Adjusting… Pregnancy

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Adjusting Pregnancy

• Modifications for the Pregnant Patient

2
What causes subluxation?

• 3Ts
• Thoughts
• Trauma
• Toxins
• Also consider hormonal and biomechanical factors

3
Hormonal Factors Alteration of supporting
structures

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

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Biomechanical Changes
Increased kyphosis Increased lordosis
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What modifications should we make?

• Alteration of supporting structures joint laxity
  
• ?
• Changes in kyphosis/lordosis
• ?

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Cervical Spine

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

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Thoracic Spine

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

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Clinical Note

• Thoracic and abdominal compression will become
  more and more uncomfortable as the baby grows
• Some DCs like to use anterior adjusting
• patient doesnt have to be prone

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Other Solutions

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

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Lumbar Spine

• Hyperlordosis gt stress on facets
• Spinous imbrication - facet jams

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Pelvis

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

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Chiropractic Assessment

• Observation
• Static Palpation
• Motion Palpation
• Instrumentation
• Radiography
• Adjustments

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Observation Pregnancy

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

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Observation Pregnancy

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

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Clinical Note

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

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For example

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

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Static Palpation Pregnancy

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

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Motion Palpation Pregnancy

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

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Instrumentation Pregnancy

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

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Radiography Pregnancy

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

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Adustments Pregnancy

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

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GONSTEAD ACTIVATOR LOGAN THOMPSON SOT
DIVERSIFIED

• Any technique can be modified!
• Limitations
• Patient comfort
• Patient size mobility/flexibility
• Your creativity

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Remember...

• Make sure shes comfortable
• Keep her spine in a neutral position
• Light thrusts!
• ...a rebound effect can occur if adjustments are
  too forceful during pregnancy.
• Larry Webster

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Positioning her comfortably

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

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Clinical Note

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

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Treatment Protocol (Fallon, 1994)

• How often should a pregnant woman be adjusted?
• Varies from patient to patient.
• 1x/month 1st trimester
• 2x/month 2nd trimester
• 1x/week leading up to following birth
• 2x/month
• 1x/month (stabilizes)

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References

• Anrig Plaugher. Pediatric Chiropractic.
  Baltimore, MD Lippincott Williams Wilkins,
  1998.
• Anrig-Howe C. Scientific Ramifications for
  Providing Pre-natal and Neonate Chiropractic
  Care. The American Chiropractor, 1993 May/June
  20-26.
• Fallon. Textbook on Chiropractic and Pregnancy.
  Arlington, VA International Chiropractors
  Association, 1994.
• Forrester J. Chiropractic Management of Third
  Trimester In-utero Constraint. Canadian
  Chiropractor, 1997 2(3) 8-13.
• Fysh. Chiropractic Care for the Pediatric
  Patient. Arlington VA ICACCP, 2002.
• Kunau P. Application of the Webster In-utero
  Constraint Technique A Case Series. Journal of
  Clinical Chiropractic Pediatrics, 1998 3(1)
  211-6.
• McMullen M. Assessing upper Cervical
  Subluxations in Infants Under Six Months. ICA
  International Review of Chiropractic, 1990
  March/April 39-41
• Pistoles R. The Webster Technique A Chiropractic
  Technique with Obstetric Implications. JMPT,
  2002 25(6).
• Webster L. Chiropractic Care During Pregnancy.
  Todays Chiropractic, 1982 Sept/Oct 20-22.