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Spinal manipulation is a safe and effective tool for pregnancy-related low back pain (P-LBP). Multiple studies have demonstrated the effectiveness of manipulation for this population.  Evidence-based recommendations for OB/Gyn’s include referral for chiropractic spinal manipulation. This blog will discuss the prevalence, predisposing factors, and treatment of P-LBP; including a video demonstration of a simple and effective SMT technique for pregnant patients.

Patient Population:

Researchers estimate that between 45-76% of pregnant women will experience low back pain at some stage of their pregnancy. (1-7) Up to 33% rate their pain as severe. (6) Pregnancy-related low back pain (P-LBP) leads to lower quality of life, restricted activity, and disability – with almost 25% of pregnant women taking sick leave for LBP. (2,8-11) The recurrence rate for pregnancy-related low back pain is 85-90%. (11-14) Consequently, almost 1 in 5 women who report P-LBP during a first pregnancy will avoid future pregnancies due to fear of returning symptoms. (15)

A recently published paper by Weis et al. demonstrated that 76% of women experience pregnancy-related back pain, and the prevalence of site-specific pain increases with increased gestation. (7)

Predisposing Factors:

Pregnancy-related low back pain is not generally the result of true structural disease, like disc lesion or spondylolisthesis, but rather a combination of “functional” stressors, including weight gain, gait changes, and postural strains that occur contemporaneously with hormone-induced ligamentous laxity. (16-20) Pregnancy creates the perfect firestorm of progressively increasing load with diminishing stability. (21) The average woman gains between 20- 40 pounds throughout pregnancy. (13,22) This predominantly frontal weight gain advances the center of gravity, forcing an anterior pelvic tilt and lumbar hyperlordosis- placing excessive stress on the ligaments, discs, lumbar facet joints and sacroiliac joints. (23-25) Since an excessive lumbar lordosis diminishes the spine’s capacity to absorb axial load, the intervertebral discs undergo excessive compression, likewise exacerbated by weight gain. (26) The abdominal muscles, which are an integral support mechanism for the lumbar spine, are stretched to accommodate the expanding uterus, thereby compromising their ability to maintain posture and support. (13) Biomechanical stressors are compounded by the hormone relaxin, which increases tenfold during pregnancy. (13) Relaxin triggers lumbopelvic hypermobility and threatens core stability. (26)

Treatment Strategies:

The goal of manual therapy is to restore normal joint mobility and reduce muscle tension. (55) Manual therapy, including chiropractic manipulation, demonstrates medium to large benefit for the management of pregnancy-related low back pain. (75,110,111) Spinal manipulation is an important component in the management of pregnancy-related low back pain. Almost 75% of women undergoing chiropractic manipulation report significant pain reduction and clinically significant improvements in disability. (51,110) Women who seek chiropractic care throughout pregnancy may have an added benefit of shorter labor times. (79,109) Incidentally, postpartum LBP also responds to spinal manipulation- approximately ten times greater than watchful waiting. (115)

Clinical Pearls:

Here are some take-home points about pregnancy-related LBP to consider before seeing your next case:

  • A history of lower back pain doubles the risk of developing P-LBP.
  • Pregnancy-related low back pain typically starts between the fifth and seventh months.
  • Forty percent of women who experience pregnancy-related LBP continue to suffer six months post-partum, and 20% report pain three years later.
  • Almost 75% of women undergoing chiropractic manipulation report significant pain reduction and clinically meaningful improvements in disability.
  • Healthy women may begin or continue the moderate-intensity aerobic exercise for at least 150 minutes per week. Women should not start vigorous activity during pregnancy. In addition to musculoskeletal benefits, ongoing exercise during pregnancy decreases one’s risk of excessive weight gain, pre-eclampsia, gestational diabetes, and pre-term birth, while improving self-image and pain tolerance.

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1. Wu WH, Meijer OG, Uegaki K, Mens JM, van Diee¨n JH, Wuisman PI, et al. Pregnancy related pelvic girdle pain (PPP), I: terminology, clinical presentation, and prevalence. Eur Spine J 2004;13:575–89.
2. Pierce H, Homer C, Dahlen H, King J. Pregnancy related low back and/or pelvic girdle pain: listening to Australian women. Abstract presented at the XI International Forum for Low Back Pain Research in Primary Care, Melbourne, Australia, 15–18 March 2011.
3. Diakow P.R.P., Gadsby T.A., Gadsby J.B., Gleddie J.G., Leprich D.J., Scales A.M. Back pain during pregnancy and labor. J Manipulative Physiol Ther. 1991;14(2):116–118.
4. Berg G., Hammer M., Moller-Nielsen J., Linden U., Thorblad J. Low back pain in pregnancy. Obstet Gynecol. 1988;71:71–75.
5. Mogren IM, Pohjanen AI. Low back pain and pelvic pain during pregnancy: prevalence and risk factors. Spine . 2005 Apr 15;30(8);983-91.
6. Hall J, Cleland J, Palmer J. The Effects of Manual Physical Therapy and Therapeutic Exercise on Peripartum Posterior Pelvic Pain: Two Case Reports. Journal of Manual and Manipulative Therapy. 2005;13(2): 94-102
7. Weis CA, et al. Prevalence of Low Back Pain, Pelvic Girdle Pain, and Combination Pain in a Pregnant Ontario Population. J Obstet Gynaecol Can. 2018

Additional references are listed in the ChiroUp protocol for P-LBP.

About the Author

Dr. Brandon Steele

Dr. Brandon Steele


Dr. Steele began his career at The Central Institute for Human Performance. Dr. Steele has trained with experts including Pavel Kolar, Stuart McGill, Brett Winchester, and Clayton Skaggs. He has been certified in Motion Palpation, DNS, ART, and McKenzie Therapy. Dr. Steele lectures extensively on clinical excellence and evidence-based musculoskeletal management. He currently practices in Swansea, IL and serves on the executive board of the ICS.

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