ABSTRACT In the first Caution Column, pregnancy is discussed as a condition that is commonly found on contraindication lists for manual therapy. Rolfing® SI Instructor, Lu Mueller-Kaul aims to dispel the myth that fascial manipulation during pregnancy is harmful, and proposes that perpetuating the narrative of harm has itself been a detriment. Current peer-reviewed research is discussed regarding the effectiveness of manual therapy during pregnancy and a thoughtful proposal of when caution needs to be applied.
Editor’s note: This particular discussion is for manual therapy professionals and the public; it is intended as a point of view on how to stay within the scope of practice of a practitioner’s certification while helping pregnant clients. We recommend that clients follow their doctor’s advice about what is safe for them in their specific circumstances.
Do Rolfers® work with women when they are pregnant?
The short answer is yes, but there still is controversy, and it is time for this fear-based thinking to be over. Caution when working with pregnant clients is warranted, of course, and we will get into those details. First, do no harm; we all learned that in our ethics classes. Consider this – much harm is done by sending people away when they come to us in pain, hoping for relief.
From my perspective as a German-trained naturopath and now a Rolfer practicing and teaching in the United States, I had not heard about the nonsensical fear of inducing a miscarriage until I lived and worked in the United States. Many pregnancy myths still circulate in our profession, uninformed opinions, and personal preferences disguised as advice (Fogarty et al. 2019). We know that manual therapy is effective for pregnant women, specifically to address swelling in the legs, depression, anxiety, leg pain, and back pain. Observations also include a lower rate of prematurity, less labor pain, and shorter labor overall with less need for medication overall (Corban and Sirin 2010; Field et al. 2009; Field 2010).
Manual therapists have been influenced by the idea that whatever the trimester, no matter what body parts are being treated, there is a risk of physical harm to the unborn child (Fogarty et al. 2019). This belief is unfounded and a potentially dangerous message to pregnant women and their families. It distracts from reasonable concerns, and it keeps women from getting non-pharmaceutical treatments that have been proven to be helpful and are now recommended by mainstream medical sources (Tiran 2018; Osborne, Kolakowski, and Lobenstine 2021). Telling pregnant women that their manual therapy treatments are harming their unborn child increases maternal stress, which in itself leads to risks, including miscarriage (Qu et al. 2017).
As most of us know, in the first three months of pregnancy, miscarriages are common (Goldman 2018), and understandably massage school instructors are concerned about potential accusations. I’ve gone through public records about malpractice complaints, even the most ludicrous ones, and I did not find malpractice suits based on practitioner-induced miscarriages. (If you make the same inquiry, tell me if you find any complaints about miscarriage related to hands-on work.) I dug up forty years of court records, law enforcement arrest records, cases filed, and cases dismissed. Nobody got accused of rubbing an ankle and causing a miscarriage. Don’t get me wrong, much of what I found was shocking. Massage therapists do get in legal trouble, ethics complaints are not uncommon, and even cases of sexual assault. Physical therapists and chiropractors have been accused of harming patients, and there are some wrongful deaths on record. But bodyworkers like us hardly ever get sued. This is why our liability insurance is so cheap in the United States.
I don’t think we should ignore our concerns, especially since a scared practitioner cannot give good treatment. A compassionate apology while saying, “I’m not comfortable giving you the treatment I usually would, please let me refer you to a colleague,” is appropriate. It is a choice you have to make. In my practice, I work with pretty much every pregnant client that seeks my services. I am on the side of, “I’ll try, I’ll work slowly, and you tell me if something feels wrong – not only if it hurts – but also if it’s just uncomfortable for any reason. I’ll watch you as well, and if your breathing gets faster, I will slow down even more.”
In early pregnancy, manual therapy works against nausea (Agren and Berg 2006), and in later stages, it can help reduce swelling, many kinds of pain, and even postpartum problems can be treated with very little risk (Lee and Ko 2015). Massage has been reported to decrease stress, decrease pain, increase range of motion, and improve sleep during pregnancy (Fogarty et al. 2019). Meta-analyses have found positive effects of manual therapy on the pain levels of pregnant women, yet more research is still needed (Hall et al. 2016). Manual therapy during pregnancy reduces cortisol levels, the stress hormone that indicates fight-and-flight arousal (Field 2010). It has been proposed that increased vagal activity is part of the mechanism involved with lower stress markers in pregnant women and fetal activity as well (Field 2010). A randomized controlled trial found that pain during pregnancy, leg cramps, and coccyx pain are common issues that women report early in their pregnancies and they may become persistent problems after birth if treatment does not start early in the pregnancy (Sarkar et al. 2021).
Over the last thirty years, the medical establishment started prescribing massage and manual therapies as part of their clinical recommendations for stress management and pain relief. So, massage therapy educators started offering “Pregnancy Massage Certification” classes as continuing education with the best intentions to deliver qualified practitioners with the skills needed for this population. Suddenly women were warned to receive bodywork only from a practitioner who is “Pregnancy Certified.” As a result, many pregnant clients don’t get help from a highly effective manual therapist. And conversely, pregnant clients who know that manual therapy helps them are being turned away with comments like, “that’s irresponsible, I’m not allowed to work on women during the first trimester, and later I could only do that legally with special education.”
During my twelve years of practice in the United States, several of my massage therapist employees have refused to work with pregnant women. Since our clinic has a reputation for reliable pain relief, we often got requests from pregnant women to help with their back pain, and manual lymphatic drainage to treat swollen feet. One of our very best therapists continually refused to help our pregnant clients, and she influenced the whole team. I felt terrible, and my position is still that a lot more harm was done by refusing treatment, and in my opinion, the research agrees with my position. Of course, I couldn’t and wouldn’t force anyone to give a treatment they didn’t want to give, but I also hated to let those clients go to receive some light Swedish elsewhere. So I gave in, paid for my employees to have the pregnancy massage certification classes, and eventually taught those myself.
As a Rolfer, a structural integration practitioner, or any kind of manual therapist, if you have concerns about working with a pregnant client, look up the research listed here. Use that concern to fuel a deeper inquiry of your own, go look for peer-reviewed studies and a multidisciplinary literature review. This is an active area of research and we all benefit from updated information about manual therapy during pregnancy. Please let me know what you find so I can include the newest information in my classes and articles.
What caution should Rolfers keep in mind as they work with women who are pregnant?
1. Position during a manual therapy session.
The further along in a pregnancy, the more necessary the side-lying position becomes, and supine should be avoided. The client is often most comfortable on their side anyway, and lying supine might stress the fetus (Warland 2017). Starting when the baby ‘bump’ gets in the way, it’s best to stick with modified prone positioning, side-lying, and seated. During the third trimester, avoid prone positions too (Oliveria et al. 2017). I often use an adapted seated position for clients who can’t, shouldn’t, or don’t like to lie down. I’ll have the client’s chest lightly bent forward over a big pillow, resting the upper body on the treatment table, so there’s easy access to the whole back, ensuring the client does not have to be active.
2. Be careful around joints, don’t dig into the joint capsule, and test slowly for functional flexibility.
The ligaments get laxer to prepare the pelvis to widen during birth with the release of the hormone relaxin, and that affects all the ligaments of the body. That doesn’t mean everything gets flexible, just as with hypermobility conditions, there can be a lot more muscular tension leading to “feeling tight.” We can’t tell clients to do specific strength training, but we can keep in mind that stronger muscles often get looser, and there is such a thing as “weak and tight.”
3. Don’t forbid stretching, but please don’t encourage it much, either.
Yin yoga might not be ideal for an already flexible client. That’s why you test the joints slowly, and carefully, just moving through a normal range of motion, and check for end feel. But if you get a clear pull from a muscle, you can work the attachments, get into the septa, and yes, the client can stretch afterward. We don’t want to make our clients fearful of stretching, just make it clear that it’s not helpful to pull a foot behind her head just because she can.
Ligaments aren’t perfectly elastic, they don’t exactly go back to their original form after a stretch, and we can lengthen ourselves into asymmetries. We could educate our client by saying, “You might be pulling on the ligaments in a new way because you are pregnant, keep in mind that they’re softer during pregnancy, just stay within a more average range of motion.” I’ll tell you why I find that so important, many of the pelvic imbalances we encounter as Rolfers, the typical sacroiliac joint instabilities, start during pregnancy. So don’t try to lengthen everything, work on support and adaptability.
Another valuable resource can be found on the American Massage Therapy Association’s website [https://www.amtamassage.org/publications/massage-therapy-journal/massage-and-pregnancy-a-powerful-combination/]. This resource has clear contraindications and possible modifications with no mention of miscarriages at all. That’s the smart way to discuss the special population of pregnant women.
Are there any circumstances that exclude a Rolfer from working with a pregnant woman?
If the Rolfer feels discomfort or fear, I’d recommend that the practitioner listen to that feeling and “don’t do it.” We take on the role of gentle guidance while empowering the client to work with us, and we rely on the client to let us know what feels safe and what is uncomfortable. If we don’t feel safe, it’s hard to create a safe environment for the client, and we are more prone to mistakes.
Fearful clients benefit from slow work and gentle holds, but not all Rolfers like to work that way. I tell students, “You can’t learn when you’re afraid,” and that goes for our clients too. So, if we adjust our touch and our presence, and most importantly our own embodiment, a fearful client will quickly feel better. Keep holding space for the session to unfold in its own time instead of trying to impose our own agenda. It is worth mentioning that I prefer the mildly anxious practitioner to the overly confident one who believes, “I know exactly what to do here.”
I have come to understand that the hesitation some of my colleagues feel with pregnant clients comes from being responsible for two people, not just one, without the training for the additional person. That makes sense to me, more than the other arguments I’ve mentioned above. Medical doctors are not allowed to refuse a patient in need, but we can. And we should if we don’t feel secure enough in our skills to deliver the work the client requests.
Rolfers can help pregnant women in the same way massage therapists can, and I believe that with our training we can do better. Even using the ‘Recipe’ during pregnancy has shown good results. In my own practice, I work with spinal and nerve mobilizations for my clients who are pregnant, I also use my lymphatic drainage techniques and gentle work around the joints with awareness of possibly lax ligaments.
All our work with pregnant women should be focused on ensuring their comfort and well-being. We can apply the Principles of Rolfing® Structural Integration (Sultan and Hack 2021), especially adaptability above and support below the pelvis. While almost everything keeps shifting, we can help a lot by centering the growing belly over the pelvis, allowing depth in the whole abdominal space, and coming back to the feet and legs, bringing awareness to the inner line of the legs and the corresponding support for the front of the spine. And yes, it does make sense to do another ‘Ten Series’ about two years after the child is born, to address the postpartum adaptations that may have taken hold in their structure.
Lu Mueller-Kaul is a Rolfing SI Instructor with the Dr. Ida Rolf Institute since 2019 and coauthor of The Rolfing Skillful Touch Handbook (2022) with Bethany Ward and Neal Anderson. She mostly teaches Phase I courses, bringing physiology, therapeutic relationships, and Skillful Touch together so students learn an adaptable spectrum of touch skills while staying aware of the space they hold for each client. Mueller-Kaul began her journey as a licensed naturopathic physician in Germany in the 1990s. Along the way, she’s practiced acupuncture, chiropractic adjustments, and traditional Chinese medicine before coming to the United States to study Rolfing SI.
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Corban, Ayden, and Ahsen Sirin. 2010. Effect of foot massage to decrease physiological lower leg oedema in late pregnancy: A randomized controlled trial in Turkey. International Journal of Nursing Practice 16(5):454-460.
Field, Tiffany, Miguel Diego, Maria Hernandez-Reif, Osvelia Deeds, and Barbara Figueiredo. 2009. Pregnancy massage reduces prematurity, low birthweight and postpartum depression. Infant Behavior and Development 32(4):454-460.
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Fogarty, Sarah, Catherine McInerney, Cath Stuart, and Phillipa Hay. 2019. The side effects and mother or child related physical harm from massage during pregnancy and the postpartum period: An observational study. Complementary Therapies in Medicine 42:89-94.
Goldman, Rena. 2018. A breakdown of miscarriage rates by week. Available from https://www.healthline.com/health/pregnancy/miscarriage-rates-by-week.
Hall, Helen, Holger Cramer, Tobias Sundberg, Lesley Ward, Jon Adams, Craig Moore, David Sibbritt, and Romy Lauche. 2016. The effectiveness of complementary manual therapies for pregnancy-related back and pelvic pain: A systematic review with meta-analysis. Medicine (Baltimore) 95(38):e4723.
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Oliveira, Claudia, Marco Antonio Borges Lopes, Agatha Sacramento Rodrigues, Marcela Zugaib, and Rossana Pulcineli Vieira Francisco. 2017. Influence of the prone position on a stretcher for pregnant women on maternal and fetal hemodynamic parameters and comfort in pregnancy. Clinics (Sao Paulo, Brazil) 72(6):325-332.
Osborne, Carole, Michele Kolakowski, and David M. Lobenstine. 2021. Pre- and perinatal massage therapy: A comprehensive guide to prenatal, labor, and postpartum practice. London, UK: Handspring Publishing.
Qu, Fan, Yan Wu, Yu-Hang Zhu, John Barry, Tao Ding, Gianluca Baio, Ruth Muscat, Brenda K. Todd, Fang-Fang Wang, and Paul J. Hardiman. 2017. The association between psychological stress and miscarriage: A systematic review and meta-analysis. Scientific Reports 7(1): 1731.
Sarkar, Pradip Kumar, Paramvir Singh, Mandeep Singh Dhillon, Amarjeet Singh, and Sudip Bhattacharya. 2021. Impact of two intervention packages on the health and fitness of ante- and post-natal women attending in a teaching hospital. Journal of Family Medicine and Primary Care 10(10):3738-3747.
Sultan, Jan H. and Lina Amy Hack. 2021. The Rolfing SI principles of intervention: An integrated concept. Structure, Function, Integration. 49(3):16-24.
Tiran, Denise. 2018. Complementary therapies in maternity care: An evidence-based approach. London, UK: Singing Dragon.
Warland, Jane. 2017. Back to basics: Avoiding the supine position in pregnancy. The Journal of Physiology 595(4):1017-1018.
pregnancy; contraindication; leg swelling; depression; anxiety; pain; labor pain; nausea; postpartum; stress; sleep; position; joints; yoga; stretching; fear; ■
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