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

This press-release caught my attention:

Following the publication in Australia earlier this year of a video showing a chiropractor treating a baby, the Health Minster for the state of Victoria called for the prohibition of chiropractic spinal manipulation for children under the age of 12 years. As a result, an independent panel has been appointed by Safer Care Victoria to examine the evidence and provide recommendations for the chiropractic care of children.

The role of the panel is to (a) examine and assess the available evidence, including information from consumers, providers, and other stakeholders, for the use of spinal manipulation by chiropractors on children less than 12 years of age and (b) provide recommendations regarding this practice to the Victorian Minister for Health.
Members of the public and key stakeholders, including the WFC’s member for Australia, the Australia Chiropractors Association (AusCA), were invited to submit observations. The AusCA’s submission can be read here

_________________________________________________________

This submission turns out to be lengthy and full of irrelevant platitudes, repetitions and nonsense. In fact, it is hard to find in it any definitive statements at all. Here are two sections (both in bold print) which I found noteworthy:

1. There is no need to restrict parental or patient choice for chiropractic care for children under 12 years of age as there is no evidence of harm. There is however, expressed outcome of benefit by parents70 who actively choose chiropractic care for their children … 

No evidence of harm? Really! This is an outright lie. Firstly, one has to stress that there is no monitoring system and that therefore we simply do not learn about adverse effects. Secondly, there is no reason to assume that the adverse effects that have been reported in adults are not also relevant for children. Thirdly, adverse effects in children have been reported; see for instance here. Fourthly, we need to be aware of the fact that any ineffective therapy causes harm by preventing effective therapies from being applied. And fifthly, we need to remember that some chiropractors harm children by advising their parents against vaccination.

2. Three recent systematic reviews have focused on the effectiveness of manual therapy for paediatric conditions. For example, Lanaro et al. assessed osteopathic manipulative treatment for use on preterm infants. This systematic review looked at five clinical trials and found a reduction of length of stay and costs in a large population of preterm infants with no adverse events (96).

Carnes et al.’s 2018 systematic review focused on unsettled, distressed and excessively crying infants following any type of manual therapy. Of the seven clinical trials included, five involved chiropractic manipulative therapy; however, meta-analyses of outcomes were not possible due to the heterogeneity of the clinical trials. The review also analysed an additional 12 observational studies: seven case series, three cohort studies, one service evaluation survey, and one qualitative study. Overall, the systematic review concluded that small benefits were found. Additionally, the reporting of adverse events was low. Interestingly, when a relative risk analysis was done, those who had manual therapy were found to have an 88% reduced risk of having an adverse event compared to those who did not have manual therapy (97).

A third systematic review by Parnell Prevost et al. in 2019 evaluated the effectiveness of any paediatric condition following manual therapy of any type and summarizes the findings of studies of children 18 years of age or younger, as well as all adverse event information. While mostly inconclusive data were found due to lack of high-quality studies, of the 32 clinical trials and 18 observational studies included, favourable outcomes were found for all age groups, including improvements in suboptimal breastfeeding and musculoskeletal conditions. Adverse events were mentioned in only 24 of the included studies with no serious adverse events reported in them (98).

(96) Lanaro D, Ruffini N, Manzotti A, Lista G. Osteopathic manipulative treatment showed reduction of length of stay and costs in preterm infants: A systematic review and meta-analysis. Medicine (Baltimore). 2017; 96(12):e6408 10.1097/MD.0000000000006408.

(97) Carnes D, Plunkett A, Ellwood J, Miles C. Manual therapy for unsettled, distressed and excessively crying infants: a systematic review and meta-analyses. BMJ Open 2018;8:e019040. doi:10.1136/bmjopen-2017-019040.

(98) Parnell Prevost et al. 2019.

____________________________________________________________________

And here are my comments:

(96) Lanaro et al is about osteopathy, not chiropractic (4 of the 5 primary trials were by the same research group).

(97) The review by Carnes et al has been discussed previously on this blog. This is what I wrote about it at the time:

The authors concluded that some small benefits were found, but whether these are meaningful to parents remains unclear as does the mechanisms of action. Manual therapy appears relatively safe.

For several reasons, I find this review, although technically sound, quite odd.

Why review uncontrolled data when RCTs are available?

How can a qualitative study be rated as high quality for assessing the effectiveness of a therapy?

How can the authors categorically conclude that there were benefits when there were only 4 RCTs of high quality?

Why do they not explain the implications of none of the RCTs being placebo-controlled?

How can anyone pool the results of all types of manual therapies which, as most of us know, are highly diverse?

How can the authors conclude about the safety of manual therapies when most trials failed to report on this issue?

Why do they not point out that this is unethical?

My greatest general concern about this review is the overt lack of critical input. A systematic review is not a means of promoting an intervention but of critically assessing its value. This void of critical thinking is palpable throughout the paper. In the discussion section, for instance, the authors state that “previous systematic reviews from 2012 and 2014 concluded there was favourable but inconclusive and weak evidence for manual therapy for infantile colic. They mention two reviews to back up this claim. They conveniently forget my own review of 2009 (the first on this subject). Why? Perhaps because it did not fit their preconceived ideas? Here is my 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.

Towards the end of their paper, the authors state that “this was a comprehensive and rigorously conducted review…” I beg to differ; it turned out to be uncritical and biased, in my view. And at the very end of the article, we learn a possible reason for this phenomenon: “CM had financial support from the National Council for Osteopathic Research from crowd-funded donations.”

(98) Parnell et al was easy to find despite the incomplete reference in the submission. This paper has also been discussed previously. Here is my post on it:

This systematic review is an attempt [at] … 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.

_________________________________________________________________

The ACA’s submission ends with the following conclusion:

The Australian Chiropractors Association (ACA) intent is to improve the general health of all Australians and the ACA supports the following attributes to achieve this:

      • The highest standards of ethics and conduct in all areas of research, education and practise
      • Chiropractors as the leaders in high quality spinal health and wellbeing
      • A commitment to evidence-based practice – the integration of best available research evidence, clinical expertise and patient values
      • The profound significance and value of patient-centred chiropractic care in healthcare in Australia.
      • Inclusiveness and collaborative relationships within and outside the chiropractic profession…

After reading through the entire, tedious document, I arrived at the conclusion that

THIS SUBMISSION CAN ONLY BE A CALL FOR THE PROHIBITION OF CHIROPRACTIC SPINAL MANIPULATION FOR CHILDREN.

20 Responses to Towards the prohibition of chiropractic spinal manipulation for children

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

    Yet manual therapy is in the clinical guidelines for CMT. Should PTs stop?

    http://pt.or.th/download/cpg/P01.pdf

    Physical Therapy Management of Congenital Muscular Torticollis: An Evidence-Based Clinical Practice Guideline

    “PHYSICAL THERAPY INTERVENTION FOR INFANTS WITH CMT
    Manual stretching is the most common form of treatment for CMT.”

    • “I would say that there is no good evidence for chiropractic, osteopathic or other manual treatments for children suffering from any condition.
      Yet manual therapy is in the clinical guidelines for CMT. Should PTs stop?”
      yes

      • It will be interesting to see if PTs and their organizations call for a ban on manual therapy for congenital torticollis (or for any other condition)…even though their most recent guidelines place it as a first intervention for CMT.

        • This was published in 2013. Did PTs stopped treating LBP in this population?

          “It should also be noted that the results of research on the effectiveness of physical therapy in children and adolescents with LBP have serious methodological flaws in their design, implementation and data analysis. Assignment of subjects to groups should be random, masked assessors should be used and intent-to-treat analyses should be carried out. All of these measures will enable us to have greater control of potential biases in the treatment effect estimates.”

          https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/1471-2474-14-55#MOESM2

  • Do you plan to offer a submission? If it’s not too late, please do.

  • “Towards the prohibition of chiropractic spinal manipulation for children”

    This is not how healthcare works this is purely political.
    If you want to BAN practices that have minor adverse effects and questionable evidence behind them, I suggest to start with few medical procedures I can think of. Or is it just when it comes to Chiropractic, we place a different standard?
    In real healthcare no one is banning practices but rather place proper guidelines. And I am of course totally in favor of such practice guidelines.

    “there is no good evidence for chiropractic, osteopathic or other manual treatments for children suffering from any condition”…
    now lets say this is true… that we should not make assumptions and extrapolate from adults studies to pediatrics… if so how do you explain this
    “there is no reason to assume that the adverse effects that have been reported in adults are not also relevant for children” ???
    So when it comes to the benefit from treatment you claim we should not use adult studies but when it comes to adverse effects than its OK???

    No evidence of harm? Really! This is an outright lie” … adverse effects are not harm.

    One last thing… as I wrote before we need to be extra carful with treating children for many different reasons. I don’t like that video you referred to and I am in favor of sound clinical guidelines and for them to be reinforced by the regulatory agencies. Politicizing the matter is nice for PR but this eventually will not bring about better, safer healthcare for children in Australia.

    • you are soooooooooooooooo wrong!

    • “No evidence of harm? Really! This is an outright lie” … adverse effects are not harm.”

      Delayed treatment by a real doctor because you are feeding someone woo can cause considerable harm, even death.

      Just sayin’.

    • This is not how healthcare works this is purely political.
      If you want to BAN practices that have minor adverse effects and questionable evidence behind them, I suggest to start with few medical procedures I can think of. Or is it just when it comes to Chiropractic, we place a different standard?

      1. Hmm… I wouldn’t consider death as a “minor adverse effect”.

      2. False dichotomy. If you have a “few medical procedures” you think need attention by all means call them out. If your claims are valid you’ll get support from skeptics and the medical community.

      3. You do realise that you are also guilty of pulling Chiro out for special attention here? What is being proposed is that Chiro be forced to abide by the usual standards of reporting that is considered normal in other, real, medical fields.

      …I am in favor of sound clinical guidelines and for them to be reinforced by the regulatory agencies

      This isn’t a new thing. The regulatory agencies have proven to be ineffective and more of a shield for their members than a safety net for the public. If this wasn’t the case then perhaps your point would be valid. Perhaps you should be pushing for the Chiro community to get the regulatory agencies to actually do what they’re supposed to be doing? As for many of the rest of us, we’re at the point where we realise that that approach isn’t working.

      • CG…”What is being proposed is that Chiro be forced to abide by the usual standards of reporting that is considered normal in other, real, medical fields.”

        Although it may vary by country, last i saw, in places like the USA, professions such as physical therapy, dentistry and optometry do not have a “forced” standard of reporting of adverse events. So i am not sure what you are calling normal.

  • We shall live and see… I will be waiting for your post about the ban of Chiropractic treatment for children in Australia…I won’t be holding my breath though

    • and you are wrong again
      [I did not say it will be banned]
      try not to behave like a moron, please

    • From my understanding what is being discussed in Australia is a required referral from a MD for children under the age of 12.

      Consdiering some of strange things occuring there it may not be a bad idea at this time.

  • Enlighten me ho wise one… why is it OK to assume AE recorded in adults will show up in children??? And also what does “prohibition of chiropractic spinal manipulation for children” means other than the ban to manipulate children?

    Also, if you don’t care to answer to the point that is ok but that does not make me a moron… Although you did make me lough in the middle of a long working day and for that I thank you 🙂

    • Ban: to forbid someone to do something or forbid an action

      Prohibit: to officially forbid something

      Forbid: to not allow something, or to order someone not to do something

      (Cambridge dictionary)

  • Sounds like “chiropractic”…

    “Treatment includes realignment of the sacroiliac joint with physical therapy and strengthening exercises”

    “The diagnosis is made by physical examination and treatment can focus on correcting biomechanical deficits…”

    Diagnosis and Treatment of Low Back Pain in the Pediatric Population. Alysha J. Taxter, MD, Nancy A. Chauvin, MD, Pamela F. Weiss, MD, Phys Sportsmed. 2014 Feb; 42(1): 94–104

  • I hope you make a submission to the Inquiry. Be not deterred by living in another country; the Inquiry needs the input of genuine experts.

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