One of the most common symptoms experienced during pregnancy is low back pain, as over half of the pregnant patient population experience LBP during their pregnancy
[1, 14]. Chiropractic is the third most common type of Complementary and Alternative Medicine (CAM) treatment sought by pregnant patients
. This study investigated the chiropractic treatment experience of pregnant patients with LBP, as well as their chiropractors. The comments of the patients and chiropractors lend some support to previous reports in the literature of positive outcomes of chiropractic care for LBP during pregnancy and provide insight as to how or why those outcomes may be achieved
The chiropractors in this study emphasized communication with their patients
[16, 17] and educated them about pregnancy-related changes that they were experiencing and how the chiropractic treatments could be helpful. Pregnant patients often present differently in terms of their low back pain and symptoms, and the chiropractors in this study employed a patient-centered approach
, where each patient’s treatment plan was tailored to their specific needs and particular timing in their pregnancy. Knowledge and experience of both patients and their chiropractors played an important role in enhancing the doctor-patient relationship, as well as potentially contributing to a more positive therapeutic outcome.
The chiropractors in this study demonstrated concern regarding patient safety and were vigilant in evaluating for the presence of any contraindications to spinal manipulation. The safety of chiropractic treatments, and specifically spinal manipulation for pregnant patients has been evaluated in a previous survey of chiropractors
 as well as a critical literature review
. These studies indicate that chiropractors feel that their treatments are safe for pregnant patients
 and report that side effects may be rare, although further research is clearly needed
It has been reported that women who exercise during pregnancy are likely to have more energy, fewer mood swings, better able to manage stress, and get more sleep compared with sedentary pregnant women
[19, 20]. Exercise prescription appears to be an important component of the treatment program as described by the participants in our study. Most of the chiropractors advised specific stretches or exercises for their patients, depending on how far along they were in their pregnancy. Moderate exercise during pregnancy has been shown to improve overall maternal well-being
[19, 20]. This was also reflected in the responses of the patients, who indicated that their chiropractor gave them some form of exercise to do at home. Those patients who adhered to their exercise program regularly indicated positive results and improved outcomes in their functioning and activities of daily living.
Future research into chiropractic treatment of pregnant patients with low back pain is warranted and the next step should likely involve a larger scale clinical trial at a higher level of evidence such as a randomized controlled trial
[3, 5, 7]. Any future studies should employ well-defined inclusion and exclusion criteria and evaluate commonly used treatments such as those described by the participants in this study. It will also be necessary to utilize validated outcome measures for pain and disability due to low back pain, and track adverse events, while observing a suitable follow-up period.
As this was a qualitative study that employed convenience sampling as opposed to purposive sampling
, our sample is not necessarily representative of the experience of all pregnant patients who might have low back pain in their second or third trimester, nor of chiropractors who treat pregnant patients. Since only pregnant patients actively under chiropractic care were included, this study did not consider patient responses prior to receiving chiropractic treatment for their low back pain during pregnancy or after their delivery or conclusion of chiropractic care. Using clinicians to refer patients to the study team may have over-emphasized those patients with a particularly strong relationship with their chiropractors or who strongly value chiropractic care and its effects. Furthermore the clinicians may have only referred those patients that they knew or felt had good outcomes and may be more likely to express satisfaction with care, and thus the voices of those who may not have been satisfied with chiropractic care for low back pain during pregnancy may have been under-represented. These factors could limit the transferability of our findings. However, our data has potential for transferability to a wider population, in this case other chiropractors and their pregnant patients with low back pain, as chiropractors and patients from two different jurisdictions (both Ontario and Alberta) were interviewed and the chiropractors involved had a wide range of practice experience. Furthermore, there was a wide age and gestational period range among the patients interviewed. In future qualitative evaluations of this topic, more purposive sampling of both chiropractors and patients would be beneficial, in particular by seeking out pregnant patients independent of referrals from their chiropractors.
Qualitative research inevitably suffers from issues of bias as the researchers invariably have an effect on the participants and potentially the results of a qualitative study through the concept of reflexivity
. However several steps were taken to account for potential bias and reduce the influence of reflexivity as our data was triangulated as we interviewed two groups, pregnant women and their chiropractors, again potentially aiding transferability. The presence of multiple team members at each interview and multiple reviewers to evaluate transcripts and generate codes and themes should further enhance the validity and aid the credibility of our findings. Determining the point of thematic saturation is another particular instance where bias could be introduced and the validity of the findings questioned, particularly if the saturation point was chosen too early, but to reduce this possibility multiple meetings were held among the investigators to help ensure that a suitable and agreed upon thematic saturation point was found and that no new themes emerged in subsequent interviews, which were used to elaborate upon the existing themes.