Chiropractic Spinal Manipulation of Children Under 12

As a consequence of concerns expressed by members of the public following the publication of a video showing the treatment by a chiropractor of a newborn infant in August 2018, the Minister of Health for the State of Victoria in Australia commissioned an independent review of the practice of spinal manipulation in children under the age of 12 years.

In March 2019 a panel was established to conduct this review. Panelists included medical experts in pediatrics, chiropractors, and regulators. It was chaired by the head of Safer Care Victoria, Professor Euan Wallace. The panel included Adjunct Professor Matthew Fisher, Chief Executive Officer of the Australian Chiropractors Association and Dr. Wayne Minter, Chair of the Chiropractic Board of Australia.

The review included a public consultation, consultation with practitioners and regulators and a systematic review of the evidence by Cochrane Australia. For the purposes of the review, spinal manipulation was defined in terms of the application of a high velocity, low amplitude thrust beyond the physiological range of movement of a joint but within the limits of anatomical integrity. In Australia, the practice of spinal manipulation is limited to chiropractors, osteopaths, medical practitioners and physiotherapists.

Review of the evidence of harm

A search of the available literature was conducted by Cochrane Australia along with an analysis of patient complaints, practitioner notifications and an evaluation of insurance claims data from chiropractic insurers.

The review found very little evidence of patient harm for spinal manipulation in the treatment of children under 12 years. No patient complaints were identified and there were no practitioner notifications.

Three reports of serious harm were reported relative to a spinal manipulation in children under 12 years. None of these events involved chiropractors, nor did they feature techniques used by chiropractors in Australia.

It was considered that there were 2 main reasons why evidence of harm was low:

– Spinal manipulation is rarely applied by chiropractors in the treatment of children under 2 years.

– Chiropractors utilize modified force techniques such that there is little likelihood of children receiving high velocity, low amplitude thrust spinal manipulation.

Despite these findings, the review states that spinal manipulation in children under the age of 12 years cannot be considered wholly without risk and that any risk of harm should be weighed against the evidence of benefit, especially in children under the age of 2 years.

Review of the evidence of effectiveness

Safer Care Victoria commissioned Cochrane Australia to undertake a systematic review of the effectiveness and safety of spinal manipulation in children under the age of 12 years.

The resulting systematic review concluded that the evidence base was very poor. It concluded that no strong evidence of effectiveness exists for the following conditions:

– Infantile colic
– Enuresis (bedwetting)
– Back and neck pain
– Headache
– Asthma
– Otitis media
– Cerebral palsy
– Hyperactivity
– Torticollis

Weak evidence was found for a modestly reduced crying time in infantile colic and reduced wet nights in children with enuresis.

The review concluded that spinal manipulation cannot be recommended for headache, asthma, otitis media, cerebral palsy, hyperactivity or torticollis. It further concluded that the unlikely evidence of benefit versus the potential risks of harm should be considered in the use of spinal manipulation in the treatment of infantile colic and enuresis.

Public consultation

A public consultation resulted in 21,824 responses from people who had accessed chiropractic spinal care for children under the age of 12 years.

99.7% of respondents reported a positive experience of chiropractic care of children.

98% reported an improvement in symptoms following chiropractic care.

The panel noted a strong thread in the responses stressing the importance of the right of parents to choose the best care for their children.

The most common conditions for which chiropractic spinal care was sought for children under 12 years were as follows:

– Posture
– Colic
– Neck pain
– Breastfeeding issues
– Back pain
– Headache

0.3% of respondents reported a negative experience. Principal reasons cited included the cost of care relative to perceived benefit, excessive use of x-rays, the pressure to avoid medication, or advice to avoid previously-consulted health professionals).

Health practitioner consultation

2735 responses were received from health care practitioners. Of the 85% of those confirming they provided spinal care for children, 99.5% were chiropractors.

Of the respondents, 80% stated they treated children aged 0-3 months, while 88% confirmed they treated children aged 0-24 months.

The most commonly reported benefits of care described by respondents were decreased pain, improved sleep patterns, more relaxed, improved breastfeeding and latching, and improved range of movement.

RECOMMENDATIONS

Improved safety

1. Spinal manipulation should not be provided to children under 12 for general wellness or for the management of the following conditions:

– Developmental or behavioral disorders
– Hyperactivity disorders
– Autism spectrum disorders
– Asthma
– Infantile colic
– Bedwetting
– Ear infections
– Digestive problems
– Headache
– Cerebral palsy
– Torticollis

2. National boards of those professions permitted to perform spinal manipulation should consider recommendation (1) when reviewing their policies in relation to the care of children.

3. Prior to treatment with spinal manipulation of children under 12, the practitioner should provide written information setting out the proposed benefits and possible risks of care.

4. National boards should review notification data regularly to identify trends requiring modifications of policies, in line with the principle of risk-based regulation.

Improving quality

5. Practitioner groups permitted to perform spinal manipulation in Australia should urgently undertake research to develop an evidence base for spinal manipulation on children. The practice of spinal manipulation on children under 12 years should be ceased when there is evidence that shows no benefit. Ministers should consider whether funding should be allocated for the purpose of research.

6. Practitioner groups permitted to perform spinal manipulation in Australia must lead on developing evidence-based guidance on spinal manipulation of children for both practitioners and consumers, using National Health and Medical Research Council endorsed methods. This guidance material should form the basis of written information for parents in line with recommendations.

7. Consideration should be given by the Chiropractic Board of Australia to various models of advanced chiropractic training in pediatric care, particularly in spinal manipulation. Post-registration training on offer to chiropractors with a special interest in pediatrics should be assessed against the evidence-based guidelines.

Eliminating false advertising

8. Chiropractors should continue to be audited by regulatory authorities for their compliance with guidance relating to advertising.

9. National boards should consider whether prohibitive advertising statements are issued regarding spinal manipulation in children where there is evidence of no benefit.

10. Ministers should consider increasing penalties for advertising offenses where a registered practitioner claim benefits of spinal manipulation in children that have no evidence base.

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