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

systematic review of the evidence for effectiveness and harms of specific spinal manipulation therapy (SMT) techniques for infants, children and adolescents has been published by Dutch researchers. I find it important to stress from the outset that the authors are not affiliated with chiropractic institutions and thus free from such conflicts of interest.

They searched electronic databases up to December 2017. Controlled studies, describing primary SMT treatment in infants (<1 year) and children/adolescents (1–18 years), were included to determine effectiveness. Controlled and observational studies and case reports were included to examine harms. One author screened titles and abstracts and two authors independently screened the full text of potentially eligible studies for inclusion. Two authors assessed risk of bias of included studies and quality of the body of evidence using the GRADE methodology. Data were described according to PRISMA guidelines and CONSORT and TIDieR checklists. If appropriate, random-effects meta-analysis was performed.

Of the 1,236 identified studies, 26 studies were eligible. In all but 3 studies, the therapists were chiropractors. Infants and children/adolescents were treated for various (non-)musculoskeletal indications, hypothesized to be related to spinal joint dysfunction. Studies examining the same population, indication and treatment comparison were scarce. Due to very low quality evidence, it is uncertain whether gentle, low-velocity mobilizations reduce complaints in infants with colic or torticollis, and whether high-velocity, low-amplitude manipulations reduce complaints in children/adolescents with autism, asthma, nocturnal enuresis, headache or idiopathic scoliosis. Five case reports described severe harms after HVLA manipulations in 4 infants and one child. Mild, transient harms were reported after gentle spinal mobilizations in infants and children, and could be interpreted as side effect of treatment.

The authors concluded that, based on GRADE methodology, we found the evidence was of very low quality; this prevented us from drawing conclusions about the effectiveness of specific SMT techniques in infants, children and adolescents. Outcomes in the included studies were mostly parent or patient-reported; studies did not report on intermediate outcomes to assess the effectiveness of SMT techniques in relation to the hypothesized spinal dysfunction. Severe harms were relatively scarce, poorly described and likely to be associated with underlying missed pathology. Gentle, low-velocity spinal mobilizations seem to be a safe treatment technique in infants, children and adolescents. We encourage future research to describe effectiveness and safety of specific SMT techniques instead of SMT as a general treatment approach.

We have often noted that, in chiropractic trials, harms are often not mentioned (a fact that constitutes a violation of research ethics). This was again confirmed in the present review; only 4 of the controlled clinical trials reported such information. This means harms cannot be evaluated by reviewing such studies. One important strength of this review is that the authors realised this problem and thus included other research papers for assessing the risks of SMT. Consequently, they found considerable potential for harm and stress that under-reporting remains a serious issue.

Another problem with SMT papers is their often very poor methodological quality. The authors of the new review make this point very clearly and call for more rigorous research. On this blog, I have repeatedly shown that research by chiropractors resembles more a promotional exercise than science. If this field wants to ever go anywhere, if needs to adopt rigorous science and forget about its determination to advance the business of chiropractors.

I feel it is important to point out that all of this has been known for at least one decade (even though it has never been documented so scholarly as in this new review). In fact, when in 2008, my friend and co-author Simon Singh, published that chiropractors ‘happily promote bogus treatments’ for children, he was sued for libel. Since then, I have been legally challenged twice by chiropractors for my continued critical stance on chiropractic. So, essentially nothing has changed; I certainly do not see the will of leading chiropractic bodies to bring their house in order.

May I therefore once again suggest that chiropractors (and other spinal manipulators) across the world, instead of aggressing their critics, finally get their act together. Until we have conclusive data showing that SMT does more good than harm to kids, the right thing to do is this: BEHAVE LIKE ETHICAL HEALTHCARE PROFESSIONALS: BE HONEST ABOUT THE EVIDENCE, STOP MISLEADING PARENTS AND STOP TREATING THEIR CHILDREN!

43 Responses to The effectiveness of chiropractic spinal manipulations/mobilisation for children is unproven. TIME TO STOP TREATING KIDS!

  • What bayesian studies have been performed or were they all classical ? How would you suggest they do a study that would convince you? Do you have issues with physios doing physio on kids?

  • Why do you presume the researchers have no conflict of interest?

  • So you found over 1000 articles filtered out 98% (not saying why). Leaving yourself with less that 30. 90% involving chiropractors. With a grand total of 5 adverse events. I’m wondering if you have done a review of ANY traditional medical intervention, & if you would have found a greater or lesser number of events. Since these incidences likely involved more that a single adjustment per patient, statistics might say that spinal manipulation of children is overwhelmingly safe.

    • read it again!
      it does not take so much intellect to understand that I did nothing – I am merely reporting on a recent publication.
      not that difficult to grasp, is it?

  • @Ernst How many more Tweets will you post to get chiropractors to come to your blog so you can insult them?

    https://twitter.com/BrownBagPantry/status/1179434901960974337

  • Actually it is complicated, but from your response you clearly don’t realise the complexity of doing medical research. E.g. needs approval by ethics committee etc. Funding doesn’t come cheap. Do you ever post anything constructive?

  • @ Edzard

    Looking through the 26 eligible studies for this review, 6 of the 26 studies had therapists who were not chiropractors. So about 23% of the studies were done by non-chiropractors – is that enough to change your title?

    Also the systematic review looked at mobilisations and manipulations but your title only includes the word manipulations – why is that, when they are two separate types of treatment?

    Anyway, I don’t think any therapist should use manipulation on Infants or children.

    • 9 of the 12 clinical trials (tab1) were done by chiros; 15 of the 19 harms (tab2) were doe by chiros, according to my count.
      I did put chiros in brackets – on reflection, I should remove not the chiros but the brackets in the title.
      thanks for alerting me to this.

      • @ Edzard

        Glad I could help you! So 23% is the margin of error you are happy to accept in the accuracy of your title – interesting!

        I counted 6 separate references which did not involve chiropractors from the 26 studies listed – maybe you should count again.

        You did not answer my second question – the systematic review looked at mobilisations and manipulations but your title only includes the word manipulations – why is that, when they are two separate types of treatment?

        • good point!
          the 2nd one, I mean.
          changed title again.

          • @ Edzard

            Thanks – Keep up the good work! Still need to improve on the accuracy of this title.

            As a suggestion, how about the title being – The effectiveness of spinal manipulations/mobilisation for children is unproven. CHIROPRACTORS (and other therapists) SHOULD STOP TREATING KIDS WITH THESE TECHNIQUES!

            Seems a fair title to me in reflection of the content of this systematic review.

        • AN. Actually, there is no such thing as “chiropractic spinal manipulation”. This has been pointed out several times in these blogs.

          • … and your notion has been discarded as often as you stated it.

          • You tried to discard it but you failed every time to make a valid argument.

            Spinal manipulation is utilized in at least four healthcare professions. No profession owns spinal manipulation. Spinal manipulation was being performed long before the chiropractic profession. Thus, there is no such thing as chiropractic spinal manipulation.

          • it’s about the hallmark that defines a profession.
            even hairdressers do spinal manipulation but they are not defined by it.
            chiropractors are keen to muddy the water by pointing out that they do much more than spinal manipulation. however, they employ it with almost every patient they treat – much more frequently than osteos, physios, or real doctors.

          • It’s who does the spinal manipulation. Thus, the proper way to state it is…

            Spinal manipulation performed by a chiropractor.
            Spinal manipulation performed by a physical therapist.
            Etc.

            Now if chiropractors performed 100% of spinal manipulations amongst healthcare providers I suppose one could call it chiropractic spinal manipulation. Until then, nope.

          • as usual, you are mistaken.

          • @ Edzard

            What would you say is the hallmark that defines the physical therapy profession?

            Also what did you think of my alternative title suggestion for this blog post?

          • therapeutic exercise – but I did not say that every profession has one.

          • EE…as usual, you are mistaken.

            logic says otherwise.

          • you mean the fallacious logic of chiros, don’t you?

          • the chiro logic is transparent: SMT is what we use most, but it is of debatable value. so, let’s stress the fact that we also do other stuff. if we succeed, we always have plenty of wriggle room when criticised for using SMT.

          • EE…the chiro logic is transparent: SMT is what we use most,

            still doesn’t make is chiropractic spinal manipulation.

          • many of the SMT techniques were developed by chiros, are used by chiros – thus, they are chiro SMTs.

          • EE…many of the SMT techniques were developed by chiros, are used by chiros – thus, they are chiro SMTs.

            http://www.apta.org/manipulation

            “Manipulation has been a vital part of the scope of PT practice since the inception of the profession”

            “No one profession invented or owns Manipulation”

            “Evidence shows that manipulation and exercise are PTs most useful tools”

            “Textbooks such as “Manual Physical Therapy of the Spine” (Saunders, Elsevier 2009) written by Physical Therapists”

          • I have had ample contact with physios; in my part of the world, they do not agree with this statement.
            SMT was mostly developed by chiros,
            SMT is taught in chiro schools [not in the physio schools I know],
            SMT is a central part of chiro textbooks [not of chiro textbooks],
            SMT is practised by virtually all chiros [not physios],
            SMT is used for all chiro patients [not physios]
            SMT is the hallmark therapy of chiro
            SMT is chiro

          • sigh, you really should get out more….

            EE…SMT is taught in chiro schools [not in the physio schools I know],

            “Fifty-one (44%) programs responding to the survey currently include joint manipulation in their curriculum.

            J Orthop Sports Phys Ther • Volume 34 • Number 4 • April 2004 173

          • “The Manipulation Education Manual (MEM) and related activities of the Manipulation Education
            Committee and the Manipulation Task Force are in place to support the continued development of
            manipulation instruction in physical therapist education by assisting faculty in their ability to integrate
            the current best-evidence–based interventions related to manipulation into educational activities. The
            specific purpose of the MEM is to provide resource information to assist faculty in curriculum
            planning and academic and clinical teaching related to manipulation.”

            “In this era of medical cost cutting, reimbursement agencies and other interested parties are demanding evidence-based interventions. Manipulation is a safe and effective clinical intervention, and its safety and effectiveness are not dependent upon the profession of the practitioner applying it or the specific techniques used. Although manipulation has been practiced since the era of Hippocrates, only
            recently has external evidence in the form of randomized clinical trials supported the safety and
            efficacy of manipulation.8 Notably, much of the research supporting the use of spinal manipulation
            has been conducted by physical therapists.8,9”

            Manipulation Education Committee APTA Manipulation Task Force

            Jointly sponsored by:
            Education Section and Orthopaedic Section, American Physical Therapy Association
            American Physical Therapy Association American Academy of Orthopaedic Manual Physical Therapists

            2004

          • Strange that I have received spinal manipulation by physios and osteopaths if it is purely chiropractors.

          • strange that you cannot understand even the simplest of statements – nobody ever claimed it’s purely chiros.
            perhaps not the brightest?

          • @ edzard

            Why does your title of this blog post willfully misrepresent the results of this systematic review?

          • I changed it after a discussion with someone who did not like the original; see comments

          • @ Edzard

            Maybe you should change the title to what I suggested earlier – see above

          • NO THANKS

          • How to win an argument, listen to others with respect, admit when wrong, understand your topic, be willing to admit when you lack knowledge of an area. How to lose an argument is to never admit when wrong as you lose credibility, to be rude, you lose credibility, to dismiss experts, you lose credibility. So how is your arguement going?

          • CHIROPRACTORS OWN “CHIROPRACTIC”

            Ali .A., DC:
            My whole reply/post was on this board. The post is message #3640. Dr. Badanes, read it, then judge me.

            OK. I have read it and you have been judged. Of course, I wonder what makes you think I had not read it previously, never mind considered what it says.

            In any case, here’s my judgment, since you asked:

            Chiropractors own The Chiropractic Adjustment and all the Subluxations that these so-called “Adjustments” supposedly correct. The Chiropractic Subluxation and “Thuh” Adjustment are what uniquely define “chiropractic” and that is what not only gives chiropractors their ownership of all these Subluxation/Adjustment pairs, but insists on it in any discussions of who should be doing what to whom and why –scope of practice, if you will.

            Generic manipulative therapy — a modality –is not owned by any profession in particular, but can be used by PTs, DOs, MDs and DCs. In other words, spinal manipulative therapy isn’t “chiropractic” any more than Mennell, Maitland, and Fisk are chiropractors.

            Even your statement about chiropractors making spinal manipulation its main form of treatment is debatable for the reasons stated above. Had you said, chiropractors use “Thuh” Adjustment to manage the Chiropractic Subluxations they diagnose, there would be no possibility of argument — by definition.

            Ali .A., DC:
            Why don’t you comment on the questions asked by the AHCPR review (also asked by the authors of the JAOA article).

            Is that a rhetorical question or are you asking me to comment now? No matter. I certainly don’t mind talking a bit about each of the the questions you posted. Let’s take a look:

            1. Is chiropractic really an alternative to medicine?

            The question needs to be more clearly stated before it can be answered. Did you (or the AHCPR, if you like) want to know if “chiropractic” is an Alternative Medicine™ — OR –is “chiropractic” an alternative treatment for any given medical diagnosis? These are two separate balls of chiropractic wax.

            Currently, “chiropractic” is a free-for-all of chirodigms asserting all manner of Chiropractic Subluxation/Adjustment combos. Of course, that doesn’t mean that every single licensed practitioner relies on one or more of these arbitrary diagnostic/treatment algorithms. But, according to chiropractors’ own statistics published in the NBCE “Job Analysis of Chiropractic,” there are enough ideas “out there,” that in any given chiropractic line-up, you can’t ever tell “which witch is which.” Even those who might be considered “more medical” (notably, a concept unique to the chiropractic profession), they, too, get hopelessly lost in the fracas, becoming still another kind of chiropractor doing still another –“more medical”– kind of “chiropractic.” In this way, then, “chiropractic” must be considered an Alternative Medicine™ –similar to homeopathy and TCM. It’s called “chiropractic,” in case you hadn’t noticed.

            Now, consider the other side of this chiropractic coin — “chiropractic” as a specific treatment for any given medical diagnosis such as glaucoma, hypertension, bicipital tendinitis, muscular dystrophy, or a boil, for example. While this is a more straightforward question to ask — can “chiropractic” effectively manage hypercholesterolemia, let’s say, compared to a statin –again there’s no good answer, and for a similar reason. Which “chiropractic” are you referencing when you say “chiropractic?”

            It’s a little like saying, “Mediciine can lower cholesterol” without stating which particular treatment, from everything that’s medical, has been demonstrated to lower it. “Chiropractic” is like having a pharmacy with only one medicine on its shelves –but with many different colors and shapes of pills, all indicated for, and presumably equally effective for the same thing. Just take two chiropractors and call me in the morning.

            It’s possible, I imagine, for you to comb the literature and find some specific studies that suggest spinal manipulative therapy (SMT) is sometimes helpful for some people some of the time for some named diagnosis. But then, recall that SMT isn’t “chiropractic” anymore than Mennell, Fisk, and Maitland are chiropractors. An endorsement of SMT for a named condition only means that it is a treatment option –not an entire profession as chiropractors would like to believe. SMT isn’t an Alternative Medicine but “chiropractic” is — at least until it can be defined consistently from one chiropractor to another and as something more specific than: “Anything done by a chiropractor.”

            2. Is there a complementary role that includes collaborative care?

            Do you mean a complementary role for Activator, NUCCA, Thompson, Chiropractic BioPhysics, Motion Palpation, Gonstead, SOT, Toftness, AK, and Pierce-Stillwagon practitioners, let’s say, to treat … *burp* … “whut?” What’s Collaborative Care™, anyways, without a diagnosis and a statement of what therapy you’re using, what OTHER “collaborative” therapy is being used with it, and who you’re collaborating with? Yes, I can see a chiropractor collaborating with another practitioner — an acupuncturist or a homeopath, for example– although I think “colluding” would be a more appropriate term, if you know what I mean.

            Again, if you (or the AHCPR, if you prefer) are referencing some sort of manual medicine as part of the management, let’s say, of a peripheral neuropathy in a diabetic — I wouldn’t consult the Yellow Pages for a chiropractor. Would you? It’s a crap shoot once you open the door to the Chiropractic Byzantium even for the management of a headache. That’s what we’re talking about, in case you hadn’t noticed. Collaborations can only occur when collaborators are on the same medical or non-medical page. This is more likely to occur with a PT, DO, or another MD. Even the few DCs who do “collaborate” often aren’t really “collaborating” –in the so-called “multidisciplinary setting,” let’s say. Too often, the only thing the massage therapist and/or DC have in common with the MD is the secretary who coordinates the patient billing.

            I wouldn’t call what PTs do a “collaboration,” either. An MD might refer to one, even within the same office, for a course of some sort of physical therapy. In a similar fashion, I suppose an MD might refer a patient for a trial of Chiropractic Care(TM). But, how would they do this without knowing which “chiropractic” their patient was going to get? In other words, is the patient going to get a trial of SMT or “chiropractic” if they are referred to an Activator office, let’s say.

            It’s a jungle out there in Chiroville. Until this is resolved completely –there’s hardly much more that can be said about “working” together and/or “collaborating” –except for a DC here and there, perhaps. And, what can be done about this, really, except to put padlocks on most every chiropractic school door. If you do this, however, what are you going to tell Dr. Blum and his organization of SOT adherents? What is SOTO-USA going to tell you? What are the Gonsteaders going to do with their neurocalometers and rolling X-ray markers? And what is the Upper Cervicalist, who has put all their chiropractic eggs into a monobonal basket, supposed to tell their patients — that they were only kidding?

            You see the problem.

            3. Should chiropractic remain a separate and distinct profession or seek inclusion into medicine as a subspecialty in musculoskeletal conditions?

            What musculoskeletal conditions and what subspecialty of medicine are we talking about — a new “subspecialty” called “chiropractic?”

            I think, in a society with limited health care resources, chiropractors should take responsibility for their mess, give-up the chiropractic ghost, and gracefully bow-out of the race. If people want to see a chiropractor, homeopath, acupuncturist, colonic therapist, or psychic healer — this should remain their business, but not mine. Enthusiasts can pay out of pocket like they would for any other form of entertainment.

            If a trial of manipulative therapy in a particular patient is warranted, have it done by a trained physical therapist. The argument we hear from chiropractors that PTs don’t have enough training is easily remediable — considerably easier and more “down-hill” compared to cleaning a chiropractic house, in case you hadn’t noticed. For one reason after another, chiropractors apparently don’t have what it takes to heal themselves. For one thing, they can’t imagine that they’re ill in any way. “Sure we’ve got problems; every profession has problems” is as close as I’ve observed chiropractors ever get to house-cleaning.

            4. Should chiropractic education seek affiliation with major universities and colleges housing medical education?

            If you’ve read this far, I think you’ll understand –but maybe not agree– why I would think this is a bad idea. For one thing, it assumes “a chiropractic” that has yet, despite all the inertia and infrastructure that’s in place, to establish itself in any consistent and credible way. Have you noticed? It’s that “free-for-all” thing again. So, at the very least, it would be a waste of a society’s already limited resources, in my opinion.

            Since its inception, chiropractic oobleck has been finding its way through every crack it can find in the health care woodwork. Some of this is just the mindless automatism of the chiropractic organism finding new and better ways to adapt and survive. Affiliating with universities, medical schools, and hospitals seems to represent such an effort. I guess the idea would be to get close to medical science and medicine as a way of legitimizing a profession with its long history of anything “butt.”

            A chiropractor can say, “SEE? That’s me standing next to a medical doctor” –the hope being that the critical association will be made. And, I suppose there’s some idea that since chiropractors can’t take responsibility for what takes place at most every one of their own pantheons of chiropractism, they might imagine that these chiropractic ding-dong schools will at some point fall off their chiropractic body like so much dead skin.

            In short, I think this sort of chiropractic maneuvering is poorly motivated, self-serving, and neurotically driven.

            ~TEO.

  • If my doctor recommended I would have no issues taking any of my kids to a chiropractor. All I see is people like you just scaremongering.

  • SMT is also taugth in physio schools.

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