The 11 included patients were between the ages of 24 and 36 years and the timing of their pregnancies ranged from 17 to 38 weeks. The 12 included chiropractors were in practice between three and 38 years. During analysis five themes emerged from the DC and PT interviews. The themes identified were: Treatment and Effectiveness; Chiropractor-Patient Communication; Pregnant Patient Presentation and the Chiropractic Approach to Pregnancy Care; Safety Considerations; and Self-Care.
Treatment and effectiveness
Nearly all of the chiropractors indicated that chiropractic treatment was effective in relieving the LBP of pregnant patients. Most of them indicated that they saw positive results in their pregnant patients, for instance: (DC02) “their symptoms seem to improve with the treatment, and also objectively I find that the joint restrictions improve as well.” One chiropractor spoke of some of the important outcomes of care for pregnant patients:
"DC10: “
The impact for the pregnant patient is usually profound, as being able to reduce pain and increase function and getting them back into exercise, which is all important for the outcomes of the pregnancy
.”"
In terms of treatment procedures, most of the chiropractors indicated employing the Diversified technique, previously reported by 86% of surveyed Canadian chiropractors,[8, 9] employing high-velocity, low-amplitude spinal manipulation maneuvers[10], as well as soft tissue therapy and exercise prescription. One particular chiropractor, among the most experienced of those interviewed, said that her treatment plan depended on the patient:
"DC09: “
depends on what the patient comes in with, and it also depends on what time they’re at in their pregnancy, which month. So there are a few variables to consider. We can say essentially Diversified, but again I modify it according to the presenting symptoms and the spinal configuration of the patient
.”"
A few of the chiropractors used instrumented techniques for spinal manipulation, such as the Activator®[9, 11] or the IntegratorTM[9] when working on any sensitive areas towards the latter parts of the pregnancy. Two of the chiropractors used the Webster technique[12]:
"DC05: “
The second component of the Webster technique just requires some soft tissue work for the round ligament. I find that works quite well, people respond really well to it
.”"
All of the interviewed patients reported that they found chiropractic treatment to be effective and that it helped relieve them of their LBP and associated symptoms. Patients reported that chiropractic treatment had improved their daily living activities and their mobility, while it decreased their overall pain and discomfort:
"PT01: “
I can walk longer periods of time. So that’s excellent. I can go standing for four to five hours. Because prior to that I’d be standing 40 minutes to do the dishes and I’d be in agony. even the basic things, like picking things up off the floor, you’d get stuck in that position, I haven’t experienced that yet [in this pregnancy]. Or just sitting for long periods of time, because I do work an office job from home, so I do sit long periods of time. I know for most people [they] have to get up and stretch for a couple minutes, even in doing that I’ve been doing okay
.”"
"PT02: “
The pain is gone. but I do feel like I have more energy and I can do more activities. The pain doesn’t prevent me anymore
.”"
"PT05: “
It really allowed me to function. I could barely walk before or stand, the pain was intense, but after I went to the chiropractor. I found I could function day to day, I could walk from the bus stop to work, I could do these things, so that was pretty significant. It’s just helping me function. It’s just teaching me how to pick up my daughter so I don’t hurt myself. To still function, to still play with my daughter and be able to go to the grocery store and do all these things without really hurting myself. As well as it allows me to sleep at night
.”"
"PT06: “
I found within five days I had greater mobility in terms of twisting and turning. I’m a drama teacher so I’m constantly up on my feet and I need to be able to lean down, jump over, so I need to have a full range of motion, and I found that my range of motion had been very limited and I was getting cranky because I was in pain. I think after the treatment, it was decreased pain and increased sense of mobility, increased range of motion and decreased sense of frustration and grumpiness
.”"
"PT11: “
that’s the whole reason I go, [for] the pain relief, especially now that I’m a stay-at-home mom, and picking up a 30-pound, 19 month-old all day long. So seeing a chiropractor really helps because it’s not ideal to be lifting a child all day long when you’re in a lot of pain, just the pain relief and the effect that it has on making your daily life easier
.”"
Chiropractor-patient communication
The chiropractors generally emphasized communicating well with their patients as part of providing care and outlining the outcomes to expect. A few of the chiropractors placed great emphasis on patient education about pregnancy, particularly with respect to the changes that are taking place in the patient’s body as they are going through their pregnancy, or the various reasons behind their LBP symptoms. For instance, with respect to doing yoga, DC09 said: “I encourage that if there are no contraindications, and I give them simple postural advice and things they can do at their workplace.”
One chiropractor said educating his patients is 50% of what he does, and that it is (DC11) “a great component initially”:
"DC11: “
I think the more knowledge they have, the better they are… the woman who is going through the first pregnancy is very scared, hesitant, anxious and wants that kind of knowledge, and wants the practitioner to know what they’re going through and set their mind at ease
.”"
Chiropractors were generally open to referring their patients to other professionals if necessary. DC12 said when a patient comes in with a concern “that is a bit out of my scope,” he encourages her to contact her midwife or OB-GYN.
One pattern that emerged from the interviews was that communication between chiropractors and patients depended on the knowledge level of both parties. Only a few of the patients seemed to be very knowledgeable about their pregnancy and asked questions or challenged their chiropractors about various techniques or treatments:
"PT06: “
I think we sort of have more of a dialogue about what treatment options to pursue, I think I’m more assertive in terms of asking ‘why’ or ‘how come’ or ‘is this a good option’ and ‘what else could we do’
.”"
The approach of one chiropractor in particular was shown to help her patients emotionally regarding the changes going on in their bodies. While educating the patient, the chiropractor also eased their mind simply with her communication skills, as explained by her patient:
"PT06: “
It’s been emotionally helpful because at the same time I’m getting advice beyond… there’s been explanations of ‘physiologically this is what’s happening to your body’ and ‘this is why your ligaments are pulling’, ‘this is why you’re compensating with the extra weight at the front’, ‘this is why your posture is changing’… and things like that
.”"
Pregnant patient presentation and the chiropractic approach to pregnancy care
Each chiropractor’s approach to treatment depended on their knowledge and experience with pregnant patients. A few of the chiropractors had more preventive maintenance and wellness-based practices where they provided a long-term treatment plan for their pregnant patients. For instance, patients went for regular visits and adjustments, regardless of having any pain or symptoms. One pattern that emerged among the chiropractors, was that most of the pregnant patients they saw and treated were previous “on-going” patients who later became pregnant, and then continued with modified care throughout their pregnancies. In terms of their specific approach to treatment, one chiropractor said:
"DC05: “
I definitely take a very holistic approach with my health history and my assessment. I want to get a good sense of what their pregnancy has been like, from the overall standpoint. What type of stressors have been in their world, physical stressors, chemical stressors, the foods that they eat, nutrition is a big piece, activity is a big piece, any mental or emotional concerns or fears going into labor, birth or even pregnancy in general. It can be an emotional time for some women
.”"
Another chiropractor (DC06) who frequently treated pregnant women in his practice had a “protocol” that he used with them, and believed that chiropractic care is a great “adjunct” to treating these patients, as part of their larger health care team.
Pregnant patients present differently in terms of their LBP symptoms, its onset, location and duration. The chiropractor’s approach depended on the patient’s presentation, and most of them had a patient-centered approach:This was emphasized by another chiropractor:
"(DC03) “
Some will respond differently than others and obviously not every pregnant patient with back pain has exactly the same issues as well. So, we obviously tailor those situations to patients
.”"
"DC09: “
There are a variety of pregnant patients that come in, some who are ‘die-hard’ chiropractic patients who really don’t care or ask you anything. They just know they are going to feel well, so they just want to be there to continue. Then there are the others who kind of want to try it to see where they’re at, so the first trimester patient in that sense can be particular. The second trimester patient will probably ask more questions because they’ve heard more about chiropractic, so they know it can be beneficial in terms of their delivery especially. they are there for a reason and want to know how often they can come
.”"
DC09 further added, “The bio-psycho-social model is very relevant too. Because they are not all coming to me from nice family units… I’ve got single moms, I’ve got pregnancies that have gone particularly bad… that has a huge impact on the pregnancy as well.” One chiropractor simply said: (DC12) “It depends on what trimester they start at and how far along they are and what stresses they have on their body.”
Many of the patients had received chiropractic treatment prior to their pregnancy. Depending on their symptom presentation and background (in terms of previous pregnancies), some patients received chiropractic treatment when they felt the need, or when they felt their symptoms were flaring up. One patient said: (PT05) “We don’t really have a treatment plan. It’s more like, ‘when it hurts, come back’. So I’ve just been keeping tabs on how I’m feeling and when it hurts I go back.”
A few patients received long-term spinal care from their chiropractors who had more of a preventive maintenance and wellness-based approach to therapy, where they received treatment on regular visits for the duration of their pregnancy, even when no symptoms were present, while others were receiving treatment for other conditions and continued on with the care when the low back pain during their pregnancy came on:
"PT03: “
I’ve seen chiropractors over the years. I started seeing chiropractors when I was 17, I had low back problems by then and yeah, with the pregnancies it was just getting worse
.”"
"PT01:
“prior to the pregnancy I used to see the chiropractor for my mid back section and my neck for headaches, so that’s how it all started
.”"
Several patients chose chiropractic care for their back pain because they had found results from their first pregnancy:
"PT11:
“it worked so well the first time, I’d even come away from the appointment feeling better. It was almost an immediate fix. So because of my positive experience the first time, there was no question that I was going to use chiropractic care for the second pregnancy
.”"
Generally, most of the chiropractors were knowledgeable about treating pregnant patients and had either some kind of formal post-graduate training, or had attended seminars or workshops. A few of them said they kept up-to-date with the research on pregnancy, although they admitted, (DC09) “there is not much” or (DC12) “there is not a lot out there.”
Safety considerations
All of the treating chiropractors directly stated in their interviews that they believed chiropractic treatment for their pregnant patients was safe, and they had seen no adverse effects. For instance, one chiropractor said: (DC03) “I primarily do Diversified adjusting in my practice and I consider that to be safe” This was further emphasized by saying: (DC08) “in pregnant patients the ligaments are very loose and require very little force to adjust, which I feel makes it much more safe, because you don’t have to do a whole lot to get the response you want.” With respect to the Webster technique, it was said: (DC05) “the method of assessment and adjustment is very safe. The patient is very comfortable lying prone on the table with the use of pregnancy pillows”.
In terms of any contraindications to treatment, most of the chiropractors said that they would not use any electrical modalities on their pregnant patients. One said he would not do much treatment in the first trimester (DC06), whereas two said they wouldn’t start their patient on a new exercise program in the last trimester. One chiropractor said he would not use any SMT on a pregnant patient if he knew that she had a miscarriage before (DC04), or if she had early dilation of the cervix (DC09).
All of the patients directly stated in their interviews that they believed chiropractic treatment was safe and they had not experienced any adverse events after any treatment, which has been reported in previous studies[13]: (PT07) “I wouldn’t say I’ve ever had any side effects.” Patients also described their comfort levels changing with particular treatments throughout the pregnancy, while their chiropractors generally modified the treatments to make their patients feel safe and comfortable:
"PT11: “
I’m always very aware of what he’s doing to me and where the position of the baby is. I can’t say I’m 100% comfortable, I know it works, and I’ve read quite a number of articles about it. I haven’t experienced any problems, but it’s always in the back of my mind [safety of my baby], especially in the very beginning, not so much right now, because I’m really big now and it has to be done differently. Now the reservations are there but they’re very small, and I think that’s the case with anything in pregnancy. You just want to make sure you’re doing the right thing for your body and the baby.
”"
"PT11: “
I was on my back for a couple of the adjustments, and now because I’m so big, I can’t lay too long on my back so comfortably and I can’t lay on my front. He’s given me a cushion but it’s not very comfortable, and so the last adjustment I had was primarily on my side and on my back for a short period of time and nothing on my front
.”"
Self-care
All 12 chiropractors discussed advising exercises or encouraging their patients to follow an exercise program before, during or after their pregnancy. Generally, they emphasized exercise throughout the pregnancy: (DC01) “I do a lot of exercise therapy with my pregnant patients. It could alleviate some of their aches and pain if they worked out on a regular basis with someone who knows what they’re doing and what exercises to give them.” Many of the chiropractors had a specific exercise plan or regime that they prescribed to their patients, depending on which stage of pregnancy they were in. For instance:
"DC03: “
What we’re recommending are often core-strengthening exercises, and a lot more women these days are much more aware of getting ahead of the game in terms of fitness training during their pregnancy. If we have the opportunity to work with someone earlier in their pregnancy we’d be working harder to get them moving. Once they’re in the latter half of their pregnancy, really what we’re trying to do is maintaining and making sure we’re not adding anything more than their body can handle at that point and time
.”"
Almost all the chiropractors who included exercise in their treatment said that they would not start a new exercise program if the patient was not exercising before pregnancy, and they would not introduce anything new later in the pregnancy: (DC04) “If there is developing low back pain, I would give them… cat-camel, or basic yoga style stretching.”; (DC05) “I walk patients through the type of exercises that I recommend to them. Show them and ask them to do it.”; “(DC06) Yoga and Pilates is the only thing that I recommend. I try to keep [their] heart rate low.”; (DC08) “I avoid extension exercises, but I still give them some pelvic tilts, of course get them to work on their kegels. Again it depends on the stage of pregnancy and assuming there is no complications or risks.”; (DC12) “I’m only suggesting very low impact things, and they all seem to do fine and I haven’t had anyone have a hard time with it.”
One patient said that her chiropractor did not give her any exercises to do, but generally most of the patients were given some sort of exercise regimen to follow, or were encouraged to do yoga, stretches and/or walking. One patient said: (PT07) “She’s given me a sheet of stretching exercises that are specifically for pregnancy.” Patients believed that this active component of their treatment empowered them to take care of themselves when in pain: (PT05) “he gave [me] some stretches to do… I do them as needed… So when my back is particularly sore but I know I’m not going to the chiropractor for a few days, then I’ll do those stretches and go from there.”