MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

The question whether spinal manipulation is an effective treatment for infant colic has attracted much attention in recent years. The main reason for this is, of course, that a few years ago Simon Singh had disclosed in a comment that the British Chiropractic Association (BCA) was promoting chiropractic treatment for this and several other childhood condition on their website. Simon famously wrote “they (the BCA) happily promote bogus treatments” and was subsequently sued for libel by the BCA. Eventually, the BCA lost the libel action as well as lots of money, and the entire chiropractic profession ended up with enough egg on their faces to cook omelets for all their patients.

At the time, the BCA had taken advice from several medical and legal experts; one of their medical advisers, I was told, was Prof George Lewith. Intriguingly, he and several others have just published a Cochrane review of manipulative therapies for infant colic. Here are the unabbreviated conclusions from their article:

The studies included in this meta-analysis were generally small and methodologically prone to bias, which makes it impossible to arrive at a definitive conclusion about the effectiveness of manipulative therapies for infantile colic. The majority of the included trials appeared to indicate that the parents of infants receiving manipulative therapies reported fewer hours crying per day than parents whose infants did not, based on contemporaneous crying diaries, and this difference was statistically significant. The trials also indicate that a greater proportion of those parents reported improvements that were clinically significant. However, most studies had a high risk of performance bias due to the fact that the assessors (parents) were not blind to who had received the intervention. When combining only those trials with a low risk of such performance bias, the results did not reach statistical significance. Further research is required where those assessing the treatment outcomes do not know whether or not the infant has received a manipulative therapy. There are inadequate data to reach any definitive conclusions about the safety of these interventions”

Cochrane reviews also carry a “plain language” summary which might be easier to understand for lay people. And here are the conclusions from this section of the review:

The studies involved too few participants and were of insufficient quality to draw confident conclusions about the usefulness and safety of manipulative therapies. Although five of the six trials suggested crying is reduced by treatment with manipulative therapies, there was no evidence of manipulative therapies improving infant colic when we only included studies where the parents did not know if their child had received the treatment or not. No adverse effects were found, but they were only evaluated in one of the six studies.

If we read it carefully, this article seems to confirm that there is no reliable evidence to suggest that manipulative therapies are effective for infant colic. In the analyses, the positive effect disappears, if the parents are properly blinded;  thus it is due to expectation or placebo. The studies that seem to show a positive effect are false positive, and spinal manipulation is, in fact, not effective.

The analyses disclose another intriguing aspect: most trials failed to mention adverse effects. This confirms the findings of our own investigation and amounts to a remarkable breach of publication ethics (nobody seems to be astonished by this fact; is it normal that chiropractic researchers ignore generally accepted rules of ethics?). It also reflects badly on the ability of the investigators of the primary studies to be objective. They seem to aim at demonstrating only the positive effects of their intervention; science is, however, not about confirming the researchers’ prejudices, it is about testing hypotheses.

The most remarkable thing about the new Cochrane review  is, I think, the in-congruence of the actual results and the authors’ conclusion. To a critical observer, the former are clearly negative but  the latter sound almost positive. I think this begs the question about the possibility of reviewer bias.

We have recently discussed on this blog whether reviews by one single author are necessarily biased. The new Cochrane review has 6 authors, and it seems to me that its conclusions are considerably more biased than my single-author review of chiropractic spinal manipulation for infant colic; in 2009, I concluded simply that “the claim [of effectiveness] is not based on convincing data from rigorous clinical trials”.

Which of the two conclusions describe the facts more helpfully and more accurately?

I think, I rest my case.

19 Responses to Chiropractic manipulation for infant colic?

  • Professor Ernst wrote: “The analyses disclose another intriguing aspect: most trials failed to mention adverse effects. This confirms the findings of our own investigation and amounts to a remarkable breach of publication ethics (nobody seems to be astonished by this fact; is it normal that chiropractic researchers ignore generally accepted rules of ethics?). It also reflects badly on the ability of the investigators of the primary studies to be objective. They seem to aim at demonstrating only the positive effects of their intervention; science is, however, not about confirming the researchers’ prejudices, it is about testing hypotheses.”

    On the subject of publication ethics, I think that the work of two researchers (one of whom, JE Bolton, is from the Anglo European College of Chiropractic) needs highlighting. At the end of their 2002 paper which looked at chiropractic as an effective treatment for infantile colic, they recommended “Where the infant may be at risk of harm and possible long term repercussions…the advice is to seek chiropractic treatment”
    http://adc.bmj.com/cgi/content/full/archdischild%3b86/5/382
    How they could be confident in issuing that advice is a mystery as, five years later, a systematic review which looked at the most up-to-date evidence on the safety of (chiropractic) spinal manipulation for children found that, despite the fact that spinal manipulation was widely used on children, paediatric safety data were virtually non-existent.
    http://pediatrics.aappublications.org/content/119/1/e275.abstract

    Still on the subject of publication ethics, it’s worth noting that the Anglo European College of Chiropractic researcher, JE Bolton, went on to claim in early 2008 (in response to valid criticism) that, in the UK alone, there were an estimated *four* million manipulations of the neck carried out by chiropractors each year.
    http://onlinelibrary.wiley.com/doi/10.1211/fact.13.1.0020/full
    Yet, six months earlier, in October 2007, in a letter to the Journal of the Royal Society of Medicine, she claimed that the figure was “estimated to be well over *two* million cervical spine manipulations” in the UK each year.
    http://jrsm.rsmjournals.com/content/100/10/446.1.full
    Is the discrepancy in the above two figures evidence of a desperate attempt by biased authors to play down the risks of chiropractic by deliberately over-estimating manipulation numbers?

  • to me, the overt lack of ethics is one of the most striking thing about chiropractic….and nobody seems to bat an eyelash about it?!?!

  • In the responses to some of my complaints to the General Chiropractic Council, their Investigating Committee said:

    The Investigating Committee did note the reference to ‘Paediatric care’. The Investigating Committee considered that this could give a member of the public reading the webpage the impression that you provide treatment to babies.

    Other letters mentioned similar claims about children. Despite the fact that the Bronfort report found that there was no good evidence that chiropractic worked for children or babies for any condition, the GCC have taken the opportunity to remind all the chiropractors:

    It was mindful that there is no high or moderate positive evidence from randomised controlled trials that would support a claim to treat children using manual therapy. In the absence of such evidence, it concluded that it could be inappropriate to make such an advertised claim.

    It remains a mystery why many chiropractors are still claiming to treat children.

  • To me the most striking things about chiropractic are:
    – The speed of assessment on a first visit;
    – The virtual absence of assessment on subsequent visits;
    – The fact that, whatever symptoms are presented, the treatment is always the same – has a chiropractor ever referred a patient to another medical discipline rather than taking the money? Chiropractic is a one trick pony.
    – The interminable nature of chiropractic treatment – has a chiropractor ever told a patient that they were cured and didn’t need to come back?
    – The cost of treatment given that the chiropractor tries to get you out of the door as quickly as possible.

    Chiropractic is based on the idea that it relieves problems caused by pressure between misaligned vertebral discs. However when I went to a chiro with an actual case of pressure between my discs – sciatica – the treatment was pretty disastrous, leaving me more or less unable to walk. Fortunately my parlous condition was sorted out by an MD (lots of drugs) and a great physiotherapist who showed me what exercises to do to heal myself, thus doing himself out of the fees that a chiro would get for all those repeat visits. I think that chiropractic can provide some temporary relief for a “bad back” but it doesn’t address the underlying issues such as postural habits, repetitive strain and lack of appropriate exercise.

    • some chiros try to address the underlying problems of back pain; if they do, they become amateur physios – or am I seeing this wrong?

      • Yes I think chiros in my experience have seemed amateurish when they recommend exercises or other remedies apart from “spinal manipulation”.

  • Thanks to Dr. Ernst for taking the time in his retirement to provide us with an objective and reliable source of information on all forms of alternative medicine. I especially enjoyed his blog today about chiropractic manipulation for infant colic.

    My article “Pediatric Chiropractic Care: Scientifically Indefensible?”, published May 3, 2010, on Science-Based Medicine, offers some additional caveats about chiropractic care for children: http://www.sciencebasedmedicine.org/index.php/pediatric-chiropractic-care-scientifically-indefensible/

  • Samuel’s article mentioned above is well worth reading, in my view.

  • When you apply the philosophy of medicine to Chiropractic, that is, diagnosis, then treatment, often times it appears to fall down, just like if you apply this philosophy to improving someones actual health it does too. Let me please explain what I mean, medicine and some chiropractors apply an allopathic model, mentioned above, of diagnosis and treatment to back pain and other musculoskeletal conditions. For this they firstly need someone who is complaining of a condition and then they need to diagnose it and then treat it. These are conditions and they are the end result of problems, they are mostly not the problem ie: vomitting is the diagnosis, any manner of things could be the cause. This is the fireman putting out the fire, very necessary, if you have a fire…
    But what if you were a Chiropractor and didn’t apply this philosophy to your practice, what if you practiced from the point of view that biomechanical problems were associated with dysfunction of more than just what may be obvious symptoms, such as dyskinesia or abnormal postural patterns we term vertebral subluxations. These conditions may or may not show obvious symptoms such as pain or paresthesia, but we know without a doubt that changes in movement patterns have physiological and even psychological impacts on the body, not to mention the increase in conditions such as degeneration of the joint complex and stress to the sympathetic nervous system which can have massive impacts on long term chronic conditions that about 70% of our Western population now suffer. This is more like a repairman getting to a problem before it causes an issue or in the case of children’s spines, more like a builder.
    Most Chiropractors are just like you, they have children, they work hard and they absolutely have ethics behind what they do, it requires a little more understanding about the principles of why they are doing what they are, if you have not had the benefit of regular care or never been to a patient education night with a reputable local Chirorpractor I would encourage you to do so, my Father was the biggest sceptic ever and went through years of problems before he gave up and saw a Chiropractor, he enjoyed not only the benefits of the care for pain relief but lived a significantly longer life as he was then able to exercise, concentrate on learning about his diet and what he had missed out on from years of well intended, emergency medical care.
    If you bring a tool belt to a house fire you look pretty stupid and if you bring a fire hose to a barn raising you look equally stupid, when you make comparisons about Chiropractors and Medical Allopathy, applying one philosophy to the other results in one looking stupid and dishonest when the that may not necessarily be the case.

    • what a very weird view you have – not least of conventional medicine!!! who says doctors only treat symptoms? we do always aim at finding the causes and then treat them, if possible. but causes have to be real, not just figments of imagination or “philosophies” , as you put it.

    • Tom

      How would I go about finding a reputable chiropractor?

    • Tom, the problem is that the chiropractor only brings one tool, regardless of whether it is a house fire or a barn raising. And that tool is a chocolate teapot.

      In my experience chiropractors can’t even treat problems caused by pressure between the vertebrae, and that is all they claim to treat. It is an incredibly impoverished profession in terms of the scope of its theoretical basis and its treatment options. Has anyone ever had a proper medical training and then chosen to practise as a chiropractor? Your suggestion that physicians only treat symptoms shows such a profound lack of respect for the science that heals us of illnesses that were previously incurable. Think about the achievements of medical science over the last 100 years. Now think about the achievements of chiropractic, or for that matter alternative medicine as a whole: they exist only in fantasy.

  • Chiropractic treatment is useful for individuals of all ages, sex, and group. Chiropractic care is really best for infant colic.

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