Informed consent for chiropractors who treat children

I came across an article entitled “Consent for Paediatric Chiropractic Treatment (Ages 0-16)“. Naturally, it interested me. Here is the full paper; I have only inserted a few numbers in square brackets which refer to my comments below:

By law, all Chiropractors are required to inform you of the risks and benefits of chiropractic spinal manipulation and the other types of care we provide. Chiropractors use manual therapy alongside taking a thorough history, and doing a neurological, orthopaedic and chiropractic examination to both diagnose and to treat spinal, cranial and extremity dysfunction.  This may include taking joints to the end range of function, palpating soft tissues (including inside the mouth and the abdomen), mobilisation, soft tissue therapy and very gentle manipulation [1]. Our Chiropractors have been educated to perform highly specific types of bony or soft tissue manipulation and we strive to follow a system of evidence-based care [2].  At the core of our belief system is “Do No Harm”. We recognise that infants and children are not tiny adults.  The force of an adjustment used in a child is at least less than half of what we might use with a fully grown adult.  Studies by Hawk et al (2016) and Marchand (2013) agreed that Chiropractors use 15 – 35 x less force in the under 3-month age group when compared to medical practitioners doing manipulation (Koch, 2002) [3].  We also use less force in all other paediatrics groups, especially when compared to adults (Marchand, 2013). In addition to using lower force, depth, amplitude and speed in our chiropractic adjustments [4], we utilise different techniques. We expect all children under the age of 16 years to be accompanied by a responsible adult during appointments unless prior permission to treat without a consenting adult e.g., over the age of 14 has been discussed with the treating chiropractor.

Risks

• Research into chiropractic care for children in the past 70 years has shown it to have a low risk of adverse effects (Miller, 2019) [5]. These effects tend to be mild and of short duration e.g., muscular or ligament irritation. Vorhra et al (2007) found the risk of severe of adverse effects (e.g. fracture, quadriplegia, paraplegia, and death) is very, very rare and was more likely to occur in individuals where there is already serious underlying pathology and missed diagnosis by other medical profession [6].  These particular cases occurred more than 25 years ago and is practically unheard of now since research and evidence-based care has become the norm [7].
• The most common side effect in infants following chiropractic treatment includes fussiness or irritability for the first 24 hours, and sleeping longer than usual or more soundly. (Miller and Benfield, 2008) [8]
• In older children, especially if presenting with pain e.g., in the neck or lower back, the greatest risk is that this pain may increase during examination due to increasing the length of involved muscles or ligaments [9]. Similarly, the child may also experience pain, stiffness or irritability after treatment (Miller & Benfield, 2008) [10].  Occasionally children may experience a headache.[11] We find that children experience side effects much less often than adults.[12]

Benefits

• Your child might get better with chiropractic care. [13] If they don’t, we will refer you on [14].
• Low risk of side effects and very rare risk of serious adverse effects [15].
• Drug-free health care. We are not against medication, but we do not prescribe [16].
• Compared with a medical practitioner, manual therapy carried out by a chiropractor is 20 x less likely to result in injury (Koch et al 2002, Miller 2009).[17]
• Children do not often require long courses of treatment (>3 weeks) unless complicating factors are present.[18]
• Studies have shown that parents have a high satisfaction rate with Chiropractic care [19].
• Physical therapies are much less likely to interfere with biomedical treatments. (McCann & Newell 2006) [20]
• You will have a better understanding of diagnosis of any complain and we will let you know what you can do to help.[21]

We invite you to have open discussions and communication with your treating chiropractor at all times.  Should you need any further clarification please just ask.

References

• Hawk, C. Shneider, M.J., Vallone, S and Hewitt, E.G. (2016) – Best practises recommendations for chiropractic care of children: A consensus update. JMPT, 39 (3), 158-168.
• Marchand, A. (2013) – A Proposed model with possible implications for safety and technique adaptations for chiropractic spinal manipulative therapy for infants and children.   JMPT, 5, 1-14
• Koch L. E., Koch, H, Graumann-Brunnt, S. Stolle, D. Ramirez, J.M., & Saternus, K.S. (2002) – Heart rate changes in response to mild mechanical irritation of the high cervical cord region in infants. Forensic Science International, 128, 168-176
• Miller J (2019) – Evidence-Based Chiropractic Care for Infants: Rational, Therapies and Outcomes. Chapter 11: Safety of Chiropractic care for Infants p111. Praeclarus Press
• Vohra, S. Johnston, B.C. Cramer, K, Humphreys, K. (2007) – Adverse events associated with paediatric spinal manipulation: A Systematic Review. Pediatrics, 119 (1) e275-283
• Miller, J and Benfield (2008) – Adverse effects of spinal manipulative therapy in children younger than 3 years: a retrospective study in a chiropractic teaching clinic. JMPT Jul-Aug;31(6):419-23.
• McCann, L.J. & Newell, S.J. (2006). Survey of paediatric complementary and alternative medicine in health and chronic disease. Archives of Diseases of Childhood, 91, 173-174
• Corso, M.,  Cancelliere, C. ,  Mior., Taylor-Vaise, A.   Côté, P. (2020) – The safety of spinal manipulative therapy in children under 10 years: a rapid review. Chiropractic Manual therapy 25: 12

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1.  “taking joints to the end range of function” (range of motion, more likely) is arguably not “very gently”;
2.  “we strive to follow a system of evidence-based care”; I do not think that this is possible because pediatric chiropractic care is hardy evidence-based;
3.  as a generalizable statement, this seems to be not true;
4.  ” lower force, depth, amplitude and speed”; I am not sure that there is good evidence for that;
5.  research has foremost shown that there might be significant under-reporting;
6.  to blame the medical profession for diagnoses missed by chiropractors seems odd;
7.  possibly because of under-reporting;
8.  possibly because of under-reporting;
9.  possibly because of under-reporting;
10.  possibly because of under-reporting;
11.  possibly because of under-reporting;
12.  your impressions are not evidence;
13. your child might get even better without chiropractic care;
14. referral rates of chiropractors tend to be low;
15. possibly because of under-reporting;
16. chiropractors have no prescription rights but some lobby hard for it;
17. irrelevant if we consider the intervention useless and thus obsolete;
18. any evidence for this statement?;
19. satisfaction rates are no substitute for real evidence;
20. that does not mean they are effective, safe, or value for money;
21. this is perhaps the strangest statement of them all – do chiropractors think they are the optimal diagnosticians for all complaints?

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According to its title, the paper was supposed to deal with consent for chiropractic pediatric care. It almost totally avoided the subject and certainly did not list the information chiropractors must give to parents before commencing treatment.

Considering the arguments that the article did provide has brought me to the conclusion that chiropractors who treat children are out of touch with reality and seem in danger of committing child abuse.