MD, PhD, FMedSci, FSB, FRCP, FRCPEd

A 2016 article set out to define the minimum core competencies expected from a certified paediatric doctor of chiropractic using a Delphi consensus process. The initial set of seed statements and sub-statements was modelled on competency documents used by organizations that oversee chiropractic and medical education. The statements were then distributed to the Delphi panel, reaching consensus when 80% of the panelists approved each segment. The panel consisted of 23 specialists in chiropractic paediatrics from across the spectrum of the chiropractic profession. Sixty-one percent of panellists had postgraduate paediatric certifications or degrees, 39% had additional graduate degrees, and 74% were faculty at a chiropractic institution and/or in a postgraduate paediatrics program. The panel was initially given 10 statements with related sub-statements formulated by the study’s steering committee. On all 3 rounds of the Delphi process the panelists reached consensus; however, multiple rounds occurred to incorporate the valuable qualitative feedback received.

The results of this process reveal that the Certified Paediatric Doctor of Chiropractic requires 8 sets of skills. (S)he will …

1) Possess a working knowledge and understanding of the anatomy, physiology, neurology, psychology, and developmental stages of a child. a) Recognize known effects of the prenatal environment, length of the pregnancy, and birth process on the child’s health. b) Identify and evaluate the stages of growth and evolution of systems from birth to adulthood. c) Appraise the clinical implications of developmental stages in health and disease, including gross and fine motor, language/communication, and cognitive, social, and emotional skills. d) Recognize normal from abnormal in these areas. e) Possess an understanding of the nutritional needs of various stages of childhood.

2) Recognize common and unusual health conditions of childhood. a) Identify and differentiate clinical features of common physical and mental paediatric conditions. b) Identify and differentiate evidence-based health care options for these conditions. c) Identify and differentiate clinical features and evidence-based health care options for the paediatric special needs population.

3) Be able to perform an age-appropriate evaluation of the paediatric patient. a) Take a comprehensive history, using appropriate communication skills to address both child and parent/ guardian. b) Perform age-appropriate and case-specific physical, orthopaedic, neurological, and developmental examination protocols. c) When indicated, utilize age-appropriate laboratory, imaging, and other diagnostic studies and consultations, according to best practice guidelines. d) Appropriately apply and adapt these skills to the paediatric special needs population. e) Be able to obtain and comprehend all relevant external health records.

4) Formulate differential diagnoses based on the history, examination, and diagnostic studies.

5) Establish a plan of management for each child, including treatment, referral to, and/or co-management with other health care professionals. a) Use the scientific literature to inform the management plan. b) Adequately document the patient encounter and management plan. c) Communicate management plan clearly (written, oral, and nonverbal cues) with both the child and the child’s parent/guardian. d) Communicate appropriately and clearly with other professionals in the referral and co-management of patients.

6) Deliver skilful, competent, and safe chiropractic care, modified for the paediatric population, including but not limited to: a) Manual therapy and instrument-assisted techniques including manipulation/adjustment, mobilization, and soft tissue therapies to address articulations and/or soft tissues. b) Physical therapy modalities. c) Postural and rehabilitative exercises. d) Nutrition advice and supplementation. e) Lifestyle and public health advice. f) Adapt the delivery of chiropractic care for the paediatric special needs population.

7) Integrate and collaborate with other health care providers in the care of the paediatric patient. a) Recognize the role of various health care providers in paediatric care. b) Utilize professional inter-referral protocols. c) Interact clearly and professionally as needed with health care professionals and others involved in the care of each patient. d) Clearly explain the role of chiropractic care to professionals, parents, and children.

8) Function as a primary contact, portal of entry practitioner who will. a) Be proficient in paediatric first aid and basic emergency procedures. b) Identify and report suspected child abuse.

9) Demonstrate and utilize high professional and ethical standards in all aspects of the care of paediatric patients and professional practice. a) Monitor and properly reports of effects/adverse events. b) Recognize cultural individuality and respect the child’s and family’s wishes regarding health care decisions. c) Engage in lifelong learning to maintain and improve professional knowledge and skills. d) Contribute when possible to the knowledge base of the profession by participating in research. e) Represent and support the specialty of paediatrics within the profession and to the broader healthcare and lay communities.

I find this remarkable in many ways. Let us just consider a few items from the above list of competencies:

Identify and differentiate evidence-based health care options… such options would clearly not include chiropractic manipulations.

Identify and differentiate clinical features and evidence-based health care options for the paediatric special needs population… as above. Why is there no mention of immunisations anywhere?

Perform age-appropriate and case-specific physical, orthopaedic, neurological, and developmental examination protocols. If that is a competency requirement, patients should really see the appropriate medical specialists rather than a chiropractor.

Establish a plan of management for each child, including treatment, referral to, and/or co-management with other health care professionals. The treatment plan is either evidence-based or it includes chiropractic manipulations.

Deliver skilful, competent, and safe chiropractic care… Aren’t there contradictions in terms here?

Manual therapy and instrument-assisted techniques including manipulation/adjustment, mobilization, and soft tissue therapies to address articulations and/or soft tissues. Where is the evidence that these treatments are effective for paediatric conditions, and which conditions would these be?

Clearly explain the role of chiropractic care to professionals, parents, and children. As chiropractic is not evidence-based in paediatrics, the role is extremely limited or nil.

Function as a primary contact, portal of entry practitioner… This seems to me as a recipe for disaster.

Demonstrate and utilize high professional and ethical standards in all aspects of the care of paediatric patients… This would include obtaining informed consent which, in turn, needs to include telling the parents that chiropractic is neither safe nor effective and that better therapeutic options are available. Moreover, would it not be ethical to make clear that a paediatric ‘doctor’ of chiropractic is a very far cry from a real paediatrician?

So, what should the competencies of a chiropractor really be when it comes to treating paediatric conditions? In my view, they are much simpler than outlined by the authors of this new article: I SEE NO REASON WHATSOEVER WHY CHIROPRACTORS SHOULD TREAT CHILDREN!

14 Responses to What are the competencies of a ‘certified paediatric doctor of chiropractic’?

  • If chiropractors limited their practices to evidence based treatment (lower back pain), they could not make a living. Unfortunately many chiropractors do not realize this until they have invested the time and money in their degree. Their behavior is not unexpected. They are not alone. The high levels of graduate debt in the US drive many in health care to push beyond optimum care toward maximum care.

  • Alcantara J, Ohm J, Kunz K. A practice-based
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    adverse events associated with pediatric chiropractic
    spinal manipulative therapy. Proceedings of the 2010
    ICPA Research Conference: Washington DC. Oct 21-24,
    2010:17-8.

    Miller JE. Safety of chiropractic manual therapy for
    children: How are we doing? Journal J Clin Chiropr
    Pediatr. 2009 Dec;10(2):655-60.

    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
    (NY). 2009 Sep-Oct;5(5):290-5. 24. Alcantara J, Ohm J,
    Kunz D. Treatment-related aggravations, complications
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    manipulative therapy of pediatric patients: a practicebased
    survey of practitioners. Focus on Alternative and
    Complementary Therapies 2007; 12 (Suppl 1): 3.

    Alcantara J, Ohm J, Kunz D. Treatment-related
    aggravations, complications and improvements attributed
    to chiropractic spinal manipulative therapy of pediatric
    patients: a survey of parents. Focus on Alternative and
    Complementary Therapies. 2007; 12 (Suppl 1): 4.

    Humphreys BK. Possible adverse events in children
    treated by manual therapy: a review. Chiropr Osteopat.
    2010 Jun 2;18(1):12.

    Coleman DL. The legal ethics of pediatric research. Duke
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    Doyle MF. Is chiropractic paediatric care safe? A
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    Adverse events associated with pediatric spinal
    manipulation: a systematic review. Pediatrics
    2007;119(1):e275-83.

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    2008;11(4):193-198.

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    Wiberg JM, Nordsteen J, Nilsson N. The short term
    effect of spinal manipulation in the treatment of
    infantile colic: a randomized controlled clinical trial
    with a blinded observer. J Manipulative Physiol Ther
    1999;22(8):517-22.

    Alcantara J, Alcantara JD, Alcantara J. What is the
    evidence for chiropractic management of infantile
    colic? Further considerations. Clinical Chiropractic
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    Browning M, Miller J. Comparison of the short-term
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    Miller JE, BenfieldK. Adverse effects of spinal
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    clinic. J Manipulative Physiol Ther. 2008;31(6):419–
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    Hardoin RA, Henslee JA, Christenson CP,
    Christenson PJ, While M. Colic medication and
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    Structuring research studies within chiropractic is difficult, especially within the pediatric population. However, more research has been done than chiropractic gets credit for. The consensus of the studies is that adverse events from spinal manipulative treatment exist, but are rare, minor and self-limiting. When compared to conventional medical treatment, “spinal manipulation” has far less adverse events.

    A review of cases published in Pediatrics in January 2007 showed 14 cases of direct harm from spinal manipulation.
    The National Center for Health Statistics reports children 0 to 18 years of age seeking medical treatment for an ADE between 1995 and 2005 is 585,922.In fact, the most modest number I have been able to find for ADE was between 2008 and 2012. Reported by ISMP (using FDA figures) was 45,610 adverse drug events reported in children less than 18 years of age. Of these, 64% (29,298) indicated a serious injury. ADEs grew substantially over time–from 6,320 in 2008 to 11,401 in 2012.

    • you have shown us that you can copy/paste alright. but I am not sure you understand what I tried to say: THERE IS NO GOOD EVIDENCE THAT CHIROPRACTIC MANIPULATION HAS ANY BENEFIT FOR PAEDIATRIC CONDITIONS, THEREFORE A RISK/BENEFIT ANALYSIS IS NOT LIKELY TO COME OUT POSITIVE, EVEN IF THE RISKS ARE SMALL.

      • Wow. If I had tried to have a conversation about the relative safety of chiropractic to medicine, you would have said “where is the evidence.” So instead, I provide an abbreviated list of research articles (none of which are case studies) and you respond with the least scientific response I have seen yet. Most of these articles give examples of benefit to pediatric patients, with low rates of adverse events. A review of the literature is necessary before sticking to your entrenched beliefs that chiropractic “has no research.”

        • 1) WHERE DID I MAKE THAT CLAIM “no research”?
          2) some of the articles you listed are from ‘my’ journal.
          3) stressing the over-riding importance of the risk/benefit principle is not is “the least scientific response”?
          are you for real???

    • My anti-epileptic meds have very -rare adverse event pancreonecrosis, which is life-threatening. But so can be slamming your head against some sharp or hard surface during a seizure, or walking straight in front of the running car during a minor seizure, and these are much more real that pancreonecrosis. IT IS BENEFIT-RISK BALLANCE THAT MATTERS. Of course, ideal therapy would be all benefit and no risk, but in case of serious problems it is hardly possible, because human body is a complex system and humans ar different enough that there are no solutions that will fit all (another reason not to believe in people that promise to treat conditions each of which is treated differently, and even two random patients with the same condition can be treated differently).

    • @ Derry Merbles
       
      My first reaction to your post. Oh no, not another dump of references wihout any indication exactly what each is supposed to tell us.
       
      My second reaction to your post. Are any of the citations to respectable journals as opposed to the specialist chiropractic publications that are edited and reviewed by people lacking scientific stringency? Yes, just three.
       
      Two of the three are warnings about the pediatric adverse event dangers of a couple of specific medicines. We know there are many such papers and warnings. They apply to medicines capable of curing diseases: as you’ve already been told, it is the ratio of risk to BENEFIT that matters.
       
      This leaves us with just one paper that addresses the pediatric risk of spinal manipulation: Vohra et al, 2007 (no. 8 in your reference dump). It’s a good paper. It is the source of your figure of 14 cases of direct harm, and it comes from the only 13 publications the authors could find between 1966 and 2004 that provided intelligible data on risk. In your comment you fail to mention the 20 other cases of indirect harm: the patients whose treatment for a range of cancers and a couple of cases of meningitis was delayed or inappropriately treated because they (i.e. their parents) sought to have their spines messed about with rather than seeking rational medical attention.
       
      Eleven of the 13 studies were case reports or case series which, as the authors themselves state, “do not provide information on the incidence of adverse events because of the lack of data regarding the total number of manipulations provided (i.e. denominator data)”. Which makes the entire exercise pretty worthless. There were two prospective trials analysed, with the numbers of children receiving SM 171 and 9. Among these 180 children there were two mild and two moderate adverse events. One event in 45 is not a low figure.
       
      Two further points. 1. You say: “Structuring research studies within chiropractic is difficult, especially within the pediatric population.” But you don’t say why. Chiropractors too lazy, disorganized or dumb to do proper research, perhaps?. 2. The Vohra paper defines adverse events of moderate severity in the trials as “required medical attention”. Is this finally an acknowledgement that chiropractic per se has nothing whatsoever to do with medicine?

      • Apologies to EE for lumping ‘his’ journal with the other pro-Big Snakeoil pubs on the basis of title. I should get out more and post less.

    • @Derry Merbles (chiropractor)

      As there is very little evidence chiropractic does anything for adults, why would anyone assume it would have any benefit for young children? There are videos, on this blog, showing chiros using the clicky handheld device on children, so inconsequential is the force, the child barely feels it. Do you seriously suggest this has some therapeutic benefit to the child, putting aside the benefit to the chiro’s wallet?

      • I wonder what criteria have to be met before a chiro moves on from a clicky stick to full-blown HVLA thrusts on a young customer? Any chiro able to answer that?

      • Well, Alan. Let’s hope this well meaning make-believe “Dr.” keeps to her rather benign, theatrical clicking-gadget act.

        Must be one of the most telling examples of the “pediatric” chiropractic delusion ever.

        https://youtu.be/TjrQVB0tG1g

        • “Let’s hope this well meaning make-believe “Dr.” keeps to her rather benign, theatrical clicking-gadget act.”

          Nope, it won’t happen. Such deep-seated delusion won’t change, until she twists some poor persons’ neck and kills them. Even then, when the poor bastard dies in emergency, it will be unknown to this idiot.

  • The first requirement is to be certified.
    Best thing for most of ’em!

  • This is what Consumers Union (publisher of Consumer Reports) had to say about chiropractic in general and about them treating children:

    “Overall, Consumers Union believes that chiropractic is a significant hazard to many patients. Current licensing laws, in our opinion, lend an aura of legitimacy to unscientific practices and serve to protect the chiropractor rather than the public. In effect, those laws allow persons with limited qualifications to practice medicine under another name.

    We believe the public health would be better served if state and federal governments used their licensing authority and their power of the purse to restrict the chiropractor’s scope of practice more effectively.”

    “Above all, we would urge that chiropractors be prohibited from treating children; children do not have the freedom to reject unscientific therapy that their parents may mistakenly turn to for help in a crisis.”

    (From: Editors of Consumer Reports Books. Health Quackery: Consumers Union’s Report on False Health Claims, Worthless Remedies, and Unproved Therapies. Mount Vernon, NY: Consumers Union, 1980, Chapter Eight – Chiropractors: Healers or Quacks?)

    These statements are as true today as they were in 1980. Chiropractors are either unaware of how unqualified they are or they don’t care as long as there’s money to be made.

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