Chiropractors respond

In the October issue of Canadian Family Physician, Bellamy’s letter¹ suggests an insufficient account of risks associated with chiropractic treatment of pregnant patients in regards to an article by Oswald et al.² However, Bellamy provides no evidence of these risks herself. In addition, she suggests that the prudent family physician contemplating referring any patient to a chiropractor be fully informed about chiropractic practice before doing so. We want to provide some evidence related to these unreferenced concerns.

Concerning risks with chiropractic care in pregnant patients, 2 recent reviews of the literature found few adverse events in this population.^3,4 Khorsan et al⁴ conducted a systematic review on the use of manipulative therapy, a common therapy used by chiropractors, as well as physiotherapists, medical doctors, and doctors of osteopathy, for pregnancy and related conditions. Of the 32 reviewed articles,⁴ only 1 adverse event was reported (from a manipulation performed by the patient’s general medical doctor). This review concluded that the use of manipulative therapy for pregnancy-related back pain might be considered by clinicians if contra-indications are not present. Another even more recent critical literature review⁵ of adverse events from spinal manipulation in the pregnant and postpartum periods found a total of 7 reported events (over a period of 31 years), 2 postpartum, and 5 during pregnancy. These 7 reports included the following: increasing pain resolving within a few days, fracture, stroke, and epidural hematoma. Note that 2 of these 7 reports on adverse reactions were attributed to a physiotherapist and a medical doctor, respectively.⁵ Additionally, a randomized clinical trial published in 2013 found that a multimodal approach including standard obstetric care and chiropractic manual therapy for low back and pelvic pain during midpregnancy benefits patients more than standard obstetric care alone.⁶ This study noted that no adverse events were reported from the chiropractic manual therapy.

Since the Institute of Medicine first published its report To Err Is Human,⁷ all facets of health care have been faced with the necessary task of supporting a patient safety culture. Chiropractors are community-based providers who face the same challenges identified for those in community-based primary care settings: time-consuming processes, under-reporting of adverse events, and inaccuracies of medical records.⁸ From the reviews and clinical trial mentioned above, as well as the lack of community-based patient safety culture research, it is evident that research is needed to support and measure patient safety cultures within all health care professions.

As to the concern of family physicians being fully informed about chiropractic practice before referring, we wholeheartedly agree with this statement. We would recommend all practitioners, including family physicians, examine the scientific literature for the safety and effectiveness of any proposed treatment. With respect to chiropractic care, the best available evidence supports manipulative therapy as a reasonable option for many complaints such as back pain, neck pain, and headaches.⁹ Consequently, manipulation has been included as an effective care option in a number of national and international guidelines on back pain.^10,11 Chiropractic care also holds potential value for the treatment of a variety of extremity conditions.⁹ Also note that chiropractors refer patients to other health care providers and also receive referrals from medical physicians.¹² In fact, family practitioners were the most likely physicians to refer to chiropractors, followed by family nurse practitioners, internists, neurologists, neurosurgeons, gynecologists, and general surgeons.¹² We appreciate the opportunity to respond to the letter by Bellamy,¹ and we hope this additional information will assist interdisciplinary dialogue between medical doctors and chiropractors to provide the best care for their patients, including those who are pregnant.

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