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Chiropractic Journal of Australia : CJA June 2012
64 Chiropractic Journal of Australia Volume 42 Number 2 June 2012 As a prelude to further discussion on the chiropractic care of pregnant patients and provide a context to the contribution of this study, a systematic review of the literature on the chiropractic care of pregnant patients would be appropriate. Two systematic reviews of the literature have recently been published on this topic. Stuber and Smith58 systematically reviewed the literature regarding chiropractic SMT for pregnancy-related low back pain. Six papers, 1 quasi- experimental single-group pretest-posttest design, 4 case series, and 1 cross-sectional case series study43,48,54,60,69,70 met their inclusion criteria for scoring with a 27-item revised checklist by Downs and Black.71 Stuber and Smith58 found positive reports of chiropractic care for pregnancy-related LBP with quality scores ranging from 5 to 14 of 27. As with most CAM interventions, the authors concluded that defnitive statements on the effcacy of such a treatment (i.e., SMT for pregnancy-related LBP) could not be made due to the lack of higher-level designed studies (i.e., randomised controlled studies). Khorsan and colleagues59 also recently performed a systematic review of the literature on the effectiveness of SMT on low back pain and other related symptoms during pregnancy. Thirty-two articles met their inclusion criteria consisting of 1 RCT, 2 systematic review, 1 cohort study, 2 case-control studies, 1 small non- randomised static-group comparison study (pre-experimental design), 4 narrative reviews, 6 case series, 9 descriptive surveys and 6 case reports (of 1-2 cases). Using quality checklists from the Scottish Intercollegiate Guidelines Network72 and the Council on Chiropractic Guidelines and Practice Parameters,73 the authors concluded that the use of SMT during pregnancy to reduce back pain and other related symptoms is supported by limited evidence and best described as “emergent.” For our purpose, we also performed a systematic review of the literature to examine the presenting complaints of pregnant patients to chiropractors. The following electronic databases were searched: MANTIS [1965-2009]; ICL [1984-2009]; Pubmed [1966-2009]; Medline [1965-2009] EMBASE [1974-2009], AMED [1975-200], CINAHL Plus [1965-2009], Alt-Health Watch [1965-2009] and PsychINFO [1965-2009]. Key words used were pregnancy in Boolean combination with “chiropractic” along with related words when appropriate. The search was limited to publications in the English language and in peer-reviewed journals. Additionally, chiropractic journals (i.e., Journal of Manipulative and Physiological Therapeutics, Journal of the Canadian Chiropractic Association, Clinical Chiropractic, and the Chiropractic Journal of Australia) were hand-searched for the last fve years for possible relevant materials. Key informants and experts in the feld were also contacted to provide assistance in providing relevant literature. The gray literature was also searched as well as the bibliography lists of all retrieved articles and relevant studies. Three of the authors (JA, JDA and JA) independently reviewed the title and abstracts of all articles generated from the electronic database search as well as from the reference lists of relevant articles. The full manuscripts of reports relevant to the chiropractic care of pregnant patient were retrieved by applying the following set of eligibility criteria: (1) the study was a primary investigation/report (i.e., case reports, case series, case control, randomised controlled trials and survey or surveillance studies) published in peer- reviewed journals in the English language; (2) part or all of the study population involved pregnant patients. Our review revealed 52 articles consisting of commentaries (N=31),8-38 case reports (N=6),39-44 case series (N=4),45-48 cohort studies (N=4),49-52 survey/observational studies (N=4),53-57 systematic review of the literature (N=2)58-59 and one limited review.60 To the best of our knowledge, this is the frst reporting in the scientifc literature on the presenting complaints and perceived effectiveness of chiropractic care on pregnancy- related low back pain within a PBRN setting. The fndings of our study indicate a high prevalence of NMS complaints in pregnant patients presenting for chiropractic care. Of the 243 documented clinical presentations in our study population, 85% (N=206) of the complaints were NMS in nature. Of the myriad of possible NMS conditions, sacrospinal pain (i.e., low back pain) was the most common reported (see Table 1). Based on our systematic review of the literature, we are aware of only two other studies examining the presenting complaints of pregnant patients to chiropractors. Skaggs and colleagues 54 reported the prevalence of self-reported musculoskeletal pain of pregnancy for 599 low socio-economic women in their second trimester presenting at the Women’s Wellness Center of Barnes-Jewish Hospital and the Washington University School of Medicine in St Louis, Mo. Skaggs and colleagues54 found that two-thirds of their patient population reported back pain at three sites: low back pain, pelvic pain and mid-back pain. A majority of the 599 women complaining of NMS pain was in the low back with nearly half of the women presenting with a multi-focal pattern of pain involving 2 or more sites, 1 in 3 of the women reported pain at 2 sites and 1 in 10 reported pain at all 3 sites. To triage the chiropractic visits of new and existing pediatric or pregnant patients in a 1-year period at one chiropractic clinic, Rubin49 found that the 2 most common reasons for new pregnant patients presenting for chiropractic care were to address the possible causes of breech position and pain syndromes in the low back and neck pain and headaches. Of Rubin’s existing pregnant patients, common complaints were low back pain, psoas/ligament dysfunction, headache, midback pain, sinus problems and rib pain. Given the differences in research design, a valid comparison of our fndings to those of Skaggs and colleagues54 and Rubin49 cannot be made. However, ceteris paribus - “all other things being equal” - our fndings are similar to those of Skaggs and colleagues with respect to the predominance of NMS complaints and their multi-focal patterns.” It is our humble opinion that overall, our fndings with respect to clinical presentations is relatively more representative of the chiropractic practice compared to those of Skaggs and colleagues54 (i.e., data derived from a hospital clinical setting) and Rubin49 (i.e., single practice) given the practice-based research setting of our study. With respect to our PBRN pregnancy-related clinical presentations and perceived effectiveness of chiropractic care, some 96% of the patients with 10 complaints, 97% with 20 complaints and 100% of those with 30 complaints found chiropractic SMT as effective. The perceived effectiveness were categorised, based on indicated responses, into 3 domains -- decreased pain, improved functionality and due to the heterogeneity of responses -“others” (see Table 3). At the time of the survey, the patients had attended (on average) between 9-10 office visits with a vast majority having CHIROPRACTIC AND PREGNANCY ALCANTARA ET AL
CJA March 2012
CJA September 2012