The question whether chiropractic spinal manipulations are an effective treatment of infantile colic has been raging ever since the BCA sued Simon Singh over it (and lost). On this blog, I have discussed the evidence several times (see here, here, here and here). Now a new paper has emerged with the title ‘MEDICAL MANAGEMENT OF INFANTILE COLIC AND OTHER CONDITIONS WITH SPINAL MANIPULATION: A NARRATIVE REVIEW OF THE EUROPEAN MEDICAL LITERATURE’. As it was published on a journal not listed in Medline (J Contemporary Chiropr 2019;2:60-75), I will quote more extensively from it than I do normally. Here is the abstract in its original form:
Objective: Strong evidence is found for European medical management of ‘infantile colic’ by spinal manipulation. This paper identiﬁes and describes this body of evidence. We apply the social research method of document analysis to the European medical literature and report the medical practices regarding the management of infantile colic by manual means including manipulation.
Data Sources: Primary data sources were Medline, accessed via PubMed, and the Index to Chiropractic Literature (ICL). Secondary material was sourced from the private collections of the authors. Acceptability criterion included a report of the medical management of infantile colic.
Data Synthesis: A range of languages were accepted and either translated or interpreted by clinicians known to the authors. Each retrieved paper was then hand-searched to identify additional citations which were also collected. A total of 69 papers met the acceptance criteria. The statements accepted for appraisal were those of methods descriptive of the clinical assessment and management of patients classiﬁed by the practitioner as a child with infantile colic.
Results: The medical management of infantile colic by spinal manipulation is well reported in the European medical literature. Triangulation also identiﬁed reports of medical management of a range of pediatric nonneuromusculoskeletal conditions. European medical papers report a number of positive outcomes for infantile colic with care broadly considered to be manipulative care. These outcomes parallel those known to be widely reported in the chiropractic literature.
Conclusion: We report strong evidence from the European medical literature related to the management by manipulation of infants with infantile colic and other conditions.
In the article proper, the authors conclusions are more detailed and very much longer:
It is difﬁcult to reconcile the positive evidence for manipulative management of infantile colic recorded in
the European medical literature and the known safety of chiropractic management with the need for the 2019 Safer Care Victoria inquiry into Chiropractic manipulation of infants. We consider there is no reasonable evidential basis for this inquiry.
The evidence is that “Infantile colic is an easily identiﬁed childhood entity that has no clear treatment guidelines. The management of infantile colic varies among physicians, and families are often frustrated by the medical community’s inability to prescribe a cure for colic.” (163)
Infantile colic remains a medical enigma with no evidence of safety for medical management, in fact the determination of terminology for reporting such adverse events is relatively new. (164) On the other hand the remarkable safety of chiropractic management is known and the ﬁnding that European medical literature strongly indicates manipulative management of infantile colic as a safe and effective practice, places conventional chiropractic as a safe evidence-based choice to meet parental demand.
Alcantara et al (165) show support for this position by stating “chiropractic care is a viable alternative to the care of infantile colic and congruent with evidence-based practice, particularly when one considers that medical care options are no better than placebo or have associated adverse events.”
In the absence of consistently effective management options, accepting the evidence of the European medical literature shows the beneﬁt of manipulative care for infantile colicky patients and the wider collateral beneﬁcial effect on parents. (166,167)
We consider it important to report the uncertainty of medical management of infantile colic and to recognize manual therapy as a legitimate management option as actively utilized by mostly European medical doctors. Multiple case reports document the efﬁcacy of manual therapy of infants. There is a distinct absence of original evidence contradicting the efﬁcacy of spinal manipulative management of infantile colic and an absence of evidential contraindications for its implementation.
This paper reports considerable material in the European medical literature on the manipulative management of infants, particularly infantile colic. Although supportive in safety (150,158) and efﬁcacy (145), the chiropractic literature on these topics was not the primary focus at this time. However in relation to safety, Funabashi and colleagues noted providers of spinal manipulation have similar or better dimension scores compared to the 2016 medical data base of the Agency for Healthcare Research and Quality. (158)
On balance we can state with conﬁdence that the published, indexed evidence places conventional chiropractic management of infantile colic as safe and effective in the manner clearly documented as clinical methods in the European Medical literature.
I find it hard to decide where to begin. The problem is that there is almost nothing right with this review.
Let’s start with the title, ‘MEDICAL MANAGEMENT OF INFANTILE COLIC AND OTHER CONDITIONS WITH SPINAL MANIPULATION: A NARRATIVE REVIEW OF THE EUROPEAN MEDICAL LITERATURE’. What do they mean with ‘other conditions’? As the review does, in fact, include plenty of non-European papers, this title is simply nonsensical.
Next is the objective: it states that there is good evidence for spinal manipulation as a treatment of infantile colic. The authors thus managed to disclose their bias in the very first sentence of their paper.
The rest of the abstract is similarly incompetent. Crucially, we do not learn what inclusion/exclusion criteria the authors applied and how they evaluated the methodological quality of the included studies. Remarkably, this information is also not provided anywhere else in the paper. Thus, this article lacks all the essential elements of a scientific review and turns out to be little more than a highly biased opinion piece. In fact, it is worse; the introduction, for instance, begins with what I can only call a rant: Within Australia there is a government-manufactured controversy regarding the management of infants by chiropractors…
The results section is equally remarkable. Here are a few direct quotes to give you a flavour:
Forty-ﬁve papers were accepted as valid clinical reports of the management of infantile colic by medical manipulation (Table 1). There are over 60 papers relating to infantile colic on ICL; we do not report these. The Chiropractic Resource Organisation (CRO) website essentially carries the same papers as ICL. Many of these listings are case reports and outcome-based studies. (33, 34) Reference lists were also obtained from indexed papers as well a range of medical and chiropractic textbooks. (35 – 37)
The truth is that the 45 papers are not ‘valid clinical reports’ but a mixture of comments, case reports, opinion pieces, observational studies and a few clinical trials. The latter are identical with those discussed in proper systematic reviews of the subject. There is thus no reason for arriving at different conclusions than these reviews. But, of course, the authors do exactly that, and they do not explain why. They claim that European doctors use spinal manipulation routinely for colicky babies; this is not true (I am a European doctor and have never seen this happening). They claim that unearthing the European literature revealed more positive evidence; this is also not true: this literature was not hidden but it simply does not measure up to the standard required for evidence and was thus not included in previous reviews.
The authors could not identify any original research study report that rejected spinal manipulation of infants for colic on the grounds of being unsafe or with negative clinical outcomes.
As the authors did cite a few (by no means all) review papers that clearly showed the risks of spinal manipulation, one must ask what this statement was intended for. Was it to give the false impression that chiropractic spinal manipulations are safe?
The criticism of commentators seems to be that chiropractic care for infantile colic is no better than a placebo (147), the same ﬁnding for a common colic medication. (148) In other words, chiropractic care is equal to or just as effective as placebo and medication and therefore becomes the preferred clinical option on
the basis of safety and the absence of potential adverse effects. (63,149-151)
I fail to understand the logic behind this argument. The authors seem to admit that chiropractic care is a placebo therapy. To any reasonable person, this means that any benign and cost-free intervention (such as a gentle massage or cuddle by a parent) is preferable to an expensive and potentially harmful chiropractic treatment.
Chiropractic has been examined with rigour and found safe. Our interpretation of this evidence is that there is virtually no danger to infants from carefully applied manual methods by qualiﬁed providers and perhaps the best of both worlds is concomitant care among chiropractors and medical practitioners.
This conclusion is not supported by the evidence presented, and the authors do not explain how they arrived at it.
In addition to such irrational passages, we find plenty of nonsensical or factually incorrect statements in the authors’ pseudo-review. Here are a few examples that I found amusing:
Spinal manipulation as it is known today was brought to European medical doctors by chiropractors and osteopaths, (105) and since then it has become an entrenched medical practice in most European countries, particularly Germany. In Europe, the use of spinal manipulation within the medical profession for the management of infantile colic has been a well-recognised procedure for some decades. (38,43,63,106)
The chiropractic vertebral subluxation is recognised in the medical literature (107) contrary to unsupported claims that it cannot be identiﬁed. It is this type of mechanical spinal lesion that has been identiﬁed to address as a vertebrogenic factor under this model.
However, my favourite bit is this direct quote:
The evidence is that “Infantile colic is an easily identiﬁed childhood entity that has no clear treatment guidelines. The management of infantile colic varies among physicians, and families are often frustrated by the medical community’s inability to prescribe a cure for colic.”
The authors quote here from my own review, and remarkably it is the only quote from it. The authors otherwise ignore it completely and, crucially, they do also not list it as one of the 45 included papers. Why? To answer this question, we need to see what my review says. Here is its very short abstract:
Some chiropractors claim that spinal manipulation is an effective treatment for infant colic. This systematic review was aimed at evaluating the evidence for this claim. Four databases were searched and three randomised clinical trials met all the inclusion criteria. The totality of this evidence fails to demonstrate the effectiveness of this treatment. It is concluded that the above claim is not based on convincing data from rigorous clinical trials.
Call me biased, but I do believe that this is much closer to the truth than the lengthy pseudo-review above.
Let me finish this post by revealing who its authors are.
- Peter Rome, Chiropractor, retired
- John Waterhouse, Private practice of chiropractic
- Glenn Maginness, Private practice of chiropractic
- Phillip Ebrall, Tokyo College of Chiropractic
No funding was received for this study.
No author declared a conﬂict of interest (at least, this is what they claim).
No further contact details were provided.
My conclusion of all this:
We have to search long and far before we find a SCAM article that is more misleading and less competent than this one.