It is unfortunately that individual dramatic cases are often required to garner public and regulatory attention toward a clear problem. The Australian press is reporting:
Melbourne paediatrician Chris Pappas cared for a four-month-old baby last year after one of her vertebrae was fractured during a chiropractic treatment for torticollis – an abnormal neck position that is usually harmless. He said the infant was lucky to make a full recovery.
Medicine is a game of risk vs benefit – everything we do, or don’t do, should be evaluated on the potential benefit vs the potential risk, using the best available evidence and scientific rationale. This case is important, not because it is a case of harm, which can happen with any intervention, but because it highlights the risk vs benefit question. Are there any indications for chiropractic care of children, for neck manipulation at any age, and what are the risks?
For an overview of chiropractic see my prior summaries here and here. Overall the evidence suggests some benefit for manipulative therapy for acute uncomplicated lower back strain, but probably no better than physical therapy or even minimal intervention. The risks of chiropractic are not sufficiently studied, and other indications have not been established by adequate evidence.
Chiropractic for children
The chiropractic profession generally has been aggressive in expanding its scope of practice, including treating children and infants, despite a lack of evidence or even plausible scientific rationale. The chiropractic treatment of childhood disorders was the focus of the British Chiropractic Association’s libel suit against Simon Singh. During that suit the BCA put out a statement attempting to justify the chiropractic treatment of childhood illness, but the result merely showcased the lack of evidence, and their own poor standards of science.
The BCA was claiming evidence for the chiropractic treatment of asthma, colic, otitis media, and nocturnal enuresis (bedwetting). In each case the evidence actually showed a lack of effectiveness for these indications.
The current case involved the treatment of infantile torticollis, which is a dystonic disorder, an involuntary contraction of a muscle, in the case of torticollis involving the neck. This is generally a benign disorder. A review of 624 cases found that 97% resolved with conservative management, including stretching and active stimulation, most in less than 6 months. The other 3% had an underlying anatomical defect and required surgery.
Another prospective study of 821 patients treated with manual stretching found:
subsequent surgical treatment was required by 8% (thirty-four) of the 452 patients in the sternomastoid tumor group compared with 3% (eight) of the 276 patients in the muscular torticollis group and 0% (none) of the ninety-three patients in the postural torticollis group.
There does not seem to be a role or need for chiropractic neck manipulation for this condition.
I could only find two references in PubMed presenting evidence for chiropractic manipulation of torticollis, both single case reports, one in a 6-year old, and one in a 7-month old infant. That’s it – two cases. In the case of the 7-month old, the intervention included:
chiropractic manipulation, trigger point therapy, specific stretches, pillow positioning and exercises.
We already know that stretching works, so there is no reason to conclude that the chiropractic manipulation added anything to the patient’s recovery in this case.
I also found one case report from 1992 of quadraplegia in an infant following spinal manipulation for torticollis. The child had a spinal tumor, and the manipulation caused it to bleed, resulting in the damage. There is also another report of a spinal astrocytoma presenting as torticollis. The authors conclude that such tumors should be ruled out in infantile torticollis.
Risk vs benefit
As with chiropractic care in general, there is insufficient evidence to make firm statements about the risk vs benefit of chiropractic intervention in children for any indication, including torticollis. This is due, in my opinion, to a cultural and historical lack of science-based practice within the profession of chiropractic. This represents a failure of the entire profession that is in dire need of correction.
In the case of infantile torticollis, this is a benign condition in most patients, who quickly recover with conservative and safe management. The single case report discussed above is worthless as scientific evidence because it is anecdotal, and usual care was combined with manipulation, and the patient was overwhelmingly likely to recover from the usual care alone.
Given a benign condition with an established safe and effective treatment, the standard of care dictates that any new intervention should at least demonstrate equivalency to the established therapy. If the new therapy is more expensive or has higher risk than the established therapy, it should demonstrate sufficient superiority to justify the added risk or expense.
Chiropractors have not established equivalency let alone superiority for manipulation in infantile torticollis, and therefore there is no justification for treatment.
In a risk vs benefit analysis, therefore, any incremental risk is not justified. Chiropractors, however, are not in the habit of reporting or systematically studying the risks of their interventions, so we often have to rely upon case reports from non-chiropractors who receive the results of their interventions. With regard to infantile torticollis we have the 1992 report of quadriplegia, and now we have an additional report of a fractured cervical spine.
The response of the chiropractic profession to these cases is unsatisfactory, to say the least. Dr. Pappas, the pediatrician who treated the infant with the broken neck, reported the case to the health authorities in Australia. They turned the case over to the chiropractic board.
That is the first problem – chiropractors are in the position of self-regulating. But if the profession itself has a problem with science and evidence, self-regulation will not provide the solution. Predictably, the chiropractic board closed the case with the judgement that the chiropractor can continue practicing if he obtains further education in pediatric chiropractic care.
That is a paltry slap on the wrist. The decision also implies endorsement of pediatric chiropractic, which has never been established as a legitimate practice. Training is irrelevant when you don’t have a science-based practice in the first place.
The response of the Chiropractic Association of Australia was outrage – not that one of their members committed malpractice, but at the suggestion that it was chiropractic manipulation that caused the child’s neck fracture.
The CAA is outraged that rather than clearing the chiropractor’s name, as appropriate, the newspapers have smeared the chiropractor and the profession with such an allegation
It seems clear from their response that they are more concerned with the reputation of chiropractors than the safety of their patients. Perhaps they will try the same gambit as the BCA and put out a statement reviewing the scientific evidence for the chiropractic treatment of infantile torticollis, hoping that no one actually reads the evidence and is simply impressed by the list of references.
The chiropractic profession continues to have a serious problem of being insufficiently based upon science and evidence (to put it mildly). There are a great deal of practices that occur under the banner of “chiropractic” from blatant pseudoscience, such as energy medicine, to somewhat plausible musculoskeletal management. In the latter case chiropractors are little more than physical therapists.
Chiropractors continue to use and promote chiropractic treatment for a long list of indications that are not supported by basic scientific plausibility or clinical evidence. They cannot justify their interventions on an evidence-based risk vs benefit assessment.
Rather, they seem to employ a strategy of not reporting or studying the risks of their interventions, then citing the lack of evidence for risk as evidence that their treatments are safe. Lack of evidence is not sufficient in the practice of medicine, however.
What evidence we do have suggests that there is not a single legitimate indication for chiropractic manipulation of children or infants, which is sufficient to condemn the practice. There is also evidence of potential harm, and even if rare, any harm resulting from a worthless intervention results in an unfavorable risk vs benefit.
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