Chiropractic practice is based on the theory that alterations to the biomechanics of the spinal and extraspinal structures, such as the cranial and mandible bones, can lead to altered neural signals being sent to the spine (Mullen et al, 2010). Subluxation of the spinal column and other articulations can interfere with neurological function, disrupting homeostatic balance, which may symptomatically and adversely affect health (Homola, 2016). Using chiropractic adjustment, the biomechanics are corrected, thereby restoring and improving function (Alcantara et al, 2015). Chiropractic practice has been defined as a process of diagnosis and treatment based on the role of the nervous system in co-ordinating all of the body's functions, and the idea that disease results from a lack of normal nerve function. Chiropractic alternative medicine is part of the complementary therapies model, specifically relating to manipulative and body-based methods (Shaukat Ali et al, 2018). However, chiropractic treatment is not available on the NHS and would only be available for pregnant women and parents willing or able to pay.
Chiropractic use in pregnancy
Pregnant women with specific pregnancy-related health concerns, such as back or neck pain, are increasingly visiting complementary and alternative practitioners (Frawley et al, 2016). Lower back pain and pelvic girdle pain in pregnancy is thought to be caused by structural, postural and hormonal changes; trauma; metabolic factors; poor motor control and stress on ligament structures; however, its exact aetiology is unknown (Casagrande et al, 2015).
Approximately 50–80% of women experience back pain during their pregnancy, and chiropractic care involves soft tissue massage, mobilisation, spinal manipulation or specific exercises to provide relief (Hughes et al, 2018). Many women may have already tried other methods of pain relief suggested by their midwife or doctor before seeking out a chiropractor. Other methods of pain relief include heat packs, exercises, simple analgesia, rest, narcotics (in severe cases), or referral to orthopaedic specialists. Most chiropractors use a diversified technique that involves a high velocity, low amplitude spinal manipulation, which is deemed safe during pregnancy (Vallone et al, 2017), and aims to restore joint motion and relieve muscle tension. Chiropractors have suggested that it is easier to manipulate the ligaments in pregnancy, as they are loose and require very little pressure to adjust (Hensel et al, 2016). Research offers strong evidence that chiropractic involvement in managing lower back pain and pelvic pain in low risk pregnancy can be effective (Belogolovsky et al, 2015; Hall et al, 2016), and women receiving weekly treatments for back and pelvic pain during pregnancy have reported positive outcomes after approximately 6 weeks (Hall et al, 2016). However, further research into the efficacy and safety of chiropractic care for back and pelvic pain is required due to the growing popularity of use among pregnant women.
Chiropractic management of breech presenting babies
Research into the efficacy of chiropractic practice in turning breech presentation fetuses to a cephalic presentation is limited. Some chiropractors have suggested that by using the Webster technique they have successfully turned breech presentation fetuses to a cephalic presentation (Edwards and Alcantara, 2014). The Webster technique is a specific sacral adjustment to improve the pregnant woman's pelvic alignment and nerve system function. This in turn balances pelvic muscles and ligaments and reduces torsion to the uterus. The Webster technique is used to correct sacral subluxation and related soft tissue derangements and was not developed specifically to correct breach presentation (Alcantara et al, 2012). Due to the limited research undertaken with the turning of breech presentation fetuses via chiropractic practice, further research is required before chiropractors can confidently report on the effectiveness of the use of the Webster technique.
Chiropractic management of colic
Colic has recently been re-defined as unexplained excessive crying in a healthy and thriving neonate for a period of 3 hours or more per day in a week (Banks et al, 2016). The onset of colic generally occurs within the first 2 weeks after birth and peaks at 6 weeks, then reducing and generally resolving between 3–6 months of age (Gospodinova et al, 2018). Colic affects 2–40% of neonates, with 1 in 6 families presenting to their GP for treatment (Zeevenhooven et al, 2018). The wide range in prevalence of colic is due to GPs using different criteria to diagnose the condition. Colic can have far–reaching consequences, and can potentially affect maternal bond, increase maternal stress and increase risk of shaken baby syndrome (Kommers et al, 2017; Wolke et al, 2017). Colic has an unknown aetiology, but it could be related to gastrointestinal health, as it is multifactorial. Evidence is limited, so theories are unsubstantiated as to why chiropractic intervention may be effective. Chiropractors believe that during birth significant pressure is applied to the fetus' head causing moulding and if pressure is applied while the head is asynclitic, it could lead to subluxations of the vertebrae (Holm et al, 2018). Research does support the use of manipulative therapy for colic, suggesting a statistically significant difference (Dobson et al, 2014); however, it is important to note that this does not mean clinical difference, which is the effect of the treatment on neonates and their families' quality of life.
Constipation in neonates
Constipation in babies and infants is defined as fewer than three bowel motions per week and difficulty passing firm, dry stools (Singh and Connor, 2018). Constipation can affect between 0.7–29.6% of infants and can impact on the health-related quality of life (Alcantara et al, 2015). Multiple factors can contribute to constipation, such as lack of baby-led breastfeeding, improper preparation of formula milks, factors in the maternal diet, medications, dehydration, milk, irritable bowel syndrome, low fibre diet and problems with the gastrointestinal tract (Vandenplas et al, 2015; Howarth and Sullivan, 2016). Chiropractic care for infants diagnosed with constipation is gaining popularity among parents and involves a series of manipulations to the cervical and lumbar areas to stimulate the bowel. It is very difficult to accurately diagnose an infant with idiopathic constipation and distinguish whether the improvement in symptoms is part of the natural cycle of growing or intervention. Chiropractic care is not routinely the first treatment option for idiopathic constipation in neonates.
Chiropractic management of breastfeeding issues
Chiropractors suggest that birth trauma is a common cause of difficulties with breastfeeding neonates (Vallone, 2016). Some chiropractors report breastfeeding difficulties are caused by cervico-craniomandibular syndrome resulting from birth or instrumental birth. This may affect the neonate's ability to latch correctly or transfer milk effectively, and contribute to nipple pain in women (Alcantara et al, 2015). Research suggests that after chiropractic manipulation, cervical, cranial, and sacral restrictions are released, thereby correcting neuromusculoskeletal dysfunction. This process is thought to influence the ability of a neonate to breastfeed successfully, preventing them from overarching or overextending when breastfeeding (Bernard and Alcantara, 2012; Stewart, 2012).
Safety of chiropractic care in pregnancy
Limited research has been conducted into the safety of spinal manipulation therapy during pregnancy and postpartum periods; therefore, there is very little evidence proving it to be a safe intervention. Until 2005 there was no reliable way to report adverse events; however, since 2005 chiropractors in the UK use the adverse reporting system, YellowCard. Adverse effects in women and neonates receiving spinal or cervical lumbar manipulation have been reported, and range from mild and transient events to serious adverse events, such as cerebral infarcts and epidural haematoma (Todd et al, 2015). Serious adverse outcomes among pregnant women receiving chiropractic care are rare, but can include cord and root injury, vertebrae fracture, vertebral artery dissection, epidural haematoma and cervical disc rupture (Stuber et al, 2012). It would therefore be prudent for midwives to exercise caution in recommendations to women in their care. Considering that women undergo significant hormonal and coagulation changes during pregnancy and the postnatal period, spinal manipulation therapy in this subgroup may not safe.
Safety of chiropractic care in neonates
With the increasing use of chiropractic care in paediatrics, the safety of neonates and whether this clinical intervention is appropriate must be considered. The differences in tensile strength between adult and paediatric patients is important and there is a non-linear increase with age (Marchand, 2015). As part of spinal manipulative therapy, thrust is applied to the restricted joint to restore motion and movement, and chiropractors must be careful not to exceed the anatomical limits, which could lead to joint trauma and pathology. Dosage, frequency and duration amounts are therefore dependent on age (Marchand, 2015). Other adverse events recorded from the chiropractic treatment of neonates include crying, soreness, syncope, transient apnoea and marked bradycardia (Todd et al, 2015). Adverse events may be increased if the neonate has pre-existing pathologies; therefore, it is important that a thorough history and examination is performed to rule out neurological or anatomical abnormalities.
In 2009, due to public and professional pressure, chiropractic guidelines for the care of children were developed (Hawk et al, 2009), and updated in 2016 (Hawk et al, 2016). Important considerations in the 2016 guidelines include the need for informed consent, the need for a detailed clinical history, and referral for diagnostic imaging where there is a clinical need. The guidelines also include an extensive list of conditions where medical referral is required before any chiropractic treatment, health screening and planning of paediatric care. Chiropractors are advised in this document to consider patient's size, structural development, joint flexibility and preferences.
Chiropractic practice is growing in popularity as part of the complementary and alternate medicines model. The practice involves care of the spinal and extraspinal structures by use of spinal manipulative therapy, soft tissue massage, mobilisations and exercises to ensure correct placement of structures and thus optimal functioning of the body. Adverse events may occur from chiropractic care, and although this is rare, further research is required into why these adverse events occur before chiropractic interventions can be declared safe. Early research indicates that treatment of back pain in pregnancy by a chiropractor is effective, although the research on turning breech presentations is weak, and it does not reliably indicate whether the use of the Webster technique is effective. Both practices require further research to assess efficacy and safety. Despite a statistical significance found in the treatment of colic, the effectiveness of chiropractic care for colic, constipation and breastfeeding is not conclusive, due to the lack of strong evidence.
Although in most cases women will self-refer to therapists, discussions about the effectiveness and safety of treatment may be part of the discourse between a woman and her midwife, particularly if trust has been established through continuity of care. The importance and potential benefits of chiropractic care for pregnant women and neonates cannot be disregarded, as the research is generally supportive of positive outcomes; however, there is little empirical research confirming the safety and effectiveness of chiropractic care for pregnant women and neonates. Further research regarding its safety and efficacy is indicated before a definitive conclusion can be drawn.