Question

What are the considerations for treating infants, children and adolescents with manual procedures?

Answer 1

The National Center for Health Statistics found that manipulation by chiropractors or osteopathic physicians was the most commonly used provider-based complementary and alternative (CAM) therapy among US children under age 18 in 2007. [1] The most frequent complaint causing children to seek CAM care, in general, was back or neck pain (7%). Because the prevalence of low back pain (LBP) in children has been estimated to be as high as 40%, with recurrent LBP occurring in 20% of older adolescents, this is not surprising. [2] However, children also sought CAM care for a number of other complaints, both musculoskeletal and nonmusculoskeletal, as shown in Table 1. Approximately 12% of US children used some type of CAM therapy in 2007; about 3% used manipulation (chiropractic or osteopathic). Adolescents used CAM more than younger children, and it was more commonly used among children with more health problems and doctor visits. [1]

In order to best serve the health of the public, it is important that all providers maintain and follow the highest standards of patient care. This includes adherence to the principles of evidence-based practice. Evidence-based practice is “the integration of best research evidence with clinical expertise and patient values.” [3] However, in many cases, especially for CAM practices, the higher levels of evidence such as randomized controlled trials or large observational studies are lacking. According to Sackett, the “father” of evidence-based medicine, “evidence based medicine is not restricted to randomized trials and meta-analyses. It involves tracking down the best external evidence with which to answer our clinical questions…” [4, 5]

Chiropractic care, a “package” of conservative approaches, including manipulation, for pain management and/or promoting optimal function, has accumulated a substantial evidence base, primarily for musculoskeletal complaints. [6] Manipulation, performed by trained providers, has been recommended by the American College of Physicians, as having benefit for both acute and chronic LBP in adults. [7] Serious adverse events have been found to be rare for manipulation of the low back (estimated at 1 per 3.72 million manipulations). [8] Manual procedures and exercise, commonly used by chiropractors, were found in a 2008 best evidence synthesis to be beneficial for adult patients with neck pain. [9] A large observational study published in 2008 found no excess risk of vertebrobasilar stroke associated with chiropractic neck manipulation. [10] Another study found that, although minor adverse effects such as transient soreness were commonly associated with manipulation, the overwhelming majority of these resolved within 24 hours of onset and did not affect daily activities. [11] A 2009 systematic review of manipulation for conditions of the lower extremity found limited, but positive, evidence for adult patients with conditions of the hip, knee, and ankle, with no serious adverse events observed. [12]

A 2007 systematic review of chiropractic care for nonmusculoskeletal conditions concluded that “evidence from controlled studies and usual practice supports chiropractic care (the entire clinical encounter) as providing benefit to patients with asthma, cervicogenic vertigo, and infantile colic. The evidence was promising for potential benefit of manual procedures for children with otitis media and elderly patients with pneumonia.” [13] An important distinction should be made between the terms “chiropractic manipulation” and “chiropractic care.” The term “chiropractic care” refers to the entire clinical encounter in a chiropractic setting which may include many nonmanipulative therapies such as dietary advice, nutritional or herbal supplements, posture correction, therapeutic exercise, physiotherapeutic modalities, and behavioral counseling.

However, the large body of evidence for the effectiveness of chiropractic care for adults may not necessarily be directly applicable to infants, children, and adolescents. A 2008 systematic review on chiropractic manipulation for children's health problems concluded that “the evidence rests primarily with clinical experience, descriptive case studies, and very few observational and experimental studies.” [14] The current evidence often does not make a distinction between chiropractic manipulation as a monotherapy and chiropractic care that incorporates multiple nonmanipulative therapies as a “package.”

Therefore, at this time, it is apparent that the scientific evidence base has important gaps in terms of the appropriateness of chiropractic care for infants, children, and adolescents. Safety is one of the most important issues; a recent systematic review recommended that further study is necessary to assess the safety of spinal manipulation for children. [15] There is not yet sufficient research evidence related specifically to children to definitively identify indications for spinal manipulation and other procedures within the chiropractic scope of practice. However, the chief factors cited as concerns in that systematic review were possible direct adverse events related to spinal manipulation and possible indirect adverse events related to delayed diagnosis or delayed medical treatment for serious conditions.

Consequently, we undertook this consensus project in order to bridge this gap in the scientific evidence, and ensure the highest quality of chiropractic care for infants, children, and adolescents. Expert consensus is a form of evidence which must be relied on when higher levels of evidence are lacking. [16] The purpose of the project was to make recommendations on standards of chiropractic care for children, based on the existing evidence and the consensus of a multidisciplinary group of experts on pediatrics and chiropractic. It is essential for the safety of pediatric chiropractic patients that chiropractors who care for infants, children, and adolescents have access to a document that clearly outlines the best practices for chiropractic care of infants, children, and adolescents.

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