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Pediatric Chiropractic Care: Scientifically Indefensible?

In a paper published in 2008, two academic chiropractors offered this observation: “The health claims made by chiropractors with respect to the application of manipulation as a health care intervention for pediatric health conditions continue to be supported by only low levels of scientific evidence. Chiropractors continue to treat a wide variety of pediatric health conditions.”1

Despite lack of support by the medical and scientific community, chiropractic treatment of children is growing in popularity, and more chiropractors are specializing in “chiropractic pediatrics.”

The International Chiropractic Association offers a post-graduate “Diplomate in Clinical Chiropractic Pediatrics” (DICCP) and publishes a “peer reviewed” Journal of Clinical Chiropractic Pediatrics. The diplomate syllabus is a 30-module, 360+ hours classroom course during weekends over a three-year period. There is no hospital training and no contact with diseased or injured children — only a “mandatory observational/training weekend at a chiropractic center for special needs children under multi-disciplinary care.”2 A post-graduate certification in chiropractic pediatrics (CICCP) can be earned after 180 hours of classroom instruction.

In a June 2008 joint press release, the American Chiropractic Association’s (ACA) Council on Chiropractic Pediatrics and the Council on Chiropractic Pediatrics of the International Chiropractors Association (ICA) announced that the ICA’s Diplomate in Clinical Chiropractic Pediatrics (DICCP) is now recognized by the ACA and its council as the official credential for specialization in chiropractic pediatrics.3

Noting increasing public support for chiropractic treatment of children, a January 2009 press release from the American Chiropractic Association made this announcement: “Survey data indicates that the percentage of chiropractic patients under 17 years of age has increased at least 8.5 percent since 1991.…Studies are beginning to show that chiropractic can help children not only with typical back and neck pain complaints, but also with issues as varied as asthma, chronic ear infections, nursing difficulties, colic and bedwetting.”4

A trend toward greater utilization of chiropractic by children has not gone unnoticed by the medical profession. An article in the January 2007 issue of Pediatrics (the official journal of the American Academy of Pediatrics) described chiropractic as the most common complementary and alternative medicine practice used by children, who made an estimated 30 million visits to US chiropractors in 1997.5 In 1998, children and adolescents constituted 11% of patient visits to chiropractors.6

Promoting a broad scope of practice for pediatric chiropractors, the ICA Council on Chiropractic Pediatrics offers links to abstracts from chiropractic journals that support chiropractic treatment for a great variety of a childhood ailments.7 Chiropractors commonly claim to have an effective treatment for otitis media, asthma, allergies, infantile colic, and enuresis. While many of the pediatric conditions treated by chiropractors are self limiting, treatment is offered for such serious conditions as cerebral palsy, epilepsy, myasthenia gravis, ADHD, and Tourette syndrome. For the most part, treatment for all these conditions is based upon detection and correction of “vertebral subluxations.” An article titled “The Child Patient: A Matrix for Chiropractic Care” in a 2005 edition of the Journal of Clinical Chiropractic Pediatrics, for example, stated: “Any alteration in form or function in the child may signal the presence of subluxation, and the subluxation may in turn alter the physiology of the child.”8 For wellness and prevention reasons, parents are advised that children should visit a chiropractor 6 to12 times a year to be checked for subluxations.8

A 2009 survey of chiropractors and parents of chiropractic pediatric patients, conducted by the International Chiropractic Pediatric Association, revealed that “The indicated primary reason for chiropractic care of children was ‘wellness care’.”9 Such care would require manipulating the spines of healthy children for “subluxation correction.”

There is no credible evidence to support the contention that “subluxation correction” will restore or maintain health or that such subluxations even exist.10,11,12 There are hundreds of subluxation-based studies published in chiropractic journals supporting chiropractic treatment for children but only a few studies disputing such treatment. I suspect that most medical researchers feel that claims based on the chiropractic vertebral subluxation theory are too implausible to warrant investigation. But such claims should not go unchallenged, especially when they involve treatment of children.

 

Evidence Fails to Support Chiropractic Treatment of Childhood Ailments

To date, legitimate properly-controlled studies have failed to support the claims of chiropractors who treat children for organic ailments. In the case of asthma, for example, a randomized, controlled trial of chiropractic spinal manipulation for children with mild or moderate asthma, published in a 1998 issue of The New England Journal of Medicine, revealed that “the addition of chiropractic spinal manipulation to usual medical care provided no benefit.”13 A randomized, controlled trial of infantile colic treated with chiropractic spinal manipulation, published in a 2001 issue of Archives of Diseases in Childhood, concluded that “Chiropractic spinal manipulation is no more effective than placebo in the treatment of infantile colic.”14 A recent systematic review of randomized clinical trials offered this conclusion: “There is no good evidence to show that spinal manipulation is effective for infant colic.”15

It has been suggested that use of osteopathic manipulative techniques as an adjuvant therapy in routine pediatric care of recurrent acute otitis media might have potential benefit by affecting the patency of the auditory tube.16 Chiropractors who manipulate a child’s neck in a misguided attempt to correct “subluxations” might provide some symptomatic relief for secretory otitis media by inadvertently stretching the Eustachian tube, facilitating drainage of fluids from the middle ear. But the risk of such treatment outweighs any possible benefit. (Although otitis media is normally self limiting, it should be kept under observation by a pediatrician who can prescribe antibiotics, if needed, when there is acute otitis media with bacterial infection. Otitis media commonly occurs in children under 3 years of age. As the child grows older, changes in the length and angle of the Eustachian tube reduce chances of bacteria or virus traveling from the throat to the middle ear.)

Considering the implausibility of the chiropractic vertebral subluxation theory and the training chiropractors receive, there is good reason to question the ability of chiropractors to diagnose and treat childhood ailments. A correct diagnosis notwithstanding, there is no evidence to support the belief that manipulating the spine of a child to correct “vertebral subluxations” would be appropriate treatment for anything. A 1993 risk/benefit analysis of spinal manipulative therapy for relief of lumbar or cervical pain, published in Online Neurosurgery, advised neurosurgeons that “Potential complications and unknown benefits indicate that SMT [spinal manipulative therapy] should not be used in the pediatric population.”17

Because of the damage that manipulation might do to cartilaginous growth centers, there is no known justification for using spinal manipulation on an infant or a pre-adolescent child. Yet, some chiropractors recommend that the spine of a newborn baby be adjusted at birth to correct “subluxations.” According to the ICA (International Chiropractic Association) Council on Chiropractic Pediatrics, “Chiropractic care can never start too early.”18

Generally, pediatricians think of a child as being under 18 years of age — before vertebral end plate growth is completed. In a child under the age of 8 to 10 years, the cartilaginous growth centers are too immature and too vulnerable to injury to be subjected to spinal manipulation. There is some speculation that injury to growth plates might result in spinal deformity (such as scoliosis or Scheuermann’s kyphosis) as growth progresses.19 Such injury may not be detectable. “The incidence of subtle growth plate fractures following high-velocity [manipulation] techniques in children is surely under-appreciated because of the occult nature of these injuries.”19

Under normal circumstances, it seems unlikely that the cartilaginous, flexible spine of a healthy child would be as easily injured as an adult spine that has been weakened by degenerative changes. Referred pain caused by organic disease is not commonly experienced by children. When back pain in a child does occur, it is potentially more serious than back pain in an adult and should always be brought to the attention of a board-certified pediatrician.

Spinal manipulation has the potential to injure the spine of a child. A systematic review of 13 studies published up to June 2004 uncovered 14 significant manipulation-related injuries in children up to18 years of age, 9 of which were serious (e.g., subarachnoidal hemorrhage, paraplegia) and 2 of which were fatal (one child died from a brain hemorrhage and another from dislocation of the atlas following neck manipulation). Ten of the injuries were attributed to manipulation done by chiropractors, 1 to manipulation by a physiotherapist, and 1 to manipulation by a medical doctor; 2 injuries were caused by unspecified providers of manipulation. In 20 cases of harm caused by delayed diagnosis as a result of using manipulation, 7 involved a delayed diagnosis of cancer; 2 children died because of delayed treatment for meningitis.5 The incidence of spinal injuries in children is reported to be 2 to 5% of all spine injuries.21

Dubious Methods Used to “Detect and Correct” Pediatric “Subluxations”

High velocity, low amplitude thrusting, commonly used by chiropractors, is usually the type of manipulation that injures a child’s spine. Most chiropractors who manipulate an infant’s spine may simply use light thumb pressure to “adjust” an allegedly misaligned vertebra, thus reducing possibility of injury. Gentle touch may have a calming affect on an infant. But any manipulative technique applied to the neck of an infant is unnecessary and potentially dangerous. Some chiropractors may use a spring-loaded stylus or an electrically-powered mallet in an attempt to tap vertebrae into alignment. Chiropractors who adjust newborn babies to correct “subluxations” may concentrate on the upper cervical (neck) area of the spine. The upper neck is more likely to be injured by delivery during birth and is most vulnerable to injury caused by manipulation. Pediatricians have observed that “The most common traumatically injured region of the immature spine is the first and second cervical vertebrae.”19

There is no credible evidence that chiropractors are able to find “subluxations” in the spine of an infant. It seems unlikely that a chiropractor could detect vertebral misalignment by palpating the flexible, cartilaginous spine of an infant through a thick layer of baby fat. I have always suspected that chiropractors who say they can use their fingertips to feel subluxations in a baby’s spine are either deceiving themselves or misinterpreting what they are feeling.

Some chiropractors use surface electromyography, thermography, leg-length checks, or some other questionable device or approach to locate subluxations. It goes without saying that chiropractors should not expose a child to unnecessary radiation by x-raying his or her spine in a search for elusive or nonexistent “subluxations.” In Canada, the Alberta Society of Radiology has recommended that radiologists refuse requests from chiropractors who ask for diagnostic imaging of any type involving children aged 18 years or younger.21

Of all the claims made by chiropractors, I regard the claims made by those who treat children to be the most problematic. I have always advised against manipulating the spine of a small child or a newborn baby for any reason. Manipulation of the spine of an adolescent child under the age of 18, no matter who does it, should be done in concert with an evaluation and a diagnosis provided by an orthopedist, preferably a pediatric orthopedic specialist. Caring for children is very different from caring for adults and requires a special expertise. Board-certified medical and osteopathic pediatricians are best qualified to provide or recommend appropriate care based on a correct diagnosis.

Drawing the Line on Chiropractic Treatment of Children

Although spinal manipulation is often recommended as a treatment for back pain, this recommendation does not often apply to children. When the U.S. Department of Health and Human Services published a Clinical Practice Guideline suggesting that spinal manipulation can be helpful for patients with acute low-back problems without radiculopathy (sciatic pain) when used within the first month of symptoms, the report included this statement: “The recommendations included in the guideline may not apply to persons younger than 18 years since diagnostic and treatment considerations for this group are often different than for adults.”22 An adolescent child might benefit from appropriate manipulation designed to relieve symptoms caused by uncomplicated, mechanical-type back problems. But use of chiropractic “spinal adjustments” for “subluxation correction” may delay appropriate treatment based on a correct diagnosis — and the younger the child the greater the chances of misdiagnosis or injury.

Some chiropractors believe that adjusting a child’s spine will stimulate the immune system and help prevent infection. On September 8, 2009, for example, the Journal of Pediatric, Maternal and Family Health — Chiropractic issued a press release titled “Chiropractic Part of Swine Flu Prevention Program in Children.” The editor of the journal recommended that all children should be checked for vertebral subluxations before and during the flu season. “Since the nervous system has a direct effect on the immune system and because the spine houses and protects so much of the nerve system it is important to have your child’s spine checked for any interference.”23

Such alarming and unscientific views find support in the basic definition of chiropractic and in official chiropractic publications. The National Board of Chiropractic Examiners (NBCE), for example, advises that “Psychoneuroimmunology has revealed an interrelationship between the central nervous system and immunity (consistent with chiropractic philosophy)….By manually manipulating vertebrae into their normal physiological relationship, chiropractic practitioners relieve interference with the nervous system along with accompanying symptoms.” Regarding treatment of children, the NBCE advises that “Chiropractic management of childhood disorders primarily consists of adjusting concomitant spinal subluxations and providing specific nutritional advice and/or support and other palliative measures.”24

All things considered, it is an understatement to say that “Pediatric chiropractic care is often inconsistent with recommended medical guidelines.”6 Recommendation of any complementary alternative medicine therapy that has a risk/benefit ratio that is not acceptable and is not supported in medical literature may make a referring physician liable for negligence if the referral causes harm by delaying necessary conventional treatment.25

I don’t know of any reason to believe that it might be necessary to refer a child to a pediatric chiropractor or to use spinal manipulation on a child prior to onset of adolescence. “Wellness care” in the form of “subluxation correction” is unnecessary and scientifically indefensible, and it places children at risk. 

References

  1. Gotlib A, Rupert R. Chiropractic manipulation in pediatric health conditions — an updated systematic review. Chiropractic & Osteopathy. 2008;16:11 http://www.chiroandosteo.com/16/1/11 Accessed April 17, 2010.
  2. ICA Council. Diplomate in Chiropractic Pediatrics. http://www.icapediatrics.com/members-postgrad.php Accessed April 10, 2010.
  3. ACA Council on Chiropractic Pediatrics. Pediatric diplomate certification recognized by both ICA and ACA. 2007. http://www.acapedscouncil.org/pressrelease.html Accessed April 10, 2010.
  4. ACA. Increasing numbers of children receive pediatric chiropractic care. January, 2009. http://www.acatoday.org/press_css.cfm?CID=3247 Accessed April 10, 2010.
  5. Vohra S, et al. Adverse events associated with pediatric spinal manipulation: A systematic review. Pediatrics.2007; 119(1):e275-e283.
  6. Lee A, Li D, Kemper K. Chiropractic care for children. Archives of Pediatrics and Adolescent Medicine. 2000; 154:401-407.
  7. ICA Pediatrics. Journal Abstracts. http://www.icapediatrics.com/reference-journals.php Accessed April 10, 2010.
  8. Fallon J. The child patient: A matrix for chiropractic care. Journal of Clinical Chiropractic Pediatrics (Supplement). 2005; 6(3).
  9. Alcantara J, Ohm J, Kunz D. The safety and effectiveness of pediatric chiropractic: A survey of chiropractors and parents in a practice-based research network. Explore: The Journal of Science and Healing.2009; 5(5):290-295.
  10. College of Physicians and Surgeons of the Province of Quebec. A scientific brief against chiropractic. New Physician.1996. http://www.chirobase.org/05RB/CPSQ/00.html Accessed April 10, 2010.
  11. Mirtz TA, Morgan L, Wyatt LH, Greene L. An epidemiological examination of the subluxation construct using Hill’s criteria of causation. Chiropractic & Osteopathy. 2009; 17:13. http://www.chiroandosteo.com/content/17/1/13 Accessed April 10, 2010.
  12. Nelson C. The subluxation question. Journal of Chiropractic Humanities. 1997; 7(1):46-55.
  13. Balon J, et al. A comparison of active and simulated chiropractic manipulation as adjunctive treatment for childhood asthma. The New England Journal of Medicine.1998; 339(15):1013-1020.
  14. Olafdottir E, et al. Randomised controlled trial of infantile colic treated with chiropractic spinal manipulation. Archives of Disease in Childhood. 2001; 84(2):138-141.
  15. Ernst E. Chiropractic spinal manipulation for infant colic: A systematic review of randomized clinical trials. International Journal of Clinical Practice. September, 2009; 63(9):1351-1353.
  16. Mills V, et al. The use of osteopathic manipulative treatment as adjuvant therapy in children with recurrent acute otitis media. Archives of Pediatrics and Adolescent Medicine.2003; 157(9):861-866.
  17. Powell FC, et al. A risk/benefit analysis of spinal manipulation therapy for relief of lumbar or cervical pain. Neurosurgery Online.1993; 33(1):73.
  18. ICA Home. Council on Chiropractic Pediatrics. http://www.icapediatrics.com Accessed April 10, 2010.
  19. O’Neal ML. The pediatric spine: Anatomical and Dynamic considerations preceding manipulation. Comprehensive Therapy.2003; 29(2):124-129.
  20. Hayes J, Arriola T. Pediatric spinal injuries. Pediatric Nursing. 2005; 31(6):464-467.
  21. Editorial. Alberta radiologists target chiropractors. Canadian Medical Association Journal. 1998; 159(10):1237.
  22. Bigos SJ, et al. Acute Low Back Problems in Adults.1994; Rockville, Maryland: U.S. Department of Health and Human Services. AHCPR Publication No. 95-0642.
  23. McCoy M. Chiropractic part of swine flu prevention program in children. McCoy Press Research Update. September 8, 2009. http://researchupdate.mccoypress.net/2009/09/08/chiropractic-part-of-swine-flu-prevention-program-in-children.aspx Accessed April 10, 2010.
  24. Christensen M, et al. Job Analysis of Chiropractic.2005. Greeley, CO; National Board of Chiropractic Examiners.
  25. Cohen MH, Kemper KJ. Complementary therapies in pediatrics: A legal perspective. Pediatrics. 2005; 115(3):774-780.

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