MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

An impressive 17% of US chiropractic patients are 17 years of age or younger. This figure increases to 39% among US chiropractors who have specialized in paediatrics. Data for other countries can be assumed to be similar. But is chiropractic effective for children? All previous reviews concluded that there is a paucity of evidence for the effectiveness of manual therapy for conditions within paediatric populations.

This systematic review is an attempt to shed more light on the issue by evaluating the use of manual therapy for clinical conditions in the paediatric population, assessing the methodological quality of the studies found, and synthesizing findings based on health condition.

Of the 3563 articles identified through various literature searches, 165 full articles were screened, and 50 studies (32 RCTs and 18 observational studies) met the inclusion criteria. Only 18 studies were judged to be of high quality. Conditions evaluated were:

  • attention deficit hyperactivity disorder (ADHD),
  • autism,
  • asthma,
  • cerebral palsy,
  • clubfoot,
  • constipation,
  • cranial asymmetry,
  • cuboid syndrome,
  • headache,
  • infantile colic,
  • low back pain,
  • obstructive apnoea,
  • otitis media,
  • paediatric dysfunctional voiding,
  • paediatric nocturnal enuresis,
  • postural asymmetry,
  • preterm infants,
  • pulled elbow,
  • suboptimal infant breastfeeding,
  • scoliosis,
  • suboptimal infant breastfeeding,
  • temporomandibular dysfunction,
  • torticollis,
  • upper cervical dysfunction.

Musculoskeletal conditions, including low back pain and headache, were evaluated in seven studies. Only 20 studies reported adverse events.

The authors concluded that fifty studies investigated the clinical effects of manual therapies for a wide variety of pediatric conditions. Moderate-positive overall assessment was found for 3 conditions: low back pain, pulled elbow, and premature infants. Inconclusive unfavorable outcomes were found for 2 conditions: scoliosis (OMT) and torticollis (MT). All other condition’s overall assessments were either inconclusive favorable or unclear. Adverse events were uncommonly reported. More robust clinical trials in this area of healthcare are needed.

There are many things that I find remarkable about this review:

  • The list of indications for which studies have been published confirms the notion that manual therapists – especially chiropractors – regard their approach as a panacea.
  • A systematic review evaluating the effectiveness of a therapy that includes observational studies without a control group is, in my view, highly suspect.
  • Many of the RCTs included in the review are meaningless; for instance, if a trial compares the effectiveness of two different manual therapies none of which has been shown to work, it cannot generate a meaningful result.
  • Again, we find that the majority of trialists fail to report adverse effects. This is unethical to a degree that I lose faith in such studies altogether.
  • Only three conditions are, according to the authors, based on evidence. This is hardly enough to sustain an entire speciality of paediatric chiropractors.

Allow me to have a closer look at these three conditions.

  1. Low back pain: the verdict ‘moderate positive’ is based on two RCTs and two observational studies. The latter are irrelevant for evaluating the effectiveness of a therapy. One of the two RCTs should have been excluded because the age of the patients exceeded the age range named by the authors as an inclusion criterion. This leaves us with one single ‘medium quality’ RCT that included a mere 35 patients. In my view, it would be foolish to base a positive verdict on such evidence.
  2. Pulled elbow: here the verdict is based on one RCT that compared two different approaches of unknown value. In my view, it would be foolish to base a positive verdict on such evidence.
  3. Preterm: Here we have 4 RCTs; one was a mere pilot study of craniosacral therapy following the infamous A+B vs B design. The other three RCTs were all from the same Italian research group; their findings have never been independently replicated. In my view, it would be foolish to base a positive verdict on such evidence.

So, what can be concluded from this?

I would say that there is no good evidence for chiropractic, osteopathic or other manual treatments for children suffering from any condition.

And why do the authors of this new review arrive at such dramatically different conclusion? I am not sure. Could it perhaps have something to do with their affiliations?

  • Palmer College of Chiropractic,
  • Canadian Memorial Chiropractic College,
  • Performance Chiropractic.

What do you think?

13 Responses to No good evidence for chiropractic, osteopathic or other manual treatments for children suffering from any condition

  • I totally agree the evidence is not strong.
    I myself and my associates treat children only for musculoskeletal conditions and demand pediatrician referral letter.
    For most musculoskeletal conditions we find children to respond very quickly and in cases they don’t we refer back to the pediatrician or the pediatrician orthopedic consult.
    Indeed we should apply extra care and caution when treating children.

  • Are there other options for nonspecific back pain in children that have better evidence?

    Example

    “A systematic review on Therapy treatments for LBP in children and adolescents concluded that only 8 studies of limited quality had been conducted. Interventions in these trials consisted of education, exercise, or manual therapy, or a combination of the 3. Meta-analysis showed a positive effect for these interventions over control interventions, although the low number of studies and methodological limitations prevent definitive conclusions from being made.“ https://www.jospt.org/doi/full/10.2519/jospt.2017.7376

    Or is a pharmalogical approach better?

    “For mild, acute pain (i.e., associated with tissue injury), acetaminophen and ibuprofen are the agents of choice [80]. No other NSAID has been sufficiently studied for efficacy and safety in the pediatric population so as to be recommended as an alternative to ibuprofen. Although there is evidence for the superior analgesic properties of ibuprofen versus acetaminophen, it is considered to be of limited value because the studies were mostly performed in acute pain settings and lack long-term safety data. Both acetaminophen and ibuprofen have potential toxicities. There are concerns about renal and gastrointestinal toxicity, and bleeding with ibuprofen and other NSAIDs, and risks of hepatotoxicity and acute overdose are associated with acetaminophen [80].”

    “Adjuvant analgesics (e.g., low-dose tricyclic antidepressants, gabapentinoids, α-agonists, melatonin, etc.) may serve as valuable adjuncts. Although commonly used for primary pain disorders, there is little evidence to support their use against pediatric pain.” https://www.sciencedirect.com/science/article/pii/S1934148215009958

  • Thank you for your excellent analysis of this review. I hope you will write a letter to the editor of this journal making the same points.
    In addition, I question the ethics of studies of manual treatments for ADHD, autism, asthma, and other conditions for which a biologically plausible rationale for the treatment is lacking.

    • thank you!
      I looked at the journal’s ed-board and think I rather ‘piss in a violin’ [French expression, sorry] that sending them a ‘letter to the editor’.

      • “other manual treatments”.
        Afraid to use the word physiotherapy Edzard?
        At least you put it in the “posted in” list at the bottom of the blog.
        Congenital Torticollis is treated by physio’s and the SR said “inconclusive unfavorable outcomes”.
        That was surprising as I thought on certain conditions like torticollis the physio’s had evidence.
        Checked the PEDro database for chest physio for pneumonia and a few other conditions that I thought they had nailed down and was surprised at the limited evidence.
        Pediatric Physiotherapists also treat:
        “autism,
        asthma,
        cerebral palsy,
        clubfoot,
        constipation,
        cranial asymmetry, (Plagiocephaly)
        cuboid syndrome,
        headache,
        infantile colic,
        low back pain,
        obstructive apnoea,
        otitis media,
        paediatric dysfunctional voiding,
        paediatric nocturnal enuresis,
        postural asymmetry,
        preterm infants,
        pulled elbow,
        suboptimal infant breastfeeding,
        scoliosis,
        suboptimal infant breastfeeding,
        temporomandibular dysfunction,
        torticollis,”
        Will Edzard and additionally Science Based Medicine (Jan Bellamy) be going after the pediatric physio’s ?
        I do not treat or see infants. Babies are born with pristine spines and should be left alone.
        I only see children and adolescents for musculoskeletal problems usually sport related.

        Edzard: “why do the authors of this new review arrive at such dramatically different conclusion”.
        The SR’s conclusion:
        “Favorable, albeit inconclusive, results were reported in 36 of the 50 studies we assessed that used different types of manual therapies for pediatric conditions. Compared to previous reviews of the literature, we found a number of clinical trials investigating the effects of manual therapies on pediatric musculoskeletal conditions. Twenty-four studies included information on adverse events that were all transient and mild to moderate in nature. Clearly more research investigating the clinical effectiveness of manual therapies for pediatric conditions, along with the incidence of adverse events, is required in order to allow practitioners and parents to make better informed choices with respect to care planning for children with pediatric conditions.”

        • Critical chiro – yes- physical therapists do treat each of the conditions described on your shopping list.
          As do GPs and surgeons. I think you will find these groups use neither manipulation nor magick theory to manage ill health, or sports injuries, in children.

          “pristine spines”!!! Christ on a crutch. Born free of sin too, I suppose?

          Ooooops. Sorry, I’ve just urinated on my leg with laughter!!!

          • do not despair!
            there is hope for your condition: https://edzardernst.com/2017/05/30-may-world-bedwetting-day/

          • Lipid, what treatment modalities do physios use in the management of these conditions? While you are listing the treatment methods, you might like to list the evidence available to validate your claim that physios and medial practitioners do treat these conditions, with evidence on their side.
            BTW, exercises do not work for acute low back pain and paracetemol is not recommended either. If these do not work for low back pain and the mechanism for other biomechanical problems is the same as the mechanism for low back pain, then they will not help. Nor will unproven physio modalities such as TENS, micro-wave, short wave diathermy, massage, ultra-sound, Pilates, or any of the other “shake, bake or fake” modalities that they use. Doesn’t leave much, does it?

          • Speaking of TENS…

            “The current evidence is insufficient to support or dismiss the use of TENS for acute LBP. Implications There is insufficient evidence to guide the use of TENS for acute LBP. ”

            https://www.degruyter.com/view/j/sjpain.ahead-of-print/sjpain-2018-0124/sjpain-2018-0124.xml

        • It’s true that some physiotherapists in private practice may sometimes provide non-evidence-based care, but this does not negate the excellent treatments provided by properly trained paediatric physiotherapists, who treat kids with cerebral palsy, cystic fibrosis and a host of other conditions.

          There evidence-based statement on the treatment of congenital muscular torticollis is here:
          https://journals.lww.com/pedpt/Fulltext/2013/25040/Physical_Therapy_Management_of_Congenital_Muscular.2.aspx

          Chest physiotherapy is not routinely used for pneumonia. It may be applicable for ventilated patients (https://link.springer.com/article/10.1007/s00134-002-1342-2) and conditions where there is difficulty coughing up secretions (bronchiectasis, cystic fibrosis, the elderly, asthma etc).

          Those physios providing so-called cranio-sacral therapy – pure pseudoscience – deserve as much scorn as anyone else providing pseudoscientific ‘therapy’. The majority of specialist paediatric physios, however, are highly skilled and science-based.

          • I thought the same as you Sue so I went to the physio Research database PEDro and set the filters on “Stretching, mob, manip, massage” and “pediatrics” then I looked at “guidelines, SR’s and clinical trials”.
            Cochrane Review:
            Chest physiotherapy for pneumonia in children.
            https://www.ncbi.nlm.nih.gov/pubmed/30601584
            What I found hilarious is that the relevant papers in PEDro on manual therapy for infants and babies had chiro authors.
            That is a good evidence statement on CMT by APTA. Now scroll down to “interventions levels of evidence”.
            If chiro’s touched babies with that level of evidence Friends of Science in Medicine and doctors would be furious.
            The physio’s are flying under the radar.
            I don’t touch babies but I was curious about what the chiro’s do. So I checked. Thrust manipulations are not taught like in that video posted by moron Ian Rossborough and are considered an absolute no-no. I have since found out that a complaint to AHPRA was sent be Genevieve Keating who is doing her PhD on chiro treatment for babies and a group of “paed’s” chiro’s in regards to Rossborough.

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