The purpose of this review was to

  • identify and map the available evidence regarding the effectiveness and harms of spinal manipulation and mobilisation for infants, children and adolescents with a broad range of conditions;
  • identify and synthesise policies, regulations, position statements and practice guidelines informing their clinical use.

Two reviewers independently screened and selected the studies, extracted key findings and assessed the methodological quality of included papers. A descriptive synthesis of reported findings was undertaken using a level-of-evidence approach.

Eighty-seven articles were included. Their methodological quality varied. Spinal manipulation and mobilisation are being utilised clinically by a variety of health professionals to manage paediatric populations with

  • adolescent idiopathic scoliosis (AIS),
  • asthma,
  • attention deficit hyperactivity disorder (ADHD),
  • autism spectrum disorder (ASD),
  • back/neck pain,
  • breastfeeding difficulties,
  • cerebral palsy (CP),
  • dysfunctional voiding,
  • excessive crying,
  • headaches,
  • infantile colic,
  • kinetic imbalances due to suboccipital strain (KISS),
  • nocturnal enuresis,
  • otitis media,
  • torticollis,
  • plagiocephaly.

The descriptive synthesis revealed: no evidence to explicitly support the effectiveness of spinal manipulation or mobilisation for any condition in paediatric populations. Mild transient symptoms were commonly described in randomised controlled trials and on occasion, moderate-to-severe adverse events were reported in systematic reviews of randomised controlled trials and other lower-quality studies. There was strong to very strong evidence for ‘no significant effect’ of spinal manipulation for managing

  • asthma (pulmonary function),
  • headache,
  • nocturnal enuresis.

There was inconclusive or insufficient evidence for all other conditions explored. There is insufficient evidence to draw conclusions regarding spinal mobilisation to treat paediatric populations with any condition.

The authors concluded that, whilst some individual high-quality studies demonstrate positive results for some conditions, our descriptive synthesis of the collective findings does not provide support for spinal manipulation or mobilisation in paediatric populations for any condition. Increased reporting of adverse events is required to determine true risks. Randomised controlled trials examining effectiveness of spinal manipulation and mobilisation in paediatric populations are warranted.

Perhaps the most important findings of this review relate to safety. They confirm (yet again) that there is only limited reporting of adverse events in this body of research. Six reviews, eight RCTs and five other studies made no mention of adverse events or harms associated with spinal manipulation. This, in my view, amounts to scientific misconduct. Four systematic reviews focused specifically on adverse events and harms. They revealed that adverse events ranged from mild to severe and even death.

In terms of therapeutic benefit, the review confirms the findings from the previous research, e.g.:

  • Green et al (Green S, McDonald S, Murano M, Miyoung C, Brennan S. Systematic review of spinal manipulation in children: review prepared by Cochrane Australia for Safer Care Victoria. Melbourne, Victoria: Victorian Government 2019. p. 1–67.) explored the effectiveness and safety of spinal manipulation and showed that spinal manipulation should – due to a lack of evidence and potential risk of harm – be recommended as a treatment of headache, asthma, otitis media, cerebral palsy, hyperactivity disorders or torticollis.
  • Cote et al showed that evidence is lacking to support the use of spinal manipulation to treat non-musculoskeletal disorders.

In terms of risk/benefit balance, the conclusion could thus not be clearer: no matter whether chiropractors, osteopaths, physiotherapists, or any other healthcare professionals propose to manipulate the spine of your child, DON’T LET THEM DO IT!

22 Responses to Spinal manipulation or mobilisation for kids? No, stay away from both!

  • Why do papers like this so often call for more research? There is no plausible mechanism by which spinal manipulation would treat for example nocturnal enuresis or asthma. Therefore there is no robust prior probability on which to base a trial. Indeed such trials would not even be ethical bearing in mind the documented risks of manipulation.

    • it’s like a reflex of authors to add this to their paper – I am sure I have been guilty of this crime many times too.

    • LR: Why do papers like this so often call for more research?

      Because many of their findings were labeled as inclusive or insufficient.

    • I would advocate for a far bigger role of the Bayesian principle: the lower the plausibility of a studied mechanism or effect, the higher the requirements for things such as significance and calls for extended research.
      The problem of course is that most adherents of alternative modalities will dispute the usually low to very prior plausibility of those modalities, and that this plausibility is very hard to measure at any rate.

      • RR: the lower the plausibility of a studied mechanism or effect,

        And that’s the baseline issue: they haven’t established or researched for a biologically plausible mechanism/s for most/all of these conditions (from what I have read). Until that’s put forth the inclusion/exclusion criteria and objective outcome measures are basically pulled out of the air.

        IMO the authors conclusion should have been: start with the basic science research because that will/may help drive the direction of the clinical science research.

    • Further research is needed

      The phrases “further research is needed” (FRIN), “more research is needed” and other variants are commonly used in research papers. The cliché is so common that it has attracted research, regulation and cultural commentary.

      Some research journals have banned the phrase “more research is needed” on the grounds that it is redundant;[1] it is almost always true and fits almost any article, and so can be taken as understood.

      A 2004 metareview by the Cochrane collaboration of their own systematic medical reviews found that 93% of the reviews studied made indiscriminate FRIN-like statements, reducing their ability to guide future research. The presence of FRIN had no correlation with the strength of the evidence against the medical intervention. Authors who thought a treatment was useless were just as likely to recommend researching it further.

      Indeed, authors may recommend “further research” when, given the existing evidence, further research would be extremely unlikely to be approved by an ethics committee.

      Studies finding that a treatment has no noticeable effects are sometimes greeted with statements that “more research is needed” by those convinced that the treatment is effective, but the effect has not yet been found. Since even the largest study can never rule out an infinitesimal effect, an effect can only ever be shown to be insignificant, not non‑existent. Similarly, Trisha Greenhalgh, Professor of Primary Care Health Sciences at the University of Oxford, argues that FRIN is often used as a way in which a “lack of hard evidence to support the original hypothesis gets reframed as evidence that investment efforts need to be redoubled”, and a way to avoid upsetting hopes and vested interests. She has also described FRIN as “an indicator that serious scholarly thinking on the topic has ceased”, saying that “it is almost never the only logical conclusion that can be drawn from a set of negative, ambiguous, incomplete or contradictory data.”

      [1] Godlee, Fiona (25 August 2010). “More research is needed—but what type?”. BMJ 2010;341:c4662.

      Further research is needed, Wikipedia

    • Let alone developmental issues like ADHD or autism.

      And as for cerebral palsy…

  • Indeed, the only further research needed, would be pertaining to whether criminal charges would be warranted in such outrageous health care claims.

  • I would suggest that you read the book, “Manual Therapy in Children”, edited by the German orthopaedic surgeon, Heiner Biedermann. The list of contributors is very impressive, including neurologists, orthodontists, orthopaedic surgeons and pediatricians. It deals with subjects such as dyspraxia and dysgnosia as well as the importance of the cervical spine in the autonomic regulatory system and attention deficit disorders. Well worth the purchase and read.

  • As the twig is bent, so grows the tree.

    • are you trying to say that chiros are bent?

      • Chiropractors are bent on healing the sick, safely with all ages. Early next year the final report from Safer Care Victoria will be released which will answer many concerns but will cause the formulation of many new questions.

          • As copied from their website:
            “The Paediatric Improvement Collaborative aims to reduce unwarranted variation in clinical care by developing, endorsing, publishing and promoting evidence-based paediatric clinical practice guidelines. These outline best practice clinical management of high-volume and high-risk paediatric clinical conditions. It is hoped the collaboration will become a national entity over the next few years”.

            I understand they formed this oversight organization back in 2017. I appreciate that they claim to be evidence based and sincerely hope that they do indeed address the dangers of Chiropractic in any upcoming reports, specifically when it involves the wellbeing and care of our most precious in society.

            I look forward to reading their recommendations following their upcoming publication.

    • Not all that it’s cracked up to be,
      “As the twig is bent so grows the tree”.
      The concept applied
      To the column inside
      By the Palmers, B.J. and D.D.

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