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Chiropractic Journal of Australia : CJA June 2012
Chiropractic Journal of Australia Volume 42 Number 2 June 2012 65 CHIROPRACTIC AND PREGNANCY ALCANTARA ET AL continued chiropractic care throughout their pregnancy. We are aware of only one other study examining the perceived effectiveness of CAM therapy in obstetrics. Munstedt and colleagues74 examined the perceived clinical effectiveness of acupuncture, homeopathy, and aromatherapy during childbirth by various personnel in departments of obstetrics in North Rhine-Westphalia, Germany. With respect to dystocia/protracted labour, labour pain, induction of labour (stimulation of labour, or both), placental retention, after pains and anxiety and stress, Munstedt and colleagues74 found that acupuncture and homeopathy (overall) were “believe, more or less, in the effectiveness of the method” by the responders. Aromatherapy however, was “not effective” except for addressing labour pains and anxiety and stress. On the issue of the safety of chiropractic SMT during pregnancy, Stuber,53 in an e-mail self-completion survey examined, in addition to the types of treatments employed and referral patterns of chiropractors in the care of pregnant patients, chiropractors’ perceived safety of chiropractic care for pregnant patients. Sixty- nine percent of 26 Canadian and Australian chiropractors with varying levels of clinical experience opined that SMT was a safe therapy for use on pregnant patients. Almost all of the respondents indicated there was no evidence that pregnant patients are at increased or decreased risk for vertebrobasilar incident after cervical SMT and pregnancy is not a contraindication for this therapy. Despite the predominance of MSK complaints during pregnancy in our PBRN patients, approximately 25% of the patient population reported presenting for “wellness care.” Health promotion and disease prevention, including the pursuit of wellness, have been documented as a motivating factor for using CAM therapies.75,76 Wellness care, health promotion and disease prevention are paradigms of public health and are important mitigators in this age of chronic disease epidemiology.77 With a theoretical framework founded on a vitalistic and holistic approach to patient care, chiropractic can be argued more as a wellness profession78,79 rather than the pure categorisation of manipulative and body-based therapy. Studies are now emerging to document “wellness care” as a motivation for presenting for chiropractic care. Alcantara80 and Alcantara and colleagues,80,81 in describing the clinical presentation of pediatric patients (<18 years of age) receiving care in a PBRN, found that wellness care was a popular motivation for the benefts of chiropractic care. The patients (N=1316) of Sacro-Occipital Technique (SOT) practitioners from the USA, Europe and Australia were surveyed by Blum and colleagues83 to explore the extent to which they sought wellness care when choosing chiropractors. Blum and colleagues37 found that 40% of chiropractic patient visits were for the purposes of health enhancement and/or disease prevention. Rubin,49 in analyzing the clinical presentations of both children and pregnant women for the purpose of triage found “wellness care’ as a motivation for chiropractic care. This study has several limitations. Selection bias (i.e., volunteer bias) and measurement bias (i.e., attention bias) may likely have played a role in the results. The patients in this survey study were recruited by the ICPA PBRN chiropractors and were existing patients. Bias in the way of self-selection (i.e., in favor of chiropractic care) may have played a role. Membership with ICPA implies interest in promoting chiropractic and the benefts of wellness care. As Astin77 pointed out, adult CAM users choose “health care alternatives to be more congruent with their own values, beliefs, and philosophical orientations toward health and life.” This may be refected in our study. Fundamental methodological questions about the convenience sample such as the number of patients informed about the study by letters or other forms of communications were not addressed in this study. As such, the patient response rate is unknown and further places this study to sampling bias. There is also the presumption that a known or high response rate refects a more accurate survey. In defense of our work, this study was exploratory in nature and the frst descriptive study of its kind. Further, there are now a number of studies challenging the presumption that a low response rate translates to lower survey accuracy. For example, Curtin and colleagues84 examined the consequences of a lower response rates on estimates of the Index of Consumer Sentiment (ICS). They examined the effect of excluding respondents who initially refused to participate (reducing the response rate 5-10 percentage points), respondents requiring >5 calls to complete the interview (reducing the response rate by @ 25 percentage points), and respondents requiring >2 calls (reducing the response rate by 50 percentage points). Curtin and colleagues 84 found no effect of excluding these respondent groups on estimates of the ICS using monthly samples based on hundreds of respondents and yearly estimates based on thousands of respondents. Holbrook and colleagues85 examined the results of 81 national surveys with response rates varying from 5-54% and found that surveys with much lower response rates were only minimally less accurate with respect To representativeness. Keeter and colleagues86 replicated a 1997 methodological experiment that compared results from a “Standard” 5-day survey employing the Pew Research Center’s usual methodology with results from a “Rigorous” survey conducted over a much longer feld period and achieving a signifcantly higher response rate. The original and replicant study found little to suggest that unit nonresponse within the range of response rates obtained seriously threatens the quality of survey estimates. In 77 of 84 comparable items, the original and replicant studies yielded results that were statistically indistinguishable. As a result of such studies, we support the view that response rates are informative but “do not necessarily differentiate reliably between accurate and inaccurate data.” 87. Given these limitations, we caution the reader from generalising the results of our fndings. On the issue of perceived effectiveness, we are aware of the unusually high level of patient satisfaction and clinical effectiveness reported. In hindsight, perhaps a fve-point numerical scale of patient satisfaction or a numerical scale such as: “Very Effective,” “Effective,” “Somewhat Effective,” “Not Effective” may have been more appropriate. As it stands, there is the assumption that every patient responding “Yes” for each category assumes that chiropractic care was 100% effective. While this is possible, we accept that it also seems reasonable that such may not have been the case. Despite these limitations, our study provides the starting point in providing epidemiologic and clinical information about pregnant patients who access chiropractic services in terms of their demographics, reasons for seeking chiropractic care, clinical presentations and the most common pain-causing structures and etiologies (i.e., sub-types) of pregnancy-related LBP.
CJA March 2012
CJA September 2012