Chiropractic Care in Children: Just Say No.

Our skeletons are made up of mostly soft, flexible cartilage at birth. This provides protection during childbirth . Our skeletons are not fully formed until adulthood. Bottom line: Babies don’t even have solid joints to manipulate

This is a common question in the clinic, on the internet, and in mom groups everywhere. Will my child benefit from Chiropractic Care? I always hesitate because I don’t want to come across as one-sided on the war between physical therapists and chiropractors. I want cohesion in the medical field. We need inter-professional, mutual respect in order to provide the best care possible to our patients. But, we also have a responsibility to provide transparency for our growing body of patients and clients that are (rightfully so) demanding a better patient care experience and making more informed decisions for themselves and their families. So, as with any medical service or treatment, I do extensive research (insert Hermoine Granger scuttling off to the library here), from reputable sources, regarding the benefits versus the risks. 

Background

D.D. Palmer, the founder of chiropractic care, declared that 95% of all disease was due to displaced vertebrae, and the other 5% due to other bone displacements (Leboeuf-Yde 2019). Soon after its inception, a divide arose between evidence-based practicioners and the traditional vitalists. 

As the world continues to shift towards an evidence-based society, the field of chiropractic continues to lack any such credible evidence as other professions have produced in the terms of high-quality, randomized, well-designed intervention studies. This is where the divide in the profession is most evident. The traditionalists – those who follow the orginal way of thinking – not only confuse the general population to the overall beliefs and practices surrounding the profession, but they have been known to actively block the establishment of University-Based education in chiropractic, which would then be subject to the rules and regulations of most other medical professions. The evidence-based new order of Chiropractic aims to bring the profession up to par with other medical fields by integrating both theory and science to best treat their patient population.

Do I sense a shift?

Various chiropractic associations have started to take measures to distance themselves from the traditional approach and enter the realm of evidence-based decision-making. Recently, the American Chiropractic Association produced a document to educate physicians and patients on the guidelines suggested to be the latest evidence in guiding chiropractice care. These include not obtaining spinal imaging without the presence of red flags, repeated x-rays to monitor progress, avoiding passive or palliative modalities for low back pain disorders, avoidance of long-term pain management without outside referral to a mental health professional (there is a close relationship between chronic pain and depression/anxiety), and avoidance of use of lumbar supports and braces for long-term treatment or prevention of low back pain. Numerous systematic reviews have found no value for use of these treatments in this context.

ACA-Choosing-Wisely-List

This tactic changes the focus from the chiropractor, to where the focus of any legitimate healthcare profession should be, on the patient. The end result should, hopefully, be a general shift towards a more modern approach and away from old traditions. -Leboeuf-Yde et al.

Chiropractic for Infants and Children

Photo Credit: Google

The American Chiropractic Association Consensus is a document written as a guideline to practice within their scope to treat children, but it lacks clear and concise protocols in which to use with this population. Chiropractors are (hopefully) not cracking a baby’s joints like they would an adult’s. They are providing more of a mobilizing force that gently move the bones “back into place.” 

Why all the “quotations?” The chiropractic subluxation theory has long since been debunked when it relates to the misalignment of the vertebrae.

A similar review written by Thistle in 2017 outlines responsibilities already commonplace in the medical profession, like using evidence to guide clinical desicion-making, referral with presence of red flags, and age-appropriate anatomical and physiological considerations in regards to manual therapy application. It concluded that clinical judgements in pediatric patients should be based on basic principles of evidence-based practice. Co-management with other health care providers is appropriate when the child is not showing clinically significant improvements after an initial trial of chiropractic care [read: if the kid isn’t better in one visit, refer them on to a specialist that can better treat the child. A huge concern regarding Chiropractic care is the possibility of withholding or delaying necessary medical care to those who truly need it.]

Survey Says:

  • Out of 1,200 Canadian Chiropractors that responded to a survey, almost all had treated pediatrics (<18 years of age) but only 45% had formal training in pediatrics after school. (Verhoef 1999)
  • One study found that Chiropractic care for children is often inconsistent with the recommended medical guidelines. (Lee 2000)
  • One survey found only 40% of all Chiropractic visits in Canada were for musculoskeletal conditions. 24% were for prevention, which accounts for a large portion of visits in children younger than four (Verhoef 1999)

Evidence in Adults

  • Koes et al found, in a review of randomized control trials (the highest level of evidence) that there was insufficient evidence that Chiropractic was effective in treating chronic or acute low back pain
  • Systematic reviews suggest some short-term relief from cervical manipulation in sub-acute or chronic neck pain (Hurvitz et al 1996, Coulter et al 1996), but none compared manipulative treatment to other established treatments.
  • No effectiveness has been shown in treating migraine headaches (Kapral 2001)

Evidence in Children

  • No studies have been done on back pain in children
  • No effectiveness shown to treat asthma in children (Balon)
  • No effectiveness for Colic (Olafsdottir 2001)
  • Substantial gaps in the evidence for the effectiveness of chiropractic care in children (Thistle 2017)
  • No specific recommendations were provided on age-appropriate treatment dosage, frequency or duration (Thistle 2017)
  • Limited support found in higher-quality studies for asthma, colic, bed-wetting, or respiratory disease.

“There is not yet sufficient research evidence related specifically to children to definitively identify indications for spinal manipulation within the chiropractic scope of practice” – Best Practices Recommendations for Chiropractic Care for Infants, Children and Adolescents

My Personal Beefs

Anecdotal Evidence is All You Need: As a Doctor of Physical Therapy, we are paid based on outcomes. We’re held to the highest standard by insurance companies and referring physicians alike. We must consistently produce high-level evidence supporting our methods, continue honing our craft with approved continuing education courses each year to maintain our licenses, and most of all, rehabilitate our patients as quickly and efficiently as possible with as little waste as we can manage. So, why, do Chiropractors get a free pass to treat with whatever methods they deem fit without having to prove a lick of it to a single soul? 

Supporters will tell you than anecdotal evidence is all you need. Well, if a person even thinks they may get better, they have a 30% chance of getting better. That’s science. Google the placebo effect. When I walk into a Chiropractic office, and, before I even get to talk to the Doctor, I have to watch a video on all the patients that “don’t have to come every week for the rest of my life, I want to,” you bet my mind will already be made up that “oh, this must work!” So, most of us are required to show effectiveness above and beyond this mark to substantiate our hypotheses in the literature.

Passive Treatments:

Did you know that ice packs, heat packs, massage, and manipulation are all passive, meaning you as the patient don’t do any of the work? Sounds wonderful, right? Actually, studies show the more active you are in your own care, the more effective it will be at managing symptoms and chronic pain (Cosio).

Appeal to Fear: 

Smoking causes cancer. Fact. Drunk driving causes fatal car crashes. Fact. Your infant needs an adjustment because his birth was traumatic and his spine is subluxed, which will lead to illness and suffering. Wait…..what?

Fear tactics ignite the flight or fight response inside us. A Doctor is telling your your child needs this, or else…So you do it once, keep doing it, for the health and wellness of your child. It’s a questionable tactic in proven facts let alone unsubstantiated claims (Simpson) by professionals that directly benefit from your worst fears.

So, now what?

Now, don’t get me wrong. I like to feel good like the next person. A little targeted spinal manipulation can be good for the soul. It Feel free to keep on cracking those solid, structured adult skeletons to your heart’s content. But, realize that there is no proven benefit from manipulation for acute or chronic neck and back pain in adults when compared with other treatments like massage or physical therapy treatments.

Until the profession, as a whole, can come together and:

  1. Provide some high-quality studies showing safety and effectiveness of specific treatment protocols that are proven to improve to specific problems in specific populations
  2. Stop preying on the fear of the public with threats and misguided promises of miraculous healing (or publicly denounce those who do)
  3. Demonstrate a positive inter-professional relationships by both recognizing when a medical issue is out of their scope of practice and begin making referrals to the correct professionals in a timely manner in the best interest of the patient

I cannot, in good faith, recommend this practice to anyone. Making informed decisions is kind of my goal with this whole thing, and I’ll probably get some flack for telling it like it is. But, when it comes to risking it all when your child is concerned, I’ll take all the hits if it makes you think twice about taking them in for their weekly “therapy.” Kids are my passion and I’ll take this one for the team.

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Levels of Evidence. Photo Credit: http://www.researchgate.com

Glossary
Anecdotal: Not necessarily true or reliable, because it is based on personal accounts rather than facts or research
Placebo Effect: A beneficial effect produced by a placebo treatment, which cannot be attributed to the placebo itself, but to the patient’s belief in that treatment.
Red Flags: A term used by doctors, referring to signs and symptoms found during an evaluation, to indicate the possibility of a more sinister underlying problem.
Passive/Palliative Modalities: Interventions applied to a patient with no active participation from the patient, including heat, cold, e-stim and ultrasound. These modalities have been found to increase patient inactivity, prolong recovery, and increase health care costs and are not skilled care.
Systematic Review: The highest level of evidence available. It is a single research study that compiles all the evidence on a certain topic in one place to summarize best practices.

References

  • https://www.heraldtribune.com/news/20050127/board-of-governors-kills-fsu-chiropractic-school
  • Brown R. The status of chiropractic care in Europe: A position paper. In: ECU; 2013.
  • Leboeuf-Yde C, Innes SI, Young KJ, Kawchuk GN, Hartvigsen J. Chripractic, one big unhappy family: better together or apart? Chiropractic & Manual Therapies. 2019:27;4.
  • Gleberzon BJ, Arts J, Mei A, et al. The use of spinal manipulative therapy for pediatric health conditions: a systematic review of the literature. J Can Chiropr Assoc 2012; 32: 639-647.
  • George M, Topaz M. A systematic review of complementary and alternative medicine for asthma self-management. Nurs Clin North Am 2013; 48: 53-149.
  • Alcantara J, Alcantara JD, Alcantara J. The chiropractic care of patients with asthma: a systematic review of the literature to inform clinical practice. Clinical Chiropr 2012; 15: 23-30.
  • Pepino VC, Ribeiro JD, de Oliveira Ribeiro MA, et al. Manual therapy for childhood respiratory disease: a systematic review. J Manipulative Physiol Ther 2013; 36: 57-65.
  • Alcantara J, Alcantara JD, Alcantara J. The chiropractic care of infants with colic: a systematic review of the literature. Explore 2011; 7: 168-174.
  • Ernst E. Chiropractic spinal manipulation for infant colic: a systematic review of randomized clinical trials. Int J Clin Pract 2009; 63: 1351-1353.
  • Dobson D, Lucassen PL, Miller JJ, et al. Manipulative therapies for infantile colic. Cochrane Database Syst Rev 2012; 12: CD004796.
  • Huang T, Shu X, Huang YS, et al. Complementary and miscellaneous interventions for nocturnal enuresis in children. Cochrane Database Syst Rev 2011: CD005230.
  • Cosio D and Lin, E. Role of Active Versus Passive Complementary and Integrative Health Approaches in Pain Management. Global Advances in Health and Medicine 2018;7:1–7.
  • Simpson J. Appeal to fear in health care: appropriate or inappropriate? Chiropractic & Manual Therapies (2017) 25:27.