J Altern Complement Med. 2018 (Jan); 24 (1): 90–98 ~ FULL TEXT
Joel Alcantara, Andrea Lamont Nazarenko, Jeanne Ohm, and Junjoe Alcantara
The International Chiropractic Pediatric Association,
OBJECTIVE: To quantify the quality of life (QoL) and visit-specific satisfaction of pregnant women.
DESIGN: A prospective cohort within a practice-based research network (PBRN). Setting/locations: Individual chiropractic offices.
SUBJECTS: Pregnant women (age ≥18 years) attending chiropractic care.
INTERVENTION(S): Chiropractic care (i.e., The Webster Technique, spinal adjustments, and adjunctive therapies).
MAIN OUTCOME MEASURES: The RAND VSQ9 to measure visit-specific satisfaction and the Patient Reported Outcomes Measurement Information System (PROMIS®)-29 to measure QoL.
RESULTS: A convenience sample of 343 pregnant patients (average age = 30.96 years) comprised their study population. They were highly educated with 75% attaining a 2-year associate's degree or higher. The pregnant patients presented for chiropractic care with a mean week of gestation of 25.67 weeks (median = 28 weeks; range = 0-42 weeks) and parity (i.e., the number of live births) of 0.92 live births (median = 1; range = 0-6). From baseline (i.e., at study entrance with minimum first visit) and comparative (i.e., following a course of chiropractic care), the VSQ9 measurements revealed increasingly high satisfaction on the part of the subjects (i.e., the mean difference of baseline minus comparative measures = -0.7322; p < 0.005). The median number of visits (i.e., visits attended) at baseline and comparative measures was 1.00 (standard deviation [SD] = 22.69) and 3.30 (SD = 22.71), respectively. Across outcomes, QoL improved from baseline to comparative measurement after holding constant for visit number and time lapse, trimester of pregnancy, and care provider type. There was a reduction in mean T scores associated with fatigue (p < 0.05), pain interference (p < 0.05), sleep disturbance (p < 0.05), and an improvement in satisfaction with social roles (p < 0.05). A significant decrease was also found with pain interference (p < 0.05). No evidence was found that anxiety (p = 0.1404) or depression (p = 0.8785) changed.
CONCLUSION: A PBRN study was successfully implemented among chiropractors to find pregnant patients highly satisfied and their QoL scores improving with care beyond chance.
KEYWORDS: PROMIS; Webster Technique; chiropractic; pregnancy; quality of life
From the FULL TEXT Article:
According to the Centers for Disease Control and
Prevention, the general fertility rate for the United States
in 2013 was 62.5 births per 1000 women aged 15–44 years
based on 3,932,181 registered births.  During pregnancy, the
expectant mother is faced with many physiologic and biomechanical
changes that affect her emotional, physical, and
mental well-being. Complementary and alternative medicine
(CAM) is popular for women of childbearing age with prior
use as the most significant independent associated factor for
CAM use during pregnancy. [2, 3] A review of the literature
on the use of CAM by pregnant women found varying estimates
from 1% to 87%.  CAMuse was to address a variety of
complaints such as pregnancy-related musculoskeletal (MSK)
pain, nausea and vomiting, problems with labor, postpartum
perineal discomfort, lactation disorders, as well as to fulfill
their spiritual and emotional needs. [2, 5–7]
Of the various practitioner-based CAM therapies, chiropractic
has been shown to be popular among women before,
during, and after their pregnancy.8 Chiropractic’s holistic and
vitalistic paradigm of care and its effectiveness in addressing
the myriad of MSK complaints during pregnancy [9, 10] make it
an attractive CAM option for pregnant women. [11, 12]
As with all healthcare providers (i.e., conventional or
alternative), chiropractors must implement and demonstrate
effective healthcare interventions throughout a woman’s
pregnancy, as well as during the postpartum period. There is
anecdotal evidence indicating that pregnant women report
improved quality of life (QoL) after receiving chiropractic
care. Given societal problems related to overreliance on
drugs (e.g., opioids)  and high rates of postpartum depression
and anxiety,  there is a need to explore alternative
solutions to improving maternal QoL. Toward these efforts
and in the interest of evidence-informed practice, the authors
examined the QoL and visit-specific satisfaction of
pregnant women undergoing chiropractic care in a practicebased
research network (PBRN).
In particular, the authors aimed to:
(1) better understand the population of pregnant women seeking chiropractic care during pregnancy; and
(2) understand whether these women report less problems with emotional disturbances (i.e., depression, anxiety), sleep disturbance, fatigue, pain, and physical functioning before after receiving chiropractic care.
This study was approved by the Institutional Review
Board of Life University (Marietta, GA). An e-mail invitation
was sent out to Doctors of Chiropractic (DC) previously
or currently enrolled in a postgraduate course offered
by the International Chiropractic Pediatric Association
(ICPA)  to participate in a PBRN study to characterize the
chiropractic care of pregnant patients utilizing the Webster
Technique.  The technique involves a specific chiropractic
analysis and the application of a chiropractic adjustment to
the sacrum along with soft-tissue work. A sustained thumb
contact is then applied to a specific point on the patient’s
belly to release tension in the corresponding uterine ligament.
The goal with this approach is to reduce the consequences
of sacral subluxation (i.e., P-L sacrum or +yY; P–R
sacrum or –yY) to improve the functional integrity of the
pelvic bowl with a developing fetus.
As in previous studies implementing this PBRN, [17–20]
inclusion criteria for DC participation include:
(1) the DC must be in good standing with their licensing authority;
(2) completed the National Institute of Health online course entitled, "Protecting Human Research Participants" ;
(3) agreed to a number of terms for participation as an ICPA PBRN participant—most notably that PBRN participation must not be used for practice building or marketing; and
(4) the Webster Technique  was implemented as part of the care in the presenting pregnant patient.
The participating DCs were encouraged to invite their patients as respondents for this study. Patient participation as responders in this study included the following criteria:
(1) the patient was at least 18 years of age;
(2) informed consent was agreed upon for study participation; and
(3) the responder was pregnant during the course of the study.
In addition to acquiring sociodemographic information
(i.e., age, gender, and level of education) and clinical correlates
of the history and physical examination (i.e., primary
presenting complaints and previous care strategies) from the
subjects, the authors utilized as primary outcome measures
the RAND VSQ9  and the Patient Reported Measurement
Information System (i.e., PROMIS-29 V1)  questionnaires
to measure the subjects’ visit-specific satisfaction and QoL,
respectively. The RAND VSQ9  is a 9–item questionnaire
adapted by the American Medical Group  from the Visit
Rating Questionnaire used in the RAND Medical Outcomes
Study.  The PROMIS–29 is a 29–item profile instrument
consisting of a fixed collection of short forms to measure
emotional distress (i.e., anxiety and depression), fatigue, pain
interference and intensity (i.e., 0 = no pain; 10 = worst imaginable
pain), physical functioning, sleep disturbance, and
satisfaction with participation in social roles. Patient responders
were either existing patients (i.e., currently receiving
care) or new patients (i.e., attended less than one to two
patient visits). Baseline (i.e., survey completed upon study
entrance) and comparative (i.e., survey completed following a
course of care) measures utilizing these two survey instruments
were implemented before and following a course of
chiropractic care. The survey instruments were pilot tested
with 10 respondents and implemented as a paper–and–pencil
questionnaire without difficulty.
The VSQ9 and PROMIS–29 data were entered into an
online data processing center created specifically for the
purpose of this study and exported to an Excel spreadsheet
(Microsoft Corporation, Portland, OR) for analysis. The sociodemographic
data were analyzed using descriptive statistics.
The VSQ9 questions were prefaced with "Thinking about
your visit with the physician/healthcare professional you saw,
how would you rate." with responses utilizing a five–level
scale that were linearly transformed (i.e., poor = 0%; fair =
25%; good = 50%; very good = 75%; and excellent = 100%).
These were also analyzed with descriptive statistics. These
were provided as frequencies and percentages, means, and
standard deviations (SDs). Mean difference between baseline
and comparative measures of the VSQ9 was also analyzed
using the paired t test. The PROMIS–29 data were analyzed
using the PROMIS Assessment CenterSM,  a free online data
collection tool to securely capture participant data and provide
real–time scoring. For each PROMIS short form (i.e., anxiety,
physical functioning, and pain interference), a scoring table
was developed to associate the raw scores to a T score metric,
which was referenced to (and centered upon) the U.S. General
population  with a mean of 50 and SD of 10. The greater the
T score, the greater the measured QoL domain.
Due to distributional differences across outcomes, two
different statistical models were applied to address the
question: Did self–reported QoL measures among pregnant
women improve in women under chiropractic care from
baseline to comparative? The authors tested seven different
domains of QoL: anxiety, depression, physical functioning,
sleep disturbance, satisfaction with participation in social
roles, pain interference, and fatigue. All data were nested
within individuals and chiropractic offices since QoL reports
at baseline and comparative were more similar within a
person than across people and more similar among patients
of the same office than different offices (i.e., more between
than within variation in the outcome). Thus, the authors took
this between–office variation into account using a random
effects framework. Results can be interpreted as the change
in QoL symptoms from baseline to follow–up independent
of the chiropractor.
Using the notation of Raudenbush and Bryk,  the following
equations were estimated.
where the parameter of interest is p1, representing the
change in the outcome from baseline to comparison. Visit
lapse (i.e., defined as the number of visits between baseline
and comparative QoL ratings), visit number (i.e., defined as
the number of chiropractic visits the patient received before
baseline), trimester of pregnancy, and provider type (i.e.,
with midwife as the reference group, compared to nursemidwife,
OB/GYN, and other provider) were added in as
covariates. All covariates were grand mean centered.
Three QoL domains (i.e., anxiety, depression, and physical
functioning) were highly skewed leading to significant violations
of distributional assumptions of linear models. These
outcomes were therefore dichotomized and tested in a generalized
linear model framework (logit link function). This
was the most logical approach given the particular distribution
(i.e., preponderance of zeros) and the meaningfulness of the
scale values (e.g., the difference between having one or two
symptoms was not clinically meaningful, but having no versus
any symptoms was very meaningful). A Wald test was used
to test whether the proportion of respondents endorsing any
symptoms of anxiety, depression, and physical functioning
significantly changed from baseline to comparative measurement,
after conditioning on a set of covariates (i.e.,visit lapse,
visit number, trimester of pregnancy and provider type).
In conceptualizing the rate of type I errors due to multiple
comparisons, the False Discovery Rate was held at p = 0.05.
All analyses were conducted in Mplus version 7.29 Differences
across chiropractic offices were taken into account
through the inclusion of a random intercept term in all models.
Who are the women seeking chiropractic care?
A convenience sample of 343 pregnant patients participated
in the study. Their average age was 30.96 years
(SD = 4.64). This cohort of subjects was highly educated
with the vast majority attaining a college education or above
(i.e., 2–year associate’s degree [N = 31; 9%]; baccalaureate
[N = 152; 44%]; masters [N = 68; 20%]; PhD [N = 9; 3%]),
while the remainder received some college education
(N = 63; 18%) or graduated from high school (N = 18; 5%)
with 2 (<1%) nonresponders.
The pregnant patients presented for chiropractic care, on
average, in their 25th week of gestation (SD = 9.84) with an
average parity (i.e., number of live births) of 0.92 (SD = 1.0).
Forty–five (13.1%) were in their 1st trimester, 113 (32.9%)
were in their 2nd trimester, and 185 (53.9%) were in their 3rd
trimester of pregnancy.
The vast majority indicated as their primary provider an
OB/GYN (N = 197; 57%) followed by a midwife (nursemidwife
[N = 32; 9%]; midwife [N = 94; 27%]; a medical
doctor [N = 11; 3%]; and "other" [N = 9; 3%]. Of the 9
[3%] indicating "other" as their primary provider, 4 [1%]
indicated having an OB/GYN as their secondary provider
while 1 [<1%]) indicated a midwife in this role.
Three quarters of the patients (N = 258; 75%) indicated that
their primary provider was aware of their consultation and
care with a chiropractor. This includes women (N = 48; 14%)
who reported that their provider was aware and referred them
to chiropractic. The referral came from midwives (N = 28;
8%) followed by nurse–midwife (N = 11; 3%), obstetrician/
gynecologists (N = 7; 2%), and medical physicians (N= 2;
<1%). There was a significant relationship between the provider
type and knowledge of chiropractic, such that midwives
and nurse–midwives were more likely to know and have referred
than OB/GYNs (w2 = 53.975, df = 6, p < 0.0001).
In terms of motivation for care, 88% (N = 302) reported
receiving chiropractic for MSK symptoms, 59% (N = 202)
reported chiropractic for wellness, and 41% reported both
MSK and wellness as reasons for care. The reported motivation
for care was not necessarily mutually exclusive. Note
that for those presenting with an MSK complaint, 41%
(N = 124) presented for wellness care while 36% (N = 108)
did not. For those presenting without an MSK complaint,
18% (N = 62) presented for wellness while 6% (N = 20) did
not. Specific to the MSK complaints, the following were indicated:
low back pain (N = 96; 28%), leg pain (N = 18; 5%),
mid–back pain (N = 16; 4%), neck pain (N = 4; 1%), and
shoulder pain (N = 4; 1%). One hundred and ninety–six (57%)
indicated "Other" as a response. An analysis of the 196 (57%)
motivated as "Other" found them to consist of multiple
symptom areas with low back pain as the most common accompanying
complaints (i.e., low back pain and neck pain or
low back pain and shoulder pain; N = 168; 49%), while 20
(6%) indicated multiple areas of complaint but not involving
the low back. One–fifth (20.4%; N = 58) of the women
also reported receiving care outside of chiropractic. The most
popular alternative care was self–care exercises (26.8%; N =
92). Seven percent (N = 24) also reported over–the–counter
medications, 8% (N = 27) reported seeing another DC, and 6%
(N = 20) received nutrition guidance. Three percent (N = 10)
used herbal products, acupuncture, and MD care.
The results for the baseline and comparative VSQ9 survey
are presented in Table 1. The median number of patient visits
(i.e., visits attended) at baseline was 1.00 (SD = 22.69) and at
comparative measurement was 3.00 (SD = 22.71). Overall,
visit–specific satisfaction was high among the responders at
baseline and comparative measurement. At baseline, the
mean percent score ranged from 84.94 (SD = 22.69; i.e.,
convenience of the office location) to 97.48 (SD = 7.54; i.e.,
courtesy, respect, and friendliness of DC). When examining
the comparative VSQ9 scoring, the authors observe similar
trends as baseline but more importantly, the satisfaction ratings
have increased. A paired t test of the mean VSQ9 scores
at baseline and comparative revealed this increase to be statistically
significance (t = 3.8409; df = 8; p < 0.005).
Did the women report improved QoL from baseline to comparative time points?
The mean T scores for baseline and comparative measures
with respect to the QoL domains are shown in Table 2. The
mean baseline and comparative pain numerical rating scale
(NRS) were 4.09 and 3.23, respectively. This reduction in
pain NRS scores was found to be statistically significant based
on a paired t test analysis (t = 9.05; df = 342; p < 0.0001). With
respect to the question of whether self–reported QoL among
the pregnant women improved from baseline to comparative,
results showed that there was a significant increase in QoL
based on most of the QoL domains, after holding constant for
visit number and time lapse, trimester of pregnancy, and care
provider type (Tables 3–6). There was a reduction in mean T
scores associated with fatigue (b=–2.19, standard error of the
mean [SEM] = 0.44), pain interference (b =–2.64, SEM =
0.46), and sleep disturbance (b =–1.36, SEM = 0.43) and
an increase in mean T scores for satisfaction with participation
in social roles (b = 1.58, SEM = 0.43). Beta coefficients
represent the change in the outcome across one unit
of time (baseline to comparison), after holding all possible
confounders constant. As expected, across outcomes, advanced
trimester worsened QoL, consistent with patient reports
of physical complaints as pregnancy progresses. For
dichotomous models, they found a significant decrease in mean
T scores for pain interference frombaseline to comparative, after
controlling for covariates (Wald = 12.280, df = 1, p = 0.0005).
The authors did not find evidence that there was a change in
mean T scores for anxiety (Wald = 2.174, df = 1, p = 0.1404)
or depression (Wald = 0.023, df = 1, p = 0.8785) from baseline
to comparative measurement.
Chiropractic has been suggested as an alternative solution
for problems related to low QoL,  but has not yet been
studied in the empirical literature. This is the first study to
systematically evaluate the changes in a number of domains
of QoL among pregnant women. Understanding the characteristics
and reasons that women seek chiropractic care during
pregnancy and the changes they report in their QoL with care
is an integral step in understanding this alternative and low
risk strategy for healthcare. The purpose of this study was to
understand the characteristics and reasons why women seek
chiropractic care and to test whether the changes in QoL
observed after starting chiropractic care were greater than the
changes they would expect based on chance alone. The results
show that women who seek chiropractic care during
pregnancy are well educated and under care with other
birthing professionals, most often OB/GYNs. Women sought
chiropractic care most often for MSK issues and wellness
care and communicated their treatment with other care providers,
especially with midwives (vs. traditional OB/GYN
care). One possible reason for this is the expectation that
midwives will be more supportive of chiropractic care than an
MD and suggests that more work is needed to bridge alternative
and traditional healthcare options. As this was a normative
population, most women presented with fairly good
QoL across domains, but variability existed. Over the course
of chiropractic care, women reported improvements in QoL
domains that would otherwise be considered stable in the
short term, lending support to the theory that chiropractic care
contributed to these improvements.
This study adds to the growing evidence that suggests that
chiropractic care may play a role in QoL and overall wellness,
beyond MSK conditions. There is strong theoretical
reason to believe that spinal adjustments and correction of
vertebral subluxation improve nerve system function and
therefore a function of the person as a whole. Studies have
demonstrated that chronic pain contributes to disability,
anxiety, depression, sleep disturbances, poor QoL, and
healthcare costs.  By relieving physical distress and restoring
the body’s natural way of functioning, chiropractic
may play a key role in the improvement of QoL. Future
researchers should continue to examine the role of chiropractic
care on QoL outcomes to understand the precise
mechanisms on which the outcomes are achieved. This is
particularly important for the care of pregnant women who
are more likely to experience MSK problems as part of
pregnancy and seek safe treatment solutions. This study
contributes to a growing body of literature that suggests that
chiropractic care may be an alternative strategy to traditional
pharmaceuticals to manage this discomfort and improve
QoL. Improvements in QoL for pregnant women, in
particular, are a critical area for future research, given risks
associated with postpartum distress and tendency to rely on
opioid solutions for pain relief.
Pregnancy and chiropractic care
Since chiropractic’s inception, the care of pregnant women
has been an integral part of the practice of chiropractic.  A
popular approach to pregnancy care has been the use of the
Webster Technique.  The technique involves a specific
chiropractic analysis and the application of a chiropractic
adjustment along with soft–tissue work. The goal with this
approach is to reduce the consequences of sacral subluxation
and improve the functional integrity of the pelvic bowl with
a growing fetus. Despite extensive clinical experience and
empirical data in the care of pregnant women, a systematic
review of the literature by Stuber and Smith  on chiropractic’s
effectiveness for pregnancy care consists only of
low–to–moderate quality evidence. Since the published review
by Stuber and Smith  in 2008, further support of
chiropractic’s effectiveness in the care of pregnant women
has been published. Noteworthy was the study by Peterson
et al.  These investigators reported outcomes in pregnant
patients with low back or pelvic pain under chiropractic care
using the patient’s global impression of change (PGIC), the
NRS, and the Oswestry collected at 1 week, 1 and 3 months
after initiating care. The investigators found that 52% of 115
recruited patients "improved" at 1 week, 70% at 1 month,
85% at 3 months, 90% at 6 months, and 88% at 1 year based
on significant reductions in NRS and Oswestry scores.
George et al.  performed a prospective randomized trial of
169 women receiving either a multimodal approach of
chiropractic (i.e., manual therapy, stabilization exercises,
and patient education) and obstetric management or standard
obstetric care alone to reduce pain, impairment, and
disability in the antepartum period. Baseline evaluation at
24–28 weeks gestation and comparative at 33 weeks gestation
utilizing the pain NRS and the Quebec Disability
Questionnaire (QDQ) were performed. Those receiving a
combination of chiropractic and standard obstetrics care
demonstrated significant mean reductions in NRS scores and
QDQ scores from baseline to comparative evaluation. The
group receiving standard obstetric care demonstrated no
Patient reported outcomes or PROs play an important role
in healthcare and healthcare research in that they measure or
reflect the impact of a disease or condition on the individual
patient. However, Eton et al.  lamented that there are two
pressing issues on the use of PROs in CAM therapy and
research. One, there is a lack of guidance for selecting PRO
measures and two, there is limited attention paid to the
clinical meaningfulness of the PRO results. Eton et al. 
recommended the use of PROMIS to support selection and
standardization of PROs for CAM research. Mogos et al. 
reviewed the use of QoL measures during pregnancy and the
postpartum period and found that valid, reliable, and responsive
PRO instruments are lacking. Their analysis of the
existing measurement scales revealed important validity,
reliability, and psychometric inadequacies making their use
in comparative effectiveness research challenging. Specific
to pregnancy care under chiropractic, Alcantara et al. 
published their findings on the systematic review of the
literature on the use of validated outcome measures for the
care of pregnant patients. The authors found in eight articles
the use of the PGIC, the pain NRS, the Oswestry, Bournemouth,
Fear Avoidance Belief and QDQ questionnaires,
PROMIS–29, and the Measure Yourself Medical Outcome
Profile. The use of PROMIS–29 involved a limited sample
size involving a case series of six patients.  Although the
review found some measure of effectiveness in the chiropractic
care of pregnant patients, Alcantara et al.  concluded
that given the heterogeneity and inconsistency of use
of these outcome measures, cause and effect inferences for
true measures of effectiveness in chiropractic pregnancy
care were severely limited. Others have made similar conclusions
on the use of validated outcome measures on chiropractic
patients in general. [40, 41]
Funded by the National Institute of Health, PROMIS
provides researchers and clinicians with psychometrically
sound and clinically meaningful measurement system of a
patient’s reported outcome. In addition to their reliability and
validity, the PROMIS instruments have comparability (i.e.,
the measures have been standardized so that there are common
domains and metrics across conditions that facilitate
comparisons across domains and diseases), flexibility (i.e.,
PROMIS can be administered in a variety of ways, in different
forms), and inclusiveness (i.e., PROMIS encompasses
all people, regardless of literacy, language, physical function,
or life course).  Their use of the PROMIS–29 instrument
demonstrated statistically significant changes in mean T
scores from baseline to comparative measures suggesting
that overall, the QoL of pregnant patients under chiropractic
care improved. There was a reduction in mean T scores
associated with fatigue, pain interference, and sleep disturbance
and an increase in mean T scores in satisfaction with
participation in social roles following a course of chiropractic
care. However, the authors did not have evidence that anxiety
and depression changed. With respect to the mean pain NRS
scores from baseline to comparative despite findings of a
statistically significant decrease, this decrease was not clinically
significant as per Farrar et al.  According to Farrar
et al.,  a 2–point improvement is clinically meaningful on an
11–point pain scale as that utilized in their study. Despite
findings by others on clinically meaningful changes in pain
NRS scores among pregnant patients under chiropractic
care,  the authors did not find similarly. These disparate
findings with the pain NRS deserve further investigation
particularly when they observed statistically significant decrease
in pain interference with a trial of chiropractic care. To
the best of their knowledge, this is the first reporting in the
scientific literature on the characterization of a large cohort of
pregnant patients undergoing chiropractic care using the
PROMIS questionnaire and VSQ9 as outcomes measures.
Given the PROMIS instruments’ comparability, this study
provides comparative measures for studies utilizing the
PROMIS-29 as an outcome measure for QoL of pregnant
women receiving similar care or other care approaches.
Rothrock et al.  examined the impact of individual and
comorbid conditions and those limiting activity in a sample
population with demographic characteristics matching the
2000 U.S. census figures. When compared to individuals
without one chronic condition (Table 2), baseline and
comparative mean T scores from their respondents indicate
a more compromised QoL. The authors observed lower
mean T scores in physical functioning, satisfaction in social
roles, and higher mean T scores in fatigue and sleep disturbance.
Interestingly, their chiropractic patient responders
presented with lower mean T scores in depression and
similar mean T scores in anxiety with no comparative values
for sleep disturbance. Intuitively, this comparison may indicate
that pregnant patients have a lower QoL compared to
the U.S. population of individuals with one and without a
chronic condition. This compromised QoL may also be a
motivating factor for clinical presentation to chiropractors.
Patient satisfaction is an important measure of the quality
of care as evidenced by pay-for-performance metrics such as
the Centers for Medicare & Medicaid Services reimbursements
based on patient satisfaction. A person’s satisfaction
with their healthcare is dependent on the extent to which
their general healthcare needs and condition-specific needs
are met.  Satisfied patients lead to greater compliance, a
more active and continued participation in their care, as well
as maintaining a specific system of care (i.e., chiropractic). [46–48] Patient satisfaction surveys also benefit healthcare
providers as it provides a means of assessment to improve
services and optimization of health resources.  There is no
denying on the importance of conventional clinical assessments,
but in situations such as those in chronically ill individuals,
further clinical assessment provides no further
useful information. For pregnant women, shifts to the patient’s
viewpoint as an inevitable outcome measure are a
logical measure.  Their findings with the RAND VSQ9 to
examine chiropractic patients’ access and satisfaction with
their care are consistent with previous findings. However, to
the best of their knowledge, this is the first such reporting on
patients attending care within a PBRN and the second reporting
on the use of the VSQ9 among chiropractic patients.
Gemmel and Hayes  utilized the VSQ9 in 66 patients.
Their VSQ9 scores ranged from 57.7% (i.e., convenience of
the office location) to 95.5% (stated that they would definitely
recommend chiropractic to others). Their cohort rated
their visit overall at 83.3%.
There is no denying that the interrelationship among health
needs, patient satisfaction with their care, and their QoL is
complex. It is beyond the scope of this article to address this
complexity and recommend the article by Asadi-Lari et al. 
on this subject. Their study has demonstrated contemporaneous
findings of high ratings of visit-specific satisfaction along
with reported improvements in QoL measures. These findings
are consistent with the association of satisfied healthcare
needs of patients and improved QoL, as well as their satisfaction
with health services and clinical effectiveness. [45, 51]
From a chiropractic perspective, this approach to patient assessment
(i.e., QoL) is coherent with a patient-centered, holistic
salutogenic model of chiropractic health. [52, 53]
There are a number of limitations with their study. First,
self-reported information is associated with recall bias and
possible intentional misreporting of behaviors. However,
the authors mitigated against this bias by collecting data
prospectively thereby asking patients to report on current
behaviors, which are less susceptible to recall bias than
retrospective reporting. Yet, there may be unidentifiable
response bias. Second, their study subjects were chiropractic
patients first and study responders second resulting in a selfselection
bias. As chiropractic patients, subjective validation
and expectations for clinical resolution on the part of the
chiropractic clinical encounter further contribute to recall
bias. The authors documented the characteristics and motivations
for care in this study as a way to document and accrue
evidence to help illuminate self-selection in the future. Third,
insofar as they are aware, this is the first reporting on the use
of the PROMIS instruments in the pregnant patient population.
The PROMIS measures are domain based (i.e., generic
measures) and not specific to the pregnant population. As
such, the authors echo the sentiments of Mogos et al.  in that
no study explored whether the PROMIS measures contained
all the relevant constructs and items or whether these items
have similar meaning to pregnant patients. Finally, this study
was not designed to be a pure test of the causal effect of
chiropractic care. As such they caution the reader in making
cause and effect inferences. The authors see this as an integral
part of a larger program of research on alternative treatments
for pregnant women, for which longitudinal change is a
critical component. Based on these findings, there is evidence
to support the need for a randomized trial on chiropractic care
with pregnant women. Randomized clinical trials reduce
spurious causality and bias and begin to address the covariates
leading to improved QoL.
Notwithstanding these limitations, there are a few methodological
strengths of this study worth noting. Their sample,
although a convenience sample, came from chiropractic offices
across the United States and Canada. The women in the
sample were a good sampling of women who self-select into
chiropractic care in naturalistic settings. In addition, the authors
used sophisticated statistical methodology to overcome
limitations of traditional statistics (e.g., increased standard
errors due to clustering of data and influence of confounding
variables), thereby giving a purer estimate of the change
in outcomes over time. Finally, the nature of their design
allowed easy access to baseline and comparative measurement
from many women. This demonstrates the effectiveness
and efficiency of using a practice-based network as a data
collection source for women involved in chiropractic care.
Future researchers are encouraged to tap into similar structures
to produce research.
The authors successfully implemented a PBRN study
within a chiropractic setting and successfully implement the
VSQ9 and PROMIS-29 questionnaires for pregnant patients.
They found them to be highly satisfied with their visit and
following a course of chiropractic care, their QoL measures
improved beyond statistical significance.
Author Disclosure Statement
This study was funded by the ICPA (Media, PA) and Life
West College of Chiropractic (Hayward, CA). The authors
received funding from the ICPA for the preparation of the
article, while J.A. received additional funding from Life West
College of Chiropractic in the preparation for this article.
Martin JA, Hamilton BE, Osterman MJ, et al.
Births: Final data for 2013.
Natl Vital Stat Rep 2015;64:1–65.
Pallivalapila AR, Stewart D, Shetty A, et al.
Use of complementary and alternative medicines during the third trimester.
Obstet Gynecol 2015;125:204–211.
Birdee GS, Kemper KJ, Rothman R, Gardiner P.
Use of complementary and alternative medicine during pregnancy and the postpartum period:
An analysis of the National Health Interview Survey.
J Womens Health (Larchmt) 2014;23:824–829.
Hall HG, Griffiths DL, McKenna LG.
The use of complementary and alternative medicine by pregnant women:
A literature review.
Bishop JL, Northstone K, Green JR, Thompson EA.
The use of complementary and alternative medicine in pregnancy:
Data from the Avon Longitudinal Study of parents and children (ALSPAC).
Complement Ther Med 2011;19:303–310.
Women’s use of complementary and alternative medicine in pregnancy:
A search for holistic wellbeing.
Women Birth 2014;27:276–280.
Steel A, Adams J, Sibbritt D, et al.
Utilisation of complementary and alternative medicine (CAM) practitioners within
maternity care provision: Results from a nationally representative cohort study
of 1,835 pregnant women.
BMC Pregnancy Childbirth 2012;12:146.
Metcalfe A, Grabowska K, Weller C, Tough SC.
Impact of prenatal care provider on the use of ancillary health services during pregnancy.
BMC Pregnancy Childbirth 2013;13:62.
Barnes PM, Bloom B, Nahin RL.
Complementary and alternative medicine use among adults and children:
United States, 2007.
Natl Health Stat Report 2008;12:1–23.
Bronfort G, Haas M, Evans RL, Bouter LM.
Efficacy of Spinal Manipulation and Mobilization
for Low Back Pain and Neck Pain:
A Systematic Review and Best Evidence Synthesis
Spine J (N American Spine Soc) 2004 (May); 4 (3): 335–356
Broom AF, Kirby ER, Sibbritt DW, et al.
Use of complementary and alternative medicine by mid-age women with back pain:
A national cross-sectional survey.
BMC Complement Altern Med 2012;12:98.
Oswald C, Higgins CC, Assimakopoulos D.
Optimizing pain relief during pregnancy using manual therapy.
Can Fam Physician 2013;59:841–842.
Vowles KE, McEntee ML, Julnes PS, et al.
Rates of opioid misuse, abuse, and addiction in chronic pain:
A systematic review and data synthesis.
Alderdice F, McNeill J, Lynn F.
A systematic review of systematic reviews of interventions to improve maternal mental
health and well-being.
The International Chiropractic Pediatric Association.
Online document at:
Accessed October 15, 2017.
Ohm J, Alcantara J.
The Webster Technique: Definition, application and implications.
J Pediatr Matern Fam Health Chiropr 2012;2012:49–53.
International Chiropractic Pediatric Association PBRN.
Online document at:
Accessed January 1, 2010.
Alcantara J, Ohm J, Kunz D.
The Webster Technique: Results from a practice-based research network study.
J Pediatr Matern Fam Health Chiropr Win 2012;2012:16–21.
Alcantara J, Ohm J, Kunz K, et al.
The characterisation and response to care of pregnant patients receiving
chiropractic care within a practice-based research network.
Chiropr J Aust 2012;42:60–67.
Alcantara J, Ohm J, Kunz D.
The Chiropractic Care of Children
J Altern Complement Med. 2010 (Jun); 16 (6): 621–626
Protecting human research participants. Online document at:
Accessed January 1, 2010.
Visit-Specific Satisfaction Instrument (VSQ-9).
Online document at:
Accessed January 1, 2010.
Patient-Reported Outcomes Measurement Information
Online document at:
Accessed February 1, 2010.
American Medical Group.
Online document at
Accessed February 28, 2015.
The 36-Item Short Form Survey from the RAND Medical Outcomes Study.
Online document at:
Accessed January 24, 2010.
Online document at:
Accessed January 24, 2010.
Liu H, Cella D, Gershon R, et al.
Representativeness of the Patient-Reported Outcomes Measurement
Information System Internet panel.
J Clin Epidemiol 2010;63:1169–1178.
Raudenbush SW, Bryk AS.
Hierarchical Linear Models: Applications and Data Analysis Methods, 2nd ed.
Thousand Oaks, CA: Sage Publications, 2002.
Muthe´n LK, Muthe´n BO.
Mplus User’s Guide, 7th ed.
Los Angeles, CA: Muthen & Muthen, 1998–2012.
Alcantara J, Ohm J, Alcantara J.
The use of PROMIS and the RAND VSQ9 in chiropractic patients receiving care
with the Webster Technique.
Complement Ther Clin Pract 2016;23:110–116.
Geneen LJ, Moore RA, Clarke C, et al.
Physical activity and exercise for chronic pain in adults:
An overview of Cochrane Reviews.
Cochrane Database Syst Rev 2017;4:CD011279.
Gibbons R, Palmer D.
Forgotten parameters of general practice: The chiropractic obstetrician.
Chiropr Hist 1982;2:27–33.
Stuber KJ, Smith DL.
Chiropractic treatment of pregnancy-related low back pain:
A systematic review of the evidence.
J Manipulative Physiol Ther 2008;31:447–454.
Peterson CK, Muhlemann D, Humphreys BK.
Outcomes of pregnant patients with low back pain undergoing chiropractic treatment:
A prospective cohort study with short term, medium term and 1 year follow-up.
Chiropr Man Therap 2014; 22:15.
George JW, Skaggs CD, Thompson PA, et al.
A Randomized Controlled Trial Comparing a Multimodal
Intervention and Standard
Obstetrics Care for Low Back and Pelvic Pain in Pregnancy
Am J Obstet Gynecol. 2013 (Apr); 208 (4): 295.e1-7
Eton DT, Bauer BA, Sood A, et al.
Patient-reported outcomes in studies of complementary and alternative medicine:
Problems, solutions, and future directions.
Explore (NY) 2011;7:314–319.
Mogos MF, August EM, Salinas-Miranda AA, et al.
A systematic review of quality of life measures in pregnant and postpartum mothers.
Appl Res Qual Life 2013;8:219–250.
Alcantara J, Alcantara JD, Alcantara J.
The use of validated outcome measures in the chiropractic care of pregnant patients:
A systematic review of the literature.
Complement Ther Clin Pract 2015;21:131–136.
Alcantara J, Ohm J.
Improvement in quality of life for six pregnant patients undergoing
chiropractic care: The promise of PROMIS.
J Ped Matern Fam Health Chiropr 2013;1: 11–14.
Khorsan R, Coulter ID, Hawk C, Choate CG.
Measures in chiropractic research: Choosing patient-based outcome assessments.
J Manipulative Physiol Ther 2008;31: 355–375.
Goertz CM, Pohlman KA, Vining RD, et al.
Patientcentered outcomes of high-velocity, low-amplitude spinal manipulation
for low back pain: A systematic review.
J Electromyogr Kinesiol 2012;22:670–691.
Patient Reported Outcomes Measurement System. Online document at:
Accessed December 7, 2016.
Farrar JT, Young JP Jr, LaMoreaux L, et al.
Clinical importance of changes in chronic pain intensity measured on an
11-point numerical pain rating scale.
Pain 2001;94: 149–158.
Rothrock NE, Hays RD, Spritzer K, et al.
Relative to the general US population, chronic diseases are associated with poorer
health-related quality of life as measured by the Patient-Reported Outcomes
Measurement Information System (PROMIS).
J Clin Epidemiol 2010;63:1195–1204.
Asadi-Lari M, Tamburini M, Gray D.
Patients’ needs, satisfaction, and health related quality of life:
Towards a comprehensive model.
Health Qual Life Outcomes 2004;2:32.
Can patient satisfaction improve health among patients with angina pectoris?
Int J Qual Health Care 1999; 11:233–240.
Marquis MS, Davies AR, Ware JE Jr.
Patient satisfaction and change in medical care provider: A longitudinal study.
Med Care 1983;21:821–829.
Aharony L, Strasser S.
Patient satisfaction: What we know about and what we still need to explore.
Med Care Rev 1993;50:49–79.
Leplege A, Hunt S.
The problem of quality of life in medicine.
Gemmel HA, Hayes BM.
Patient Satisfaction With Chiropractic Physicians
In An Independent Physicians' Association
J Manipulative Physiol Ther 2001 (Nov); 24 (9): 556–559
Doyle C, Lennox L, Bell D.
A systematic review of evidence on the links between patient experience and
clinical safety and effectiveness.
BMJ Open 2013;3:e001570.
A patient-centered paradigm: A model for chiropractic education and research.
J Altern Complement Med 1995;1:371–386.
Becker CM, Glascoff MA, Felts WM, Kent C.
Adapting and using quality management methods to improve health promotion.
Explore (NY) 2015;11:222–228.
Return to the PEDIATRICS Section
Return to the PATIENT SATISFACTION Section