J Can Chiropr Assoc 2021 Apr; 65 (1): 32–49.

Table 2.
Evidence table for SRs including treatment/intervention, quality rating, number and type of studies and overall study conclusions.

Citation and quality^* Treatment/ intervention Number and studies and participants and type of studies Adverse events reported Overall study conclusion

Liddle 2015⁷⁶
High Multimodal 34 studies (n=5,121): pertaining to: The adverse event that were reported were considered transient and minor and mostly experienced by those who received acupuncture. Overall, there is simply not good enough quality evidence to make confident decisions about treatments for these complaints. When reported, there were no lasting side effects on any of the studies.

LBP LBP LBP

16 RCTs Overall, there were no serious adverse events to mother or fetus to report.
Exercise (Group or individual): Studies reported no adverse events as a result of the intervention
Support devices: No adverse events reported
Manual therapy: One trial reported no adverse events; 1 trial reported that adverse events were similar amongst the groups, but no further details were given; 1 did not report on adverse events; 1 trial reported post-treatment soreness but no adverse effects as a result of the treatment
TENS: No adverse event to report
Taping: No adverse event reported There is low quality evidence that exercise improves pain and disability for women with LBP. Exercise interventions (from five to 20 weeks duration) improved the level of LBP and disability than women who just received regular prenatal care.

PGP PGP PGP

6 RCTs Overall, no long-lasting adverse effects were reported.
Acupuncture: Data not provided on adverse events, but some Issues with needles (pain, bleeding, fainting).
Exercise + Education: No adverse events reported
Belts: Adverse effects not measured
Craniosacral Therapy: some discomfort with belt, drowsiness and temporary increase in PGP In general, there is less evidence on treatment for pelvic pain. There is evidence from single studies that suggesting that acupuncture or craniosacral therapy improved PGP more than usual prenatal care.

Both LBP and PGP Both LBP & PGP Both LBP & PGP

12 RCTs Overall, adverse events were minor and transient, when reported by subjects or investigators. There were no reported problems with any of the deliveries and neonates.
Acupuncture: minor and transient adverse effects including bruising, local pain, nausea, weakness, heat or sweating
Physiotherapy: some adverse effects, such as preterm uterine contractions, pre-eclampsia but unlikely to have been caused by physiotherapy There is moderate quality evidence that exercise results in less sick leave and fewer women reporting pain. Although the results are variable, exercise (eight to 12 weeks duration) reduced the number of women who reported back pain and land-based exercises reduced sick leave in 2 studies. However, 2 other studies suggested that sick leave was no better at preventing LBP or PGP than usual care. In addition, there is evidence from low quality studies that multimodal care (manual therapy, exercise and education) reduced pain and functional disability, but not sick leave.

Franke 2017⁷⁸
High OMT 8 RCTs^*
Pregnancy: 5 RCT
Postpartum: 3 RCT
^*5 of 8 were grey literature Only 1 of the studies reported on adverse events and they suggested that they were minor in nature; occasionally patients reported they were tired following treatment. In personal communication, authors of 2 other studies, they reported no adverse event occurred. Clinically relevant effects of OMT were found for reducing pain and improving functional status in pregnant and postpartum (3 months posttreatment) women experiencing LBP.

Ruffini 2016⁷⁷
High OMT 24 studies total but those pertaining to: Overall, adverse events were not sufficiently described; only 3studies mentioned adverse events. Researchers suggested a more systematic reporting of adverse events in order to obtain solid and generalizable results. OMT can be considered effective on pregnancy-related back pain.

Pregnancy Pregnancy

8 studies (n=914)
4 RCTs, 2 case controls, 1 observational study and 1 case-series Craniosacral Therapy: Minor events listed in the intervention group including increased PGP, elastic belt discomfort and drowsiness. Minor events listed in the control group including elastic belt discomfort and increases in PGP

Labour and delivery Labour and delivery

4 studies (n=597): 1 RCT, 2 case-series and 1 observational study Only reported adverse events in 2 studies and determined that OMT was well tolerated

Hall 2016 High¹⁸ CAM 11 full text articles on 10
RCTs (n=1,198) Researchers stated that their findings are similar to others in that very few adverse events have been reported in the literature and suggest complementary manual therapies are a safe option compared to no treatment at all. There is limited evidence to support the use of complementary manual therapies as an option for managing LBP and PGP during pregnancy.

Gutke 2015⁷⁰
Acceptable Modalities 34 RCTs; 8 CCTs; 3 long-term follow ups; 2 observational studies 4 observational retrospective studies; 1 experimental case study; 1 case series; and 3 pilot studies No specific adverse events were recorded for any intervention (acupuncture, exercise, pelvic belt, physiotherapy, massage). There was evidence for the positive effects of acupuncture and pelvic belts but weak for specific exercises.

Sharma, 2014⁷⁹
Acceptable Physical therapy 9 RCTs; 1 cohort; 3 CS No specific adverse events were recorded for any interventions (exercise, pelvic/sacroiliac belt, muscle energy techniques, soft tissue mobilization, postural alignment). These authors recommend a combination of specific stabilizing exercises, nonelastic sacroiliac belt in the high position and ergonomic educationas the most beneficial interventions in the management of sacroiliac dysfunction/PGP for pregnant individuals experiencing this pain.

Scottish Intercollegiate Guideline Network (SIGN) Quality rating:
>9 = high quality, low risk of bias (H);
6–9 = acceptable quality, moderate risk of bias (A);
<6 = low quality, high risk of bias (L)
CAM = complementary alternative medicine;
CCT = controlled clinical trials;
CS = case series; LBP = low back pain;
OMT = osteopathic manipulative therapy;
PGP = pelvic girdle pain;


Citation and quality^*	Treatment/ intervention	Number and studies and participants and type of studies	Adverse events reported	Overall study conclusion

Liddle 2015⁷⁶ High	Multimodal	34 studies (n=5,121): pertaining to:	The adverse event that were reported were considered transient and minor and mostly experienced by those who received acupuncture.	Overall, there is simply not good enough quality evidence to make confident decisions about treatments for these complaints. When reported, there were no lasting side effects on any of the studies.
		*LBP*	*LBP*	LBP
		16 RCTs	Overall, there were no serious adverse events to mother or fetus to report. Exercise (Group or individual): Studies reported no adverse events as a result of the intervention Support devices: No adverse events reported Manual therapy: One trial reported no adverse events; 1 trial reported that adverse events were similar amongst the groups, but no further details were given; 1 did not report on adverse events; 1 trial reported post-treatment soreness but no adverse effects as a result of the treatment TENS: No adverse event to report Taping: No adverse event reported	There is low quality evidence that exercise improves pain and disability for women with LBP. Exercise interventions (from five to 20 weeks duration) improved the level of LBP and disability than women who just received regular prenatal care.

		*PGP*	*PGP*	*PGP*
		6 RCTs	Overall, no long-lasting adverse effects were reported. Acupuncture: Data not provided on adverse events, but some Issues with needles (pain, bleeding, fainting). Exercise + Education: No adverse events reported Belts: Adverse effects not measured Craniosacral Therapy: some discomfort with belt, drowsiness and temporary increase in PGP	In general, there is less evidence on treatment for pelvic pain. There is evidence from single studies that suggesting that acupuncture or craniosacral therapy improved PGP more than usual prenatal care.

		*Both LBP and PGP*	*Both LBP & PGP*	*Both LBP & PGP*
		12 RCTs	Overall, adverse events were minor and transient, when reported by subjects or investigators. There were no reported problems with any of the deliveries and neonates. Acupuncture: minor and transient adverse effects including bruising, local pain, nausea, weakness, heat or sweating Physiotherapy: some adverse effects, such as preterm uterine contractions, pre-eclampsia but unlikely to have been caused by physiotherapy	There is moderate quality evidence that exercise results in less sick leave and fewer women reporting pain. Although the results are variable, exercise (eight to 12 weeks duration) reduced the number of women who reported back pain and land-based exercises reduced sick leave in 2 studies. However, 2 other studies suggested that sick leave was no better at preventing LBP or PGP than usual care. In addition, there is evidence from low quality studies that multimodal care (manual therapy, exercise and education) reduced pain and functional disability, but not sick leave.

Franke 2017⁷⁸ High	OMT	8 RCTs^* *Pregnancy:* 5 RCT *Postpartum:* 3 RCT ^*5 of 8 were grey literature	Only 1 of the studies reported on adverse events and they suggested that they were minor in nature; occasionally patients reported they were tired following treatment. In personal communication, authors of 2 other studies, they reported no adverse event occurred.	Clinically relevant effects of OMT were found for reducing pain and improving functional status in pregnant and postpartum (3 months posttreatment) women experiencing LBP.

Ruffini 2016⁷⁷ High	OMT	24 studies total but those pertaining to:	Overall, adverse events were not sufficiently described; only 3studies mentioned adverse events. Researchers suggested a more systematic reporting of adverse events in order to obtain solid and generalizable results.	OMT can be considered effective on pregnancy-related back pain.
		*Pregnancy*	*Pregnancy*
		8 studies (n=914) 4 RCTs, 2 case controls, 1 observational study and 1 case-series	Craniosacral Therapy: Minor events listed in the intervention group including increased PGP, elastic belt discomfort and drowsiness. Minor events listed in the control group including elastic belt discomfort and increases in PGP

		*Labour and delivery*	*Labour and delivery*
		4 studies (n=597): 1 RCT, 2 case-series and 1 observational study	Only reported adverse events in 2 studies and determined that OMT was well tolerated

Hall 2016 High¹⁸	CAM	11 full text articles on 10 RCTs (n=1,198)	Researchers stated that their findings are similar to others in that very few adverse events have been reported in the literature and suggest complementary manual therapies are a safe option compared to no treatment at all.	There is limited evidence to support the use of complementary manual therapies as an option for managing LBP and PGP during pregnancy.

Gutke 2015⁷⁰ Acceptable	Modalities	34 RCTs; 8 CCTs; 3 long-term follow ups; 2 observational studies 4 observational retrospective studies; 1 experimental case study; 1 case series; and 3 pilot studies	No specific adverse events were recorded for any intervention (acupuncture, exercise, pelvic belt, physiotherapy, massage).	There was evidence for the positive effects of acupuncture and pelvic belts but weak for specific exercises.

Sharma, 2014⁷⁹ Acceptable	Physical therapy	9 RCTs; 1 cohort; 3 CS	No specific adverse events were recorded for any interventions (exercise, pelvic/sacroiliac belt, muscle energy techniques, soft tissue mobilization, postural alignment).	These authors recommend a combination of specific stabilizing exercises, nonelastic sacroiliac belt in the high position and ergonomic educationas the most beneficial interventions in the management of sacroiliac dysfunction/PGP for pregnant individuals experiencing this pain.