Spinal manipulation and adverse event reporting in the pregnant patient limits estimation of relative risk: a narrative review

ABSTRACT

Objective

To describe variability in spinal manipulation technique details and adverse event (AE) documentation of spinal manipulation during pregnancy.

Methods

Five databases were searched for peer-reviewed investigations of spinal manipulation during pregnancy. Criteria for inclusion was as follows: high velocity, low amplitude thrust manipulation performed, subjects pregnant during manipulation, and English language. Studies were excluded when participants were not currently pregnant, and when the manipulation performed was not high-velocity, low-amplitude thrust. Data extraction included study design, number of participants, gestational age, spinal region, number of manipulations, manipulation technique details, profession of manipulator, AE reporting (Yes vs. No), type, and number of AE.

Results

Out of 18 studies included in the review, only three provide details of the spinal manipulation technique. The reported variables include patient position, practitioner position, and direction of thrust. Fourteen studies documented AE; however, only seven provide AE details.

Discussion

Reporting of spinal manipulation techniques and AE during pregnancy were inconsistent. Replication of methods in future investigations is limited without more detailed documentation of manipulation techniques performed. Furthermore, determining the relative risk and safety of spinal manipulation during pregnancy is not possible without more detailed reporting of AE. Due to these inconsistencies, a checklist is proposed for standardized reporting of spinal manipulation techniques and AE. With more consistent reporting of these parameters, results of future investigations may allow for more definitive and generalizable safety recommendations on spinal manipulation during pregnancy.

Introduction

In the United States, there are roughly 5 million pregnancies each year [1] and musculoskeletal symptoms, including back pain, pelvic girdle pain, neck pain, and headaches, are common complaints throughout pregnancy. Back pain during pregnancy was reported by 68% [2] of survey respondents, while a separate questionnaire reported 76% [3] of women had back pain, pelvic girdle pain, or a combination of the two during pregnancy. Upper back pain has been reported in up to 42% of pregnancies [4]. Neck pain prevalence during pregnancy has been reported as high as 20% [5] with headaches experienced by 17% [6] of women. Common treatments for these complaints include medication, hot/cold packs, pelvic girdle belts, exercise, neuromuscular reeducation, and spinal manipulation.

Spinal manipulation, defined as high-velocity, low-amplitude thrust [7,8] is a treatment used by multiple professions, including physical therapists, chiropractors, and osteopathic physicians. As a treatment, spinal manipulation has been shown to have benefits, including decreased pain and improved function [9–11]. A recent systematic review and meta-analysis found that lumbar thrust manipulation led to modest improvements in acute low back pain and function [9]. The clinical practice guidelines endorsed by the Orthopedic Section of the American Physical Therapy Association (APTA) for the management of acute and chronic low back pain recommend both thrust and non-thrust joint mobilization [12]. Similarly, the American College of Physicians clinical practice guidelines recommend non-pharmacologic treatment, including spinal manipulation, for acute, subacute, and chronic low back pain [13]. Cervical and thoracic manipulations have been shown to improve neck pain [14] and reduce cervicogenic headaches [15]. Clinical practice guidelines endorsed by the Orthopedic Section of the APTA for neck pain recommend thoracic manipulation for acute and chronic neck pain with mobility deficits [16].

Spinal manipulation, however, does have inherent risks ranging from mild soreness to more serious conditions, such as cauda equina syndrome, lumbar disc herniations, cervical arterial dissection, and stroke [17–19]. To minimize these risks, health-care professionals are educated regarding contraindications and precautions when deciding whether spinal manipulation is appropriate for the patient. Contraindications for spinal manipulation include infection, acute circulatory condition, malignancy, constant, severe pain, and extensive radiation of pain [20–22]. Precautions include rheumatoid arthritis, presence of neurologic signs, osteoporosis, pregnancy, and dizziness [20]. Owoeye lists pregnancy as a contra-indication for lumbar spine manipulation [23] and Pettman states manipulation is ‘ill advised’ during pregnancy [24]. The Australian Physiotherapy Association includes pregnancy and post-partum periods as contraindications for cervical spine manipulation [22].

Pregnancy has been included as a precaution due to the hormonal changes in pregnancy that can lead to greater joint laxity and a change in coagulation status [25]. The reported increased joint laxity during pregnancy has been related to multiple hormonal changes, including increased cortisol in the third trimester and increased relaxin in the first trimester [26]. While there is evidence of these physiological changes it is unknown if they are significant enough to escalate the risk of spinal manipulation in this population. Also, there are multiple studies that report pregnancy is often an exclusion criterion for treatments and research due to uncertainty of risk, concerns regarding potential liability, and historical practice standards [27–30]. Concerns regarding potential liability are likely related to fear of miscarriage as roughly 26% of pregnancies end in miscarriage and 80% of those occur in the first trimester [31]. Due to the risk of miscarriage in the first trimester, many advocate being cautious with manipulation in early pregnancy to avoid being blamed for the loss of pregnancy [31].

Due to the reasons listed above, the safety of spinal manipulation during pregnancy has not been thoroughly investigated and the risk of adverse events (AE) is unknown. Therefore, the primary objectives of this narrative review were to describe variability in spinal manipulation technique detail and adverse event documentation of spinal manipulation during pregnancy.

Methods

Literature search

In March 2022, the primary author searched PubMed, EBSCO Host, MEDLINE, CINAHL Complete, and Cochrane from database inception to March 2022 using keyword/text word searches. Each database was searched for the combination of the following keywords: pregnant, pregnancy, adverse events, spinal manipulation, cervical manipulation, thoracic manipulation, lumbar manipulation, and sacroiliac manipulation. A spreadsheet was maintained throughout the process to capture data and search strategies for each of the individual databases and for ease of reproducibility. Appendix 1 details the search strategy. This study protocol was not registered a priori.

Eligibility criteria

Peer-reviewed studies including randomized control trials, case studies, cohort studies, and case series were considered for inclusion. Criteria for inclusion was as follows: high velocity, low amplitude thrust manipulation performed, patient/participant pregnant during manipulation, and English language. Studies were excluded when participants were not currently pregnant, and when the performed manipulation was not a high velocity, low amplitude thrust.

As this study was not to determine if spinal manipulation was effective in pregnancy, risk of bias was not performed.

Selection process

The primary author reviewed each full-text article to determine appropriateness for this narrative review and hand extracted the following data into a spreadsheet stored on a password protect drive:

Study

design, number of participants, and gestational age

Manipulation

spinal region, number of manipulations, profession of manipulator and manipulation technique details including patient position, practitioner position, direction of thrust, and cavitation (Yes or No)

Number of participants

number of participants receiving manipulation

Adverse events

reporting (Yes vs. No), type and number of AE

Severity of adverse events

classified into Major, Moderate, or Mild/Not Adverse based on the definitions presented by Carnes et al [32]. Major AE require further treatment, are unacceptable and are distressing. Moderate AE are less severe and distressing but still require further treatment. Mild or not AE are short term, transient events that do not alter the patient’s function, and require no further treatment.

Synthesis of results

The results of the included articles were sorted by location of manipulation into three categories: (1) cervical, (2) thoracic, and (3) lumbopelvic. Within each spinal region, manipulation technique variables and adverse event details were recorded. Descriptive analysis of spinal manipulation technique variables included the following: number of manipulations, profession of manipulator, and manipulation technique details including patient position, practitioner position, direction of thrust, or cavitation. If articles stated ‘manipulation’ of a spinal region without further description of the technique, then the article was classified as not providing details of the spinal manipulation technique. Descriptive analyses were used for comparison regarding the number of studies that did and did not report on AE.

Results

Three hundred and twelve articles were found and following full-text hand screening 18 articles met inclusion criteria (see Figure 1). Included studies were of the following designs: case study/report [33–40] (n = 8), retrospective case series [41–43] (n = 3), prospective cohort [44–46] (n = 3), randomized control trial [47,48] (n = 2), cross over [49] (n = 1), and retrospective case control [50] (n = 1). Three studies [33,38,46] reported on more than one spinal region, while all others reported on one spinal region.

Figure 1.

Search flow diagram.

Manipulation technique

Three [34,41,44]of the 18 included studies provide details about the manipulation technique that was used. The variables reported were patient position [34,41,44], practitioner position [34,41], and direction of thrust [34,41]. None of the studies reported on presence or absence of cavitation, or the number of thrusts that were performed each treatment.

Daly et al. [41] provided a figure to illustrate a rotational sacroiliac joint manipulation with a description of the force direction, practitioner position, and patient position. The practitioner was allowed to pragmatically prescribe the number of thrust manipulations based on the patient response to the initial thrust, however the total number of thrust manipulations in each subject was not reported. No details on cavitation were provided. Murphy et al. [44] briefly describe a lumbopelvic distraction manipulation performed in side-lying, but no further details were stated. Furthermore, it is unclear which spinal regions were manipulated as this study looked at both lumbar and sacroiliac joint pain. Finally, while Fallon [34] clearly describes the positioning and direction of force for a thoracic manipulation at T6, the number of thrusts and presence or absence of cavitation were not reported.

Adverse events

Lumbopelvic

Eleven articles reported on lumbopelvic manipulations during pregnancy including two case studies/reports [33,38], three retrospective case series [41–43], two randomized control trials [47,48], one cross-over study [49], one retrospective case control [50], and two prospective cohort studies [44,45]. The gestational age, practitioner, lumbopelvic manipulative technique, AE reported as Yes or No, and details of any AE are presented in Table 1. Seven of these studies reported AE with only two studies having ‘mild/not adverse’ AE reported [44,48]. No ‘major’ or ‘moderate’ AE were reported following lumbopelvic manipulations.

Table 1.

Lumbopelvic spine.

Study	Study Design	Gestational Age	Practitioner	Technique	Number of Participants	Adverse Events Reported (Y/N)	# AEs	AE Severity (Carnes 2010)	AE Details
Alcantara J. et al 200933	Case report	32 weeks	Chiropractor	NR	1	Y	0	NA	NA
Bernard M. et al 201638	Case study	32 weeks	Chiropractor	NR	1	Y	0	NA	NA
Daly et al. 199141	Retrospective Case Series	6–35 weeks (mean 24.8 weeks)	MD	Sacroiliac rotational HVLAT	11	N	NR	NA	NA
Diakow PR. et al 199143	Retrospective study	Not reported	Chiropractor	NR	170	Y	0	NA	NA
Gausel AM. 201747	RCT	18–29 weeks	Chiropractor	NR	24	Y	0	NA	NA
Haavik H. 201649	Cross-over study	16–25 weeks	Chiropractor	NR	11	N	NR	NA	NA
King HH. Et al 200350	Retrospective case control design study	Not reported	Physicians	NR	160	N	NR	NA	NA
Lisi AJ. 200642	Retrospective case series	15–38 weeks (23.7 mean)	Chiropractor	NR	17	Y	0	NA	NA
Murphy DR. et al. 200944	Prospective observational cohort study	Mean 25.2 weeks	Chiropractic physician/physical therapist team	Distraction manipulation	78	Y	3	Mild/not adverse	2 participants reported increased pain for less than 48 hours; 1 participant reported increased pain for less than 1 week
Peterson CD. et al 201248	RCT	Mean 25.4 weeks	Chiropractor	NR	15	Y	6%	Mild/not adverse	soreness after treatment
Peterson CK. et al 201445	Prospective cohort study	Mean 26.21 weeks	Chiropractor	NR	115	N	NR	NA	NA

Abbreviations: Y=Yes, N=No, NR=Not Reported, NA=Not Applicable.

Two studies were found to have ‘mild/not adverse’ AE [44,48]. Murphy et al. [44] report two participants had increased lumbopelvic pain for less than 48 hours and one participant had increased pain for less than one week after lumbar or sacroiliac distraction manipulation. Peterson et al. [48] stated 6% of patients reported soreness after a lumbopelvic manipulation.

Thoracic

Three articles reported on thoracic manipulations during pregnancy including two case studies [34,38] and one prospective cohort [46]. The gestational age, practitioner, thoracic manipulative technique, AE reported as Yes or No, and details of any AE are presented in Table 2. All of these studies reported no AE were present following thoracic manipulation.

Table 2.

Thoracic spine.

Study	Study Design	Gestational Age	Practitioner	Technique	Number of Participants	Adverse Events Reported (Y/N)	# AEs	AE Severity (Carnes 2010)	AE Details
Bernard M. et al 201638	Case study	32 weeks	Chiropractor	NR	1	Y	0	NA	NA
Fallon J. 199634	Case report	10 weeks	Chiropractor	T6 posterior to anterior, right to left HVLAT	1	Y	0	NA	NA
Skarica B. 201846	Cohort	7–36 weeks	Chiropractor	NR	115	Y	0	NA	NA

Abbreviations: Y=Yes, N=No, NR=Not Reported, NA=Not Applicable.

Cervical

Eight articles reported on cervical manipulations during pregnancy including seven case reports [33,35–40], and one cohort study [46]. The gestational age, practitioner, cervical manipulative technique, AE reported as Yes or No, and details of any AE are presented in Table 3. All eight studies reported on AE and a total of five ‘major’ AE were discussed. Unfortunately, one case reported fetal demise after right internal artery dissection [37]. Additional AE included: right sided epidural hematoma [39], right internal jugular vein occlusion [35], right vertebral artery dissection [36], and Type II odontoid fracture [40].

Table 3.

Cervical spine.

Study	Study Design	Gestational Age	Practitioner	Technique	Number of Participants	Adverse Events Reported (Y/N)	# AEs	AE Severity (Carnes 2010)	AE Details
Alcantara J. et al 200933	Case report	32 weeks	Chiropractor	NR	1	Y	0	NA	NA
Bernard M. et al 201638	Case study	32 weeks	Chiropractor	NR	1	Y	0	NA	NA
Heiner JD. 200939	Case study	29 weeks	Chiropractor	NR	1	Y	1	Major	right sided epidural hematoma with associated mass effect on the spinal cord
Hoffelner T. et al 200935	Case report	3 months	Chiropractor	NR	1	Y	1	Major	right internal jugular vein occlusion
Monari F. et al 202136	Case report	38 weeks	Osteopathic specialist	NR	1	Y	1	Major	right vertebral artery dissection with ischemia in the posterolateral right medulla oblongata
Morton A. 201237	Case report	16 weeks	Chiropractor	NR	1	Y	1	Major	Right internal artery dissection, fetal demise
Schmitz A. et al 200540	Case report	15 weeks	General Practitioner	NR	1	Y	1	Major	“Type II odontoid fracture with ventral displacement of the odontoid process leading to compression of the spinal canal” and hematoma from C2-C4.
Skarica B. 201846	Cohort	7–36 weeks	Chiropractor	NR	115	Y	0	NA	NA

Abbreviations: Y=Yes, N=No, NR=Not Reported, NA=Not Applicable.

A right internal carotid artery dissection occurred after cervical manipulation in a woman 31 years old and 16 weeks pregnant [37]. The patient was admitted to the intensive care unit for treatment and intrauterine fetal demise occurred 4 days after manipulation. Past medical history included systemic lupus erythematosus, prior deep vein thromboses, and prothrombin gene mutation.

An epidural hematoma was reported after cervical manipulation [39]. The patient reported numbness and pain in the neck and arm, along with transient upper extremity paralysis and lower extremity numbness. She was treated conservatively. At follow-up 2 weeks after incident, the patient had mild paresthesia on the posterior aspect of her neck. She did not have any disruptions to her pregnancy or harm to the fetus. No significant past medical history was reported.

Hoffelner et al. [35] reported an internal jugular vein occlusion following a treatment session including both a cervical and cervicothoracic junction manipulation. The patient was treated with intravenous heparin and admitted to the hospital for 2 weeks. Heparin treatment continued for the remainder of the pregnancy with the patient delivering a healthy baby at full term. The patient had a past medical history including hereditary thrombophilia.

A right vertebral artery dissection led to ischemia in the posterolateral right medulla oblongata following cervical spinal manipulation [36]. Cesarean delivery was performed 3 days after symptom onset with a healthy fetus. The patient was hospitalized for 12 days of rehabilitation and then discharged with continued diplopia and a walker. Follow-up at 2 and 4 months the patient still had diplopia and altered gait. No significant past medical history or vascular risk reported.

A type II odontoid fracture was reported by Schmitz et al. [40] following a cervical manipulation and paravertebral injections. Upon MRI the patient was found to have a pathological type II odontoid fracture and a tumor in the C2 vertebral body. In this case, the tumor potentially compromised the integrity of the bone, possibly predisposing the patient to a fracture. The patient did not have any neurological complications at follow-up, nor complications with her pregnancy.

Discussion

This is the first literature review to explore variability in reporting of spinal manipulation technique and documenting severity of AEs in the pregnant population. Such variability not only may impact determining the appropriateness and relative risk of applying spinal manipulation in the pregnant population, but may also make reproducing methods in future investigations difficult.

Manipulation technique

Only three studies reported any description the manipulation technique [34,41,44]. In the cases [35–37,39,40] where a major AE event occurred, there was a paucity of details provided on the technique performed. Major AE only occurred with cervical manipulation and none of the studies described the patient position, practitioner position, direction of force, spinal segment, number of manipulations performed each treatment, or the presence or absence of cavitation.

The practitioners who delivered the manipulations in the articles included in this review comprised physicians [36,40,41,50], chiropractors [33–49], and physical therapists [44]. Detailed description of technique was only reported once by each profession: chiropractors [34], physicians [41], and a chiropractor/physical therapist team [44].

The multiple layers of inconsistency in reporting on the technical aspects of the manipulations is problematic. The lack of detailed reporting on spinal segment, number of thrusts, patient position, practitioner position, presence or absence of cavitation, and direction of force of the manipulative technique performed impacts the internal and external validity of results. Without more detailed reporting of manipulation techniques from any profession investigating spinal manipulation during pregnancy, the generalizability of the results is questionable.

Moreover, the lack of consistent reporting does not allow clinicians to determine the relative risk or safety of manipulation in the pregnant patient. The lack of details regarding the manipulation technique used make it difficult, if not impossible, to reproduce the technique. Without the ability to reproduce the techniques consistently, it is impossible to study the safety or outcomes of the technique.

Adverse events

Fourteen of the included studies reported whether AE occurred; however, only seven articles [35–37,39,40,44,48] reported any details about the AE. The remaining studies [33,34,38,42,46,47] stated ‘no adverse events reported’ without describing how AE were defined or measured.

None of the included studies reported a predetermined method of documenting or categorizing AE. This lack of consistency of classifying and reporting AE makes it difficult to compare studies or generalize the results. It is unknown if the studies that state ‘no adverse events reported’ included soreness or increased spinal pain as AE or if only AE requiring further treatment were considered.

The five major AE reported included right internal artery dissection with fetal demise [37], right sided epidural hematoma [39], right internal jugular vein occlusion [35], right vertebral artery dissection [36], and Type II odontoid fracture [40]. All of the ‘major’ AE were single case reports suggesting that documenting worst-case scenarios may lead to overestimation of the relative risk of spinal manipulation during pregnancy. Additionally, due to the design of the studies, it is unknown if the reported major AE occurred due to the patients’ pregnancy or if the patient would have experienced the AE without being pregnant. Three of the women had medical comorbidities that may have impacted the outcome of treatment [35,37,40]. Furthermore, there are reports of serious AE in non-pregnant patients following spinal manipulation [51–53]. Despite all five major AE following cervical manipulation, there can be no causal statements made between cervical manipulation or the practitioner delivering the manipulation directly causing the AE.

It is important to comment that of all the manipulations performed, fetal demise was only documented in one case [37]. Multiple studies [34,35,46,48,50] reported no complications with delivery and others [33,38,41–43,45,47,49] did not report on long-term outcomes. One fear many clinicians potentially have is performing techniques that have not been thoroughly investigated on pregnant patients, which may lead to poor outcomes for the pregnancy and potential liability for the clinician [28]. Although this review is not able to determine the relative safety or risk of spinal manipulation during pregnancy there appears to be a low risk of harm to pregnancy, as only five major AE were reported out of 724 participants. Other systematic reviews of spinal manipulation during pregnancy have not found manipulation to be a safety concern [25,54]. Specifically, no major AE were reported after thoracic, lumbar or lumbopelvic manipulation. All major AE were after cervical manipulation, which should give clinicians a caution to be thorough in their pre-manipulative exam prior to performing cervical manipulation on a patient that is pregnant.

It is unknown if pregnancy without other risk factors or symptoms should be a reason to exclude patients from cervical manipulation treatment. Beyond pre-manipulative screening of the cervical spine [8,19,55] to mitigate risk, clinicians may alternatively consider thoracic manipulation over cervical manipulation for neck pain. Thoracic manipulation has been recommended to result in short-term improvements in patients with mechanical neck pain [56–59]. A recent systematic review and meta-analysis [56] concluded that thoracic manipulation may be more beneficial for mechanical neck pain with fewer side effects and no major adverse events when compared to thoracic mobilization and cervical mobilization.

Implications for clinical practice

Adverse events following spinal manipulation have been documented across all spinal regions [19,55,60,61] in the general patient population. Despite documented AE, no causation can directly be attributed to spinal manipulation which underscores the importance of appropriate screening of risk factors to mitigate risk. While there is no consensus, pregnancy has been considered a precaution [20,60] or contraindication [22,23,60] to spinal manipulation. The documented AE [35–37,39,40] in this narrative review all followed cervical manipulation. Four [35–37,39] were vascular in nature and two [35,37] had documented vascular risk factors. The International Federation of Orthopedic Manipulative Physical Therapists (IFOMPT) proposed a framework to guide clinicians screening potential vascular pathologies presenting as cervical pain to weigh relative risk versus benefit prior to treatment targeting the cervical spine [8]. Despite pregnancy not being mentioned in the IFOMPT framework, clinicians may consider pregnancy as a risk factor due to the documented vascular changes during pregnancy [62], including venous hypertension. While there are no similar formal guidelines or frameworks for the thoracic or lumbopelvic spines, recommendations from a recent survey [63] and systematic reviews [61,63] all recommend screening for risk factors to mitigate risk. Consequently, the most tangible recommendation for clinicians working with the pregnant population is to weigh the relative risk versus benefit of considering a spinal manipulation in light of a thorough subjective and past medical history, systems review, screening for risk factors [20–24], and physical examination.

Implications for future research

This narrative review found broad variability in reporting the parameters of spinal manipulation techniques and lack of clarity on classifying and documenting AE following spinal manipulation. Consequently, the relative risk and safety of spinal manipulation treatment during pregnancy cannot be estimated without improvement in reporting of AE and manipulation techniques. Without a more standardized method to report and provide context to cases of AE following spinal manipulation, determining relative risk of manipulation during pregnancy is not possible. Explicit reporting of AE in future studies would allow for improved assessment of risk versus benefit analysis of manipulation in pregnant patients. To address these inconsistencies, we propose a standardized checklist of items to be included in future investigations on manipulation during pregnancy (Figure 2). A standardized means of reporting spinal manipulation techniques and AE will improve both internal and external validity of future investigations. Furthermore, the generalizability and comparison of future study results will be improved and potentially may allow for more definitive recommendations of the safety and effectiveness of manipulation during pregnancy.

Figure 2.

Pregnancy manipulation randomized controlled trial checklist.

Limitations

There is limited guidance on performing a narrative review and by description it is potentially open to risk of bias. Low level evidence, such as case reports, were included in this study which may affect the interpretation of findings.

This review was exploratory and descriptive based on the data extracted. No definitive statements can be made on the relative risk of performing spinal manipulation in pregnant populations. Furthermore, relative incidence of AE following manipulation in the pregnant population is unable to be determined.

Conclusion

Reporting of manipulation technique and AE were inconsistent in the 18 studies in this narrative review. Consequently, we could not make any recommendations on the relative risk or safety of manipulation during pregnancy. Based on these findings, reporting of AE after spinal manipulation should be standardized in the clinical and research settings to inform safety recommendations. Further research is needed to determine if spinal manipulation is an effective and safe treatment for pregnant women with musculoskeletal pain.

Biographies

Kellie Stickler, PT is a practicing physical therapist in a multidisciplinary employee health clinic. She obtained her DPT from the University of Kansas Medical Center in 2016 and became a Board Certified Orthopedic Specialist in 2019. She is a current Fellow-in-Training with the North American Institute of Orthopaedic Manual Therapy.

Gary Kearns is an Assistant Professor in the Doctor of Physical Therapy Program at Texas Tech University Health Sciences Center. He is a Board Certified Specialist in Orthopaedic Physical Therapy (OCS) and a Fellow in the American Academy of Orthopaedic Manual Physical Therapists (FAAOMPT). He is an assistant professor in the entry-level DPT program at Texas Tech University Health Sciences Center where he coordinates the musculoskeletal and differential diagnosis curriculum. His research interests include dry needling safety, clinical reasoning and mechanisms of manual therapy.

Appendix 1. Each database was searched with the following keywords

Pregnancy AND “spinal manipulation”

pregnancy AND “spinal manipulation” AND adverse events

pregnancy AND “lumbar manipulation”

pregnancy AND “cervical manipulation”

pregnancy AND “sacroiliac manipulation”

pregnant AND “sacroiliac manipulation

pregnant AND “cervical manipulation

pregnant AND “lumbar manipulation

pregnant AND “spinal manipulation”

Funding Statement

There was no funding for this narrative review.

Disclosure statement

No potential conflict of interest was reported by the author(s).