on a trust of the inner wisdom of the body, support and commitment for non-invasive procedures and personalized patient-centered care.
Ohm [127]/ 2005/ USA	An article to warn about the neuro toxicity of mercury for both mother and child	The author indicated the presence of mercury in a number of vaccines and can cause potential harm for both mother and fetus. For example, thimerosal as a preservative in vaccine, mercury in the influenza vaccine and in RhoGAM.
Ursprung et al. [128]/ 2006/ USA	To discuss the biological effects of low dose ionizing radiation and the use of plain film radiography in pregnancy.	According to the author, fetal radiation effects depend on dose and fetal gestational age. During the preimplantation age, radiation is an all-or-nothing response and with kill the fetus or not. After 9 days of gestation, the fetus responds to radiation much like the adult human. Radiation during organogenesis results in growth retardation with doses ranging from 100 mSv (10 rad [0.1 Gy]) to 200 mSv (20 rad [0.2 Gy]) at 8 weeks gestation resulting in congenital anomalies. A minimum dose of 10 mSv (1 rad [0.01 Gy]) to the fetus during the last trimester of pregnancy increases the risk of childhood leukemia by 40% and dose of 10 mSv (1 rad [0.01 Gy]) at any stage of pregnancy increases the risk of childhood leukemia by a multiple of 1.5.
Shaw [129]/ 2007/ USA	To advocate for pregnancy care to avoid or relieve LBP and prepare a woman’s back and pelvis for the stresses of labor and delivery.	The author commented that a gentle, non-invasive option for relief of pregnancy-related back and neck pain include chiropractic care by balancing the hips and pelvis. The care provided may involve gentle procedures such as gentle stretching and the use of the Activator instrument and the use of proper chiropractic tables such as a high-lo table to accommodate the protruding abdomen later in the woman’s pregnancy.
Zerdecki and Passmore [130]/2008/USA	The authors review the chiropractic approach to pregnant women.	The authors reviewed the sources of LBP as a result of hormonal changes on the biomechanics of the spine during pregnancy, the effects of lumbar disc herniations, and the effects of an anterior pelvic rotation. In addition, the authors discussed peripheral nerve entrapments, headaches, transient osteoporosis and pubic pain. The association between pain and depression and pregnancy were also discussed as well as the appropriate treatments and contraindications to chiropractic SMT.
Andrews [131]/2010/USA	To describe non-optimal fetal positioning in the chiropractic context	A woman presenting with non-optimal fetal positioning may show signs of pelvic asymmetry, muscular imbalances, postural influences, delayed or disrupted neuromuscular control/functioning or inhibition. The author noted that form closure and force closure ensure the stability of the pelvis and functional movement and that dysfunction in either of these mechanisms can result in pain and/or dysfunction and consequently have an effect on the available space in the pelvis for the fetus to engage and negotiate during birth. The author advocated that chiropractic care ensures proper posture and re-positioning of the pelvis would restore or retain a change towards proper biomechanics of the body during pregnancy.
Browning et al. [132]/United Kingdom	To explores the current evidence supporting chiropractic care for LBP and PGP with recommendations for diagnosis and clinical management.	The author outlines the reliable clinical tests used by chiropractors for monitoring pregnant women and the number of chiropractic techniques available to them to address pregnant women suffering from LBP and/or PGP.
Marriott [133]/2010/USA	To provide an overview of the classifications, diagnosis, and management diabetes and gestational diabetes mellitus, and discuss adverse pregnancy outcomes associated with gestational diabetes mellitus along with post-partum recommendations.	Diagnosis of diabetes is based on fasting plasma glucose (FPG) or with an oral glucose tolerance test (OGTT) after consuming 75 grams of carbohydrate. Additional tests include impaired fasting glucose (IFG) and impaired glucose tolerance (IGT). Management of diabetes involves glycemic control resulting in significantly decreased rates of microvascular and neuropathic complications. Weight control, nutritional therapy i.e., carbohydrate-controlled meal plan), physical activity and patient self- monitoring of blood glucose (SMBG) or interstitial glucose and HgA1c and drug therapy. During pregnancy, normoglycemia is maintained by compensatory increase in insulin secretion and a progressive increase in insulin resistance and development of gestation diabetes mellitus (GDM). Adverse outcomes with GDM during early pregnancy include early miscarriage and fetal malformations and macrosomia (i.e., a large fetus for their gestational age or an infant with a birth weight that is greater than the 90th percentile for gestational age and sex). Macrosomia can lead to prolonged labor, labor enhanced with oxytocin, Caesarean delivery, post-partum hemorrhage, infection, third- and fourth-degree lacerations, thromboembolic events, and anesthetic accidents.
Riva et al. [134]/2011/USA	Commentary to advocate for collaborative efforts between chiropractors and pharmacists	Due to concerns for potential for risk with medication use, the United States Food and Drug Administration (FDA) assigned pregnancy categories and used by pharmacists and medical physicians in clinical situations. As part of this new classification system, an alternative therapeutic section will be included with summaries of the evidence discussed supporting it. As a clinical example for the need for collaboration if alternative therapies are used, the authors related the story of a family physician referring a patient with pregnancy-related LBP to a chiropractor. The use of Biofreeze was deemed contraindicated by the community pharmacist due to the presence of menthol 3.5% and camphor 0.2%. Both menthol and camphor are rated in the Pregnancy Risk Factor C Category.
Gordon et al. [135]/2012/USA	Commentary on the role of the chiropractor in patient care such as the use of specific history and examination procedures for the appropriate co-management and referral of a pregnant woman with pre-eclampsia.	The diagnosis of pre-eclampsia is typically made at 20 WOG in the presence of hypertension (i.e., blood pressure > 140/90 mmHG) and proteinuria, with or without edema. The severe form often features hemolysis, elevated liver enzymes, and low platelet count (i.e., HELLP syndrome). Comorbidities include hyper-reflexia, clonus, visual disturbances, epigastric pain, and headaches. Complications include eclampsia (i.e., pre-eclampsia plus seizures), rapid weight gain, disseminated intravascular coagulation, nausea, vomiting, headaches, visual disturbance, hyper-reflexia, clonus, convulsions, cerebral ischemia, right upper quadrant pain or epigastric pain, and HELLP syndrome. The role of the chiropractor includes screening for pre-eclampsia, blood pressure monitoring and neurological examination, use of low force techniques and observe contraindications to SMT, lifestyle and dietary counselling to lower BMI.
Ohm and Alcantara [136]/2012/USA	To clarify the philosophical, theoretical and clinical framework of the Webster Technique	The authors address the inaccuracy of the statement that the Webster Technique was a breech turning technique based. Scope of practice and malpractice issues necessitated this clarification with the Webster Technique defined as a specific chiropractic analysis and the use of various chiropractic techniques to address pelvic bowl dysfunction and restoration of neurobiomechanical function in the sacral/pelvic region resulting in the resolution of fetal malposition/malpresentation and decrease in LBP and PGP.
Oswald et al. [15]/2013/USA	The authors advocate for massage therapy and chiropractic care as highly safe and effective evidence-based options for pregnant women suffering from mechanical low back and pelvic pain.	The authors outline the biomechanical and postural changes during pregnancy: in the second and third trimesters, the centers of mass shift anteriorly resulting in an increase in lumbar lordosis. This in turn causes overactivity of the low back and pelvic muscles, and hypermobility of the thoracic joints, typically at the T6 to T8 levels of the spine, lumbar spine, and pelvis. This, coupled with the expanding pelvis, leads to increased activity in the paraspinal musculature, as well as in the rectus femoris, external oblique, psoas major, and adductor longus muscles bilaterally. Along with SMT, chiropractors can also prescribe exercise and stretches.
Alcantara et al. [137]/2013/USA	A response to a case report of a pregnant woman with systemic lupus erythematosus (SLE) suffering from vertebra-basilar artery insufficiency (VBAI) temporally associated with chiropractic care.	To counter claims that the woman’s VBAI was attributed to the chiropractic care she received, the authors opined that the woman’s preexisting conditions of pregnancy, migraine headaches and SLE were possible risk factors for stroke. The authors also countered that a recent population-based case-control and case-crossover study findings that an increased risk for VBAI with chiropractic care may be inaccurate as patients with headaches and neck pain presenting for chiropractic care may be presenting for care with complaints associated with undetected VBA dissection.
Pettigrew [138]/2014/USA	To advocate for pregnancy chiropractic care with a focus on alleviating back pain, sciatica and symphysis pubic dysfunction.	The author outlined that distortion of the shape, position and function of the birth canal, fetal malposition and uncoordinated or inefficient nervous system input to the uterus and perineum all increase the difficulty of birth leading to birth trauma for the woman and her baby. The Webster Technique was recommended to address the above-described distortions.
Bernard-Giglio [139]/2016/Australia	To advocate for chiropractic care to address pregnancy-related lumbo-pelvic pain	The authors cited recent studies by George et al. [23]and Peterson et al. [22] on the effectiveness of chiropractic for pregnancy-related lumbo-pelvic pain.
Curnow and Geraghty [140]/ 2019/ Australia	A commentary on the benefits of chiropractic care during pregnancy for both the pregnant woman and their child.	The authors commented on the role of chiropractic care in relieving back pain, facilitating the correction of breech presentations, and treatment of colic, breastfeeding and constipation in the neonate.
Conner et al. [141]/ 2021/ United States	The authors advocate for chiropractic care due to its safe and drugless approach and a review of commonly treated conditions with SMT and adjunctive therapies.	Common conditions amenable to chiropractic care include LBP with or without radiculopathy, PGP, headaches. The authors further discussed the safety of chiropractic care and the use of the Webster Technique.
AS = antero-superior; BMI = body mass index; FPG = fasting plasma glucose; FDA = Food and Drug Administration; GDM = gestation diabetes mellitus; Gy (gray) = unit of radiation dose = 1 joule/kilogram = 100 rad; HbA1c = hemoglobin A1C test to measure the amount of glucose (sugar) attached to hemoglobin; HELLP = hemolysis, elevated liver, low platelet count; IFG = impaired fasting glucose; IGT = impaired glucose tolerance; LBP = low back pain; mmHg = millimeters mercury; MSK = musculoskeletal; OGTT = oral glucose tolerance test after consuming 75 grams of carbohydrate; PGP = pelvic girdle pain; RhoGAM = rhod immune globulin human; SOT = sacro-occipital technique; SIJ = sacro-iliac joint; SMBG = self- monitoring of blood glucose; SMT = spinal manipulative therapy; USA = United States of America; VBAI = vertebra basial artery insufficiency; yr = year

Table 4

Summary findings of the systematic reviews.
Reference/yr/ country	Study aim(s)/purpose	Inclusion/Exclusion Criteria	Databases	Commentary
Borggren [142]/2007/ USA	To review the literature on chiropractic care of pregnant women	Inclusion criteria not indicated but used search terms: pregnancy and chiropractic.	PubMed (1987–2006)	A narrative review. Whether this article is a systematic review is questionable. The authors failed to follow a protocol for performing systematic reviews. The author’s use of references to support statements on chiropractic care for LBP, safety of chiropractic care, and chiropractic care in the postpartum. Many of the cited references were not indexed or published in peer reviewed journals.
Stuber and Smith [143]/ 2008/Canada	To review the literature on chiropractic care, including spinal manipulation, for pregnancy-related LBP.	Inclusion criteria: (1) manuscripts in English (2) involved the care of pregnant with lower back pain 3) cared for by a chiropractor (4) published in peer reviewed journals.	PubMed, CINAHL, ICL (First journal publication to October 2011}	The authors found six studies meeting their inclusion criteria. The use of the Downs and Black [155] methodological quality assessment produced scores ranging from 5 to 14 (maximum score = 27). All of the included studies reported positive results with chiropractic care for pregnancy-related LBP. Outcome measures between the studies was inconsistent as were descriptions of patients, treatments, and treatment schedules.
Khorsan et al. [144]/ 2009/ USA	To examine/evaluate the evidence on the effects of SMT on back pain and other related symptoms during pregnancy.	Inclusion criteria: (1) publication in English, (2) use of chiropractic and osteopathic SMT during pregnancy/childbirth.	PubMed (1966-September 2008), MANTIS (1966-September 2008), CINAHL (1982-September 2008), ICL (inception -September 2008), Google Scholar	A total of 32 manuscripts were reviewed. Overall, the studies varied in treatment protocols and outcome measures. The authors concluded that the use of SMT during pregnancy to reduce back pain and other related symptoms was supported by limited evidence and described as emergent.
Stuber et al. [12]/ 2012/ Canada	To critically review reported cases on adverse events associated with SMT during pregnancy and 6 weeks postpartum.	Inclusion criteria: (1) manuscripts in English /French, (2) involved pregnant/ postpartum women and (3) received SMT with documented associated adverse events with the SMT.	PubMed, CINAHL, ICL (journal inception to October 2011)	Five articles reported on adverse events in seven subjects; and remaining two were systematic reviews. Two articles described adverse events from two postpartum women while three articles reported on five pregnant women. Injury severity ranged from minor injury to more severe injuries such as fracture, stroke, and epidural hematoma.
Alcantara et al. [145]/ 2015/ USA	To examine use of validated patient reported outcome (PRO) measures in chiropractic care of pregnant women	Inclusion criteria: (1) publication of primary investigation; (2) reports involved chiropractic care of pregnant women and (3) use of a validated outcome measure	PubMed, CINAHL, Medline, ICL and MANTIS (1966–2014). Hand-search also performed of specific chiropractic journals (2009–2014) .	Eight articles met the authors’ inclusion criteria that identified the use of PROs. Despite heterogeneity and inconsistency issues on the use of PROs, some measure of effectiveness was noted by the authors.
Weis et al. [146]/2020/ Canada	To assess the effectiveness of common care approaches employed by chiropractors for pregnancy-related low back (PRLBP) and pelvic girdle pain (PRPGP)	Inclusion criteria: (1) publication in English, (2) involve pregnant women suffering from lumbar spine or pelvic girdle pain, (3) chiropractic care (SMT and/or adjunctive therapies) were provided	PubMed, CINAHL, ICL, Cochrane Database, MEDLINE (journal inception to November 2016)	Based on 18 systematic reviews, 30 RCTs and 2 cohort studies, the authors concluded that the care of women with PRLBP had moderately favorable evidence for electrotherapy and osteopathic manipulative therapy (OMT). There was favorable strength of evidence for chiropractic care, exercise, and support devices. There was inconclusive /unclear strength for SMT. Inconclusive, unclear strength evidence for SMT, OMT and support devices for PRLBP or PRPGP.
Weber-Hellstenius [147]/ 2020/ Sweden	A scoping review of the potential risk(s) in women, particularly during the perinatal period.	Exclusion criteria: (1) non-English manuscripts, (2) case reports, (3) commentaries, (4) pilot studies and (5) letters to the editor. The search terms were: pregnancy, stroke migraine, stroke race, women, obesity, and manual therapy in various combinations.	PubMed, Research Gate (1995–2020)	According to the author, the perinatal period is associated with a 9-15-fold elevated risk for stroke. Conditions such eclampsia and preeclampsia confer the strongest risk factors (i.e., 12-fold increase) for stroke as well as a diagnosis of an infection, obesity, hypertension, and gestational diabetes mellitus and a history of migraine headaches while decreased mobility (i.e., due to PGP and LBP) increases the risk for clotting, compounding a pregnant woman’s other risk factors for stroke. The application of significantly high rotatory forces to the upper cervical spine and its effects on the vertebral artery and the possible risk for stroke remains to be fully elucidated. Regardless, the author cautions that an increased risk for stroke is a contraindication for high force manipulation of the upper cervical spine.
Weiss et al. [148]/ 2021/ Canada	To update the literature on adverse events associated with care in pregnant and postpartum women.	Inclusion criteria: (1) manuscripts documenting adverse events/iatrogenic injuries;(2) involved pregnant/ postpartum; (3) intervention performed by chiropractors, osteopaths and physiotherapists	PubMed, CINAHL, Index to Chiropractic Literature, Cochrane Database of Systematic Reviews/Cochrane Central Register of Controlled Trials and Medline (October 2011- November 2018)	Eight systematic reviews, 7 RCTs, 5 cohort studies and one case report met the authors’ inclusion criteria. The updated systematic review [14] found a case report involving a serious adverse event following SMT in the cervical spine and a number of minor and transient adverse events in the low back.
CINAHL = Cumulative Index to Nursing and Allied Health Literature; ICL = Index to Chiropractic Literature; MANTIS = Manual, Alternative and Natural Therapy Index System; OMT = osteopathic manipulative therapy; PRLBP = pregnancy-related low back pain; PRPGP = pregnancy related pelvic girdle pain; PRO = patient reported outcome; RCT = randomized controlled trial; SMT = spinal manipulative therapy; USA = United States of America

Cluster Analysis

In Fig. 2, the K means cluster analysis determined a K value of four centroids or clusters, plotted in Fig. 3 and summarized in Table 5. Despite overlapping distributions, each manuscript was assigned to a cluster based on their closest distance from a defined cluster center. The commentary by Conner et al. [141], the best practice recommendations by Weis et al. [149] and case reports by Poirier and Loranger [94] and Swenson and Acevedo [96] were not initially included in the NLP analysis but ultimately assigned to a cluster based on thematic analysis. Cluster 1 involved manuscripts with complex MSK presentations; cluster 2 with simple MSK presentations; cluster 3 focused on the use of the Webster Technique and cluster 4 were papers characterized by advocacy for chiropractic.

Table 5

Summary of findings of K-means cluster analysis
Study Design	References
	Cluster 1	Cluster 2	Cluster 3	Cluster 4
Case Reports	50, 52–53, 59, 66, 68, 70–72, 74, 77, 79–80, 82, 84–85, 87–90, 92–93	47, 48–49, 55, 73, 94	51, 54, 56–58, 60, 64–65, 67, 69, 75–76, 78, 83, 86, 91, 95, 96	46, 61–63, 81
Case Series	98, 101	97, 99–100, 106, 108	102–103, 107, 109	104–105
Case Control				34
Cross sectional cohort	40	36, 37, 39, 42	41	35, 38, 43–45
Prospective cohort	28	14, 29, 32, 33	30	31
RCTs		25–27
Qualitative study		110
Commentaries	138, 140	132, 139, 141	136	9, 15, 111–131, 133–135, 137
SRs		12, 143–146, 148		142, 147
Best practice recommendations		149
Key terms	Pain, pregnancy, treatment, back, study, pregnant patient, woman, care, exercise, low, chiropractor, pelvic, group, LBP	Care, pain, pregnancy, complaint, pregnant, week, patient, Webster, case, PROMIS, technique, visit, back, headache, migraine	Breech, Webster Technique, presentation, Cesarean. fetus, position, subluxation, vertex, section, birth, vaginal, care, pregnancy, adjustment	Pregnancy, pain, back, labor, pregnant, care, chiropractor, may, woman, baby, doctor, position, technique, adjustment, pelvic
LBP = low back pain; PROMIS = Patient Reported Outcomes Measurement Information System

Cluster 1 manuscripts were characterized overall by women presenting with various pregnancy related MSK conditions and comorbidities that elevated the complexity of their care and possibly necessitated referral to a medical specialist. The case series by Kunau [98] exemplified the breadth and depth of care provided by a chiropractor that involved mandatory reporting, fetal heart rate monitoring, women presenting with nausea, vomiting and amenorrhea, trauma from a fall, spotting, poor digestion, weakness and dizziness, an enlarged heart, high cholesterol, kidney infection, hypoglycemia and hypothyroidism, breech fetuses, and headaches. Phillips [101] similarly reported women with MSK pain with accompanying neurological symptoms, thyroiditis, headaches and restless leg syndrome. McCoy et al. [28] similarly described comorbidities of fetal mispositioning, migraine headaches, and asthma.

The case reports documented comorbidities of migraine headaches [52, 71, 74, 77], fetal malposition/malpresentation [51, 54, 56–60, 64–70, 75–76, 78, 81, 83, 86, 91, 98, 102–103, 105], constipation and acid reflux [50], lower extremity swelling and acid reflux [80], diplopia with pseudotumor of the cerebrum [74], a history of Harrington rod surgery [79], hypothyroidism, and tachycardia, visual field disturbances and neurological deficits in the face and upper extremities [71], placenta previa [68, 77, 92], peripheral neuropathy, lower extremity swelling and notable history of endometriosis, ovarian cysts, and two miscarriages [72], the desire for a natural childbirth after Caesarean (VBAC) [50, 71, 84], a history of trauma (i.e., a fall) [93], sleep disturbance [88], placental insufficiency and fetal growth restriction [82], prolonged and complicated labor [53], and twin [87] and triplet [80] pregnancies.

Cluster 2 were manuscripts that described pregnant women with pregnancy related MSK complaints along with manuscripts addressing safety and the use of validated patient reported outcomes (PROs). The manuscripts documented a significant association between LBP during pregnancy and labor [36], that pregnant women present commonly with pelvic pain [39], and that chiropractic care alleviates symphysis pubic dysfunction (SPD) [37], LBP and/or PGP [25–26, 29, 32] but not one-sided PGP [27]. In a qualitative study, Sadr et al. [108] found pregnant women’s experiences revolved around their presenting complaints, provided care and self-care options, their safety and effectiveness and the importance of chiropractor-patient communication. The case reports and case series documented various MSK complaints that included LBP with/without radiculopathy and/or PGP [49, 55, 73, 97, 99, 100, 106, 107, 108], groin pain [47], bilateral anterolateral thigh paresthesia and groin pain [48], SPD [106], leg pain [107], neck pain [107], upper extremity/shoulder pain [107]. Of the six SRs [12, 143–146, 148] in this cluster, four systematically reviewed chiropractic care for pregnancy-related LBP and/or PGP [143–146]. The remaining SRs [12, 148] reviewed the safety of chiropractic SMT and adjunctive therapies. Despite indicated contraindications to SMT (i.e., a history of a trauma, placenta previa, spotting/bleeding) [97, 130], there are cases refuting these contraindications with safe and/or beneficial outcomes [68, 77, 92, 93, 98]. In an update to the SR by Alcantara et al. [145] on the use of validated PROs, subsequent manuscripts include the use of the PROMIS-29 and RAND VSQ9 [15], the Quebec Task Force Disability Scale [47], the Roland Morris Disability [25], Oswestry Disability Index [27] and EQ-5D Health [27] questionnaires, and pain rating [25, 27, 47, 73, 108]. The best practice recommendations by Weiss et al. [149] addressed the care of pregnant women with LBP and/or PGP.

The manuscripts in Cluster 3 focused primarily the use of the Webster Technique to facilitate correction of fetal malposition/malpresentation. Early empirical observations inappropriately referred to the technique as a “breech turning” technique [136]. Intentional breech turning is outside the scope of chiropractic [156]. The Webster Technique involves a specific chiropractic analysis and the correction of sacral subluxation to restore neuro-biomechanical integrity in the lumbosacral/pelvic region [136]. An optimal environment for the fetus facilitates auto-correction to the vertex position and the alleviation of MSK pain complaints [132, 157]. Among 41 women cared for with the Websters Technique, the mean was 30.83 years (n = 35; SD = 6.32). For 34 women with known gestational age, they presented for care at a mean gestation age of 33.69 weeks (SD = 3.12). Thirty-eight pregnancies resulted in correction to vertex position except in two cases [65, 98] resulting in a Caesarean birth as did two other cases [58, 102]. Four case reports noted vaginal birth after Caesarean (VBAC) [58, 84, 87, 96]. In 39 pregnancies, the mean number of visits to determine outcome (i.e., fetus in vertex position) was 5.44 visits (SD = 5.03) with duration of care spanning a period of 1 day to several weeks. Fetal position was determined by ultrasound imaging (n = 26), palpation (n = 3), both ultrasound and palpation (n = 1), at birth (n = 2) with 8 not indicated. Twenty-three pregnancies were indicated as resulting in a natural childbirth, and 13 not indicated. The fetal presentations addressed were complete breech (n = 30) [51, 54, 57–59, 60, 64–66, 68, 75, 81, 94, 98, 102, 103, 105, 109] with three of these pregnancies involving twins [60, 103], frank breech (n = 5) [56, 76, 78, 86, 95], footling breech twins [83], and seven transverse breech [67, 69, 70, 91, 98, 105] pregnancies.

The manuscripts in Cluster 4 were characterized as advocating for chiropractic care during pregnancy [113, 116, 117, 120, 121, 124, 125, 129, 130, 142], promote the collaborative care with other health care professionals [13, 122, 123, 126, 134, 141] or address and provide instructions on management issues (i.e., pre-eclampsia, stroke following SMT, gestational diabetes, radiology during pregnancy) germane in pregnancy care [9, 31, 34–35, 38, 43–45, 46, 61–63, 104, 111–112, 114–115, 119–121, 127, 128, 131, 133, 135, 137, 147]. Ohm [122, 126] called for greater collaboration between chiropractors and midwives as both professions acknowledge and trust in the body’s inner wisdom, offer profound support and commitment to non-invasive birthing procedures, and offer individualized care.

This scoping systematic review on the chiropractic care of pregnant women provides a comprehensive systematic evaluation of the literature. Despite the heterogeneity of the reviewed studies, our use of NLP [22] and K-Means Cluster analysis [23, 158] was a novel approach to data-based convergent synthesis to identify the nature and extent of the literature on the chiropractic care of pregnant women [159].

In recent times, there have been an acknowledgement that practice patterns and patient care are affected by practitioner demographics [160]. Although six survey studies [37, 41–45] involved chiropractors as responders, the reviewed literature provided data for age in only two studies [40, 44], three studies [40, 43, 44] described gender, three studies provided practice experience [40, 43, 44], and three studies provided postgraduate training [40, 43, 44].

Patient characteristics have also been shown to be an important determinant of patient preferences regarding many aspects of their health care [161]. Excluding case reports and case series, patient characteristics such as age [14, 25–28, 30, 32–36, 40, 42], educational status [14, 25, 27], ethnicity [25, 31, 33], gestation age (i.e., WoG) [13, 25–27, 29–34, 39–40], patient satisfaction [14], quality of life [14] and motivation for care beyond MSK complaints (i.e., wellness care, fetal malposition) [14, 28, 30, 40] were minimally documented.

In addition to the Webster Technique, we found Sacro-Occipital Technique or SOT [40, 43, 98], Activator Methods [28, 38], Applied Kinesiology [43], Neuro-Emotional Technique [25], Logan Technique [34, 43], Thompson Technique [34], Upledger craniosacral therapy [34] and Gonstead Technique [43] applied to pregnant women. Our review confirmed the popularity of use of Diversified Technique [14, 25–27, 28, 29, 33, 36, 37, 42, 43], characterized as an HVLA thrust SMT, for pregnant women. Adjunctive therapies such as exercise and soft-tissue therapy [27, 37, 42–43, 115] and the use of nutritional supplementation and diet [116, 124, 133, 135] have also been documented. Despite the reported high success rate (i.e., 91%) of the Webster Technique to correct breech presentations by Pistolese [41], the study was fraught with confounders and bias (i.e., concurrent care with moxibustion, slant/tilt board) as Alcantara et al. [30] acknowledged in their study on the effectiveness of the Webster Technique.

There is minimal literature documenting the collaborative efforts of chiropractors with massage therapists [42, 43] or the receipt of referrals from midwives and obstetricians [11, 39, 42]. Through pregnancy care, chiropractors have an opportunity to demonstrate their ability and willingness to advance collaborative efforts with other healthcare providers. Alcantara et al. [11] found that among pregnant women, a high proportion of primary providers (i.e., obstetricians, midwives) were aware of the women’s chiropractic care with some making the referral to their chiropractor.

Despite three SRs [12, 147, 148] and a cross-sectional study [42] on the safety of chiropractic perinatal care, the literature is arguably lacking. The study by Stuber [42] involved a small sample size (n = 18) with minimal clinical experience in pregnancy care among the responders. The scoping review by Weber-Hellstenius [147] examined the potential stroke risk(s) in women, particularly during pregnancy and the postpartum period while the SRs by Weis et al. [148] and Stuber et al. [12] examined the documentation of adverse events associated with SMT in the perinatal period, such studies have limitations. As in medicine [162], the reporting of adverse events by chiropractors has many challenges and often unreported. To date, no prospective surveillance of adverse events has been performed to assess the prevalence and incidence of adverse events associated with pregnancy chiropractic care. We also encourage further investigations into the relative and absolute contraindications associated with pregnancy care given that existing contraindications were provided without clinical justification [42, 111, 123, 125, 130, 137].

Finally, the best practice recommendations by Weis et al [149] acknowledged the required meta-competencies for successful practice such as taking a history, performing an examination (including the use of imaging studies), implementation of care (including risks) and collaborate with other providers as necessary. However, no substantive recommendations were provided by the authors beyond “modifications or alternate chiropractic procedures should be considered” in the care approach. Specific to pregnancy care, patient positioning to avoid “torquing” the lumbopelvic and ensure patient comfort with a pregnancy pillow or a table with a drop-piece is important. In terms of modification of technique, the use of HVLA thrust SMT should give due consideration to the amount and depth of force applies. Alternative technique procedures should implement non-force techniques (i.e., SOT, Activator Methods and Thomson Technique). Chiropractors versed in pregnancy care would argue that the Webster Technique in pregnancy care is invaluable and our findings reflect this. The application of this technique was not discussed appropriately.

Overall, we found major gaps and deficits in the literature on the chiropractic care of pregnant women. To date, there exists no comprehensive examination or characterization of chiropractors (i.e., age, gender, years in practice, post-graduate training, clinical experience) involved in pregnancy care, their practices (i.e., practice environment, fee structures and reimbursement modes), their management protocols, referral patterns and collaborative efforts with other practitioners along with patient characteristics (age, pregnancy covariates). There is a need for more appropriately designed prospective cohorts and clinical trials are warranted, along with context-specific qualitative research to better understand the experiences of pregnant women under chiropractic care and the perspectives of their chiropractors.

Strengths and Limitations

Our study found a diverse body of literature on pregnancy chiropractic care and applied NLP and K-Means Cluster Analysis for data-based convergent synthesis of the literature. Time will dictate the veracity of our analytical approach given that no established protocol exists for scoping reviews [165]. Although our search methods were rigorous and comprehensive, we may have missed relevant studies (i.e., selection bias) as our search was limited to literature published in English. Restricting our review to English-only publications were for pragmatic reasons and the lack of professional language translators may have resulted in publication bias [166]. This excluded English records during our literature search since the database retrieved only those records that explicitly have defined English as a “value” in their language data “field” and not those English records that are missing such value for the field [167]. As Juni et al. [168] reported, including non-English studies influenced effect estimates in more than half of their meta-analyses. Egger et al. [169] found that authors were more likely to report their findings in English language journals when their results were statistically significant and increasingly less likely to publish in non-English language journals.

The lack of quality appraisal of the reviewed studies and the inclusion of lower quality studies implies systematic bias in our scoping review. However, the focus of our review was a comprehensive examination of the literature to identify for patterns or themes rather than identify levels of evidence.

Our scoping review appraised the current state of knowledge on the chiropractic care of pregnant women. Our findings reaffirms that chiropractic care for pregnant women has a focus on pregnancy related MSK complaints and comorbidities of pregnancy, the use of the Webster Technique, and the need for collaboration with other health care professionals.

Ethics approval and consent to participate: Not applicable
Consent for publication: Not Applicable
Availability of data and materials: All data generated or analyzed during this study are included in this published article.
Competing interests: The authors declare that they have no competing interests
Funding: This study was funded by Southern Cross University and the International Chiropractic Pediatric Association.
Authors' contributions: JA conducted the searches and retrieved the articles. RW performed the natural language processing and statistical analysis. EE, SG and SPM analyzed, reviewed and approved the contents of the manuscript. All authors assisted in the preparation of the manuscript and approved the final version.
Acknowledgements: Not applicable

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No competing interests reported.

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The chiropractic care of pregnant women: a scoping review of the literature

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Abstract

Background

Methods

Results

Conclusions

Figures

Background

Methods

STEP 1: Formulating the research question

STEP 2: Identifying and selecting the relevant literature

STEP 4: Collating, summarizing, and reporting the results

Results

Search Outcomes

Study characteristics

Cluster Analysis

Discussion

Conclusion

Declarations

References

Additional Declarations

Supplementary Files

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