Adjusting Children, Part 2

Elizabeth Anderson-Peacock
June 05, 2012
Written by Elizabeth Anderson-Peacock
In part 2, we will address two issues relating to maintaining: i) communication of our care within the chiropractic scope of practice, and ii) safety.

In my experience, challenges often arise from miscommunication or misinterpretation. Both issues stem from a lack of clarity in the message. Because we see results in a myriad of expressions of ill health, we often do become known as an alternative for a number of seemingly unrelated conditions such as asthma, colic, ear infections, etc., while we do not per se “treat” these conditions at all.

With our patients, we have an opportunity to clarify what we do and discuss the hypothesized mechanisms of how the adjustment impacts physiology. Through education of parents and others, we create a revised understanding of previously held beliefs. Greater understanding usually means greater ownership, involvement and partnership in care.

Biomechanics, the spine and function
Parents, who are untrained, do not “see” the connection between the “biomechanical problem and a disorder of the spinal engine and impact on physiological function.”1

child_table  
Table 1. Spigelblatt summary table on conditions and percentage alternative medicine (A.M.) provider consulted.

 
The fact that the evidence base is growing in this area is demonstrated through the texts of Biedermann,2 Merillo3,4 and others on neurological integrity through proper spinal function and its impact on brain, immune, cognitive/emotional development, growth and physiology. In other words, we should remember that while the infants are unable to speak, they are actually telling us so much when we observe and inquire regarding their daily habits. Furthermore, we can engage the parents in the process through educating them on our findings and what those findings mean. 

According to the research of Spigelblatt,5,6 chiropractic is the most commonly used alternative health-care provider for a myriad of complaints. Her paper identifies the most common reasons parents sought alternative health-care providers – these are noted in Table 1.

What does our scope of practice tell us to do?
Depending on the province you practise in, the wording might vary, but the scope of chiropractic is similar. In Ontario, the Chiropractic Act of 1991 states that “the assessment of conditions related to the spine, nervous system and joints and the diagnosis, prevention and treatment, primarily by adjustment of …”7 With our scope in mind we may evaluate children with various expressions of poor allostasis and “dis-ease” but there is an ongoing need to keep educating parents that we are not treating “x” condition but a spinal-muscular-neurological problem impacting function in a way that is within our scope.

To illustrate:
Case Study #1: A child with a medically diagnosed recurrent otitis media

 While we are not treating the otitis media, if findings indicate aberrant function in the motion of the spine – most often, of the upper cervical spine – we may encounter effects of vertebral subluxation complex patterns with muscle hypertonicity, loss in range of motion, specific chiropractic subluxation, and other elements of soft tissue congestion such as heat, swelling or lymph nodes. Those findings bring caring for that child into the chiropractic scope. Throughout the child’s program of care, some chiropractors may choose to observe the tympanum, pre- and post-care, by way of otic examination – or refer to audiologists to monitor tympanum flexibility – to document the possibility of impact in physiology from the adjustments. But, while we are seeing many successful cases and combined reports where adjusting the child for neuromusculoskeletal findings appears to correlate to improvement of the otitis as well, we must be clear that we are not treating the otitis itself.

Case Study #2: A child with medically diagnosed asthma 
Chiropractic care calls for “the assessment of conditions related to the spine, nervous system and joints and the diagnosis, prevention and treatment, primarily by adjustment of …”7

However, while we do not treat asthma, we do find that many of these children present with subluxation patterns, muscular hypertonitities, congestion in soft tissues, costochondral/costovertebral dysfunctions that we can address through adjustments as well as challenges in their environments that are amenable to altered diets, and lifestyle recommendations that we can make that may have positive impacts on their asthma.

When we are clear about what we are dealing with, there is less confusion as to the “why” we are doing what we do.

Is adjusting kids safe?
The last point I would like to touch on is safety. When we find ourselves being questioned regarding the issue of safety in chiropractic, we can rest assured that there is an exceptional record of care.

However, there exists literature that may suggest chiropractic for children is not safe. It is important for the profession to be familiar with, and examine, these works for any inconsistencies that may help us address questions and clarify our position.  

For instance, in Vohra’s8 Systematic Review of 2006 (published also online in 2007),  a search involving 104 years, and including many disciplines of practitioners who “manipulate” was undertaken – in this review, 10 cases involving chiropractic care were identified.

From the findings in this paper – a seminal document in the assessment of the safety of manipulations in children –  a few challenges arise for chiropractic. But, these challenges can, and should, be easily addressed by us, in the profession.

1) It is important to re-iterate that a number of disciplines that provide “spinal-manipulation” were included and no differentiation was made between spinal adjustment and manipulation.

2) The paper doesn’t actually come out to acknowledge that it cannot establish a link for causation or incidence of adverse events, whereas it does acknowledge that more work is necessary.

3) There is some confusion with respect to the application of parameters in the authors’ own definition of  search inclusion as reports were included if they were observational studies, controlled trials, surveys and only if adverse events were reported. In one case however, an inclusion was made from testimony at trial.

4) The paper mentions that it excluded over 30 articles where there were no side-effects mentioned. Even as an aside, it would actually have been important to, instead, emphasize that a number of papers had been published where no side-effects were identified.

5) The paper involved “misdiagnosis” and “delayed diagnosis” as an adverse effect of spinal manipulation. This is like saying one side-effect of a dentist doing root canals was that (s)he didn’t realize the patient had a brain tumour, and that it is, therefore,  the dentist’s fault that the brain tumour wasn’t diagnosed earlier.

6) When speaking about the lack of education in those groups who perform pediatric manipulation, the authors lump DOs  in with DCs as though they were equally deficient in pediatric training opportunities.  In fact, as we discussed in part 1 of this article, DCs do have specialized postgraduate pediatric training programs. This is not even acknowledged.

If one was to read this paper critically and dig into the references cited, one would find more questionable elements. For example, Vohra et al. made an error in the application of their own adverse event classification system. 

Dr. Joel Alcantara9 published a paper that summarizes the deficiencies and oversights the authors. and brings up two things: it questions the paper’s claim to being a thorough and academic review;  and it emphasizes the importance of critical review.

Alcantara  took the time to review the papers referenced in Vohra’s review. He noted the following:
i) Two cases cited from LeBoeuf et al., listed as moderate adverse events, involved headache/stiff neck and acute lumbar pain. These were, in fact, minor events since they were self-limiting, not requiring any further medical assistance or care.

ii) Four other cases retrieved and classified as adverse events by Vohra et al. included a 12-year-old girl who fell from an upper bunk bed and hit her head, resulting in one to two frontal headaches per week. While under chiropractic treatment after this incident, she was subsequently accidentally crushed in a collision with playmates, falling backwards to the ground. Furthermore, between chiropractic visits, she fell from her bicycle hitting her head. From the perspective of a practitioner, these incidents alone would have complicated the care and introduced new symptomatology. If these details are not disclosed, however, then yes, it certainly would have appeared as though she’d had a worsening of symptoms! But, given the knowledge of external sources of trauma, one would be challenged to ascribe the exacerbated symptoms to chiropractic care.

iii) One out of the 10 cases mentioned as adverse was cited in Zimmerman’s paper. This was a seven-year-old male who had recurrent headaches. He had pre-existing headaches, often following his gymnastics sessions where he had once attempted mid-air somersaults and landed on his occiput and neck. Vohra et al. did not mention that prior to attending chiropractic care, the patient suffered from bilateral headaches without prodrome once or twice/week, often following his gymnastics.

iv) One case cited was that of a 12-year-old female with osteogenesis imperfecta, a history of multiple fractures and sagging chin following a fall prior to chiropractic. This fall was not mentioned in Vohra et al.’s review.

v) Citing another case published by Shafir and Kaufman, Vohra et al. leads us to believe a four-month-old patient’s demise held a close temporal association between chiropractic care and neurological deterioration. However, the source paper indicated the patient had an intraspinal mass prior to chiropractic care that may have compromised the blood supply to the tumour and spinal cord. The subsequent pathology demonstrated was mostly necrotic tissue suggestive of pre-existing pathology.

Vohra et al. does not mention this but simply states that while that patient was under chiropractic care neurological deterioration occurred. 

A growing safety record
When we consider the critical analysis above, as well as all this additional information that can be gleaned from the papers cited in Vohra et al., we see inconsistencies throughout the paper, including that some of the events classified as adverse had pre-existing morbidities or a history of trauma. In addition, four other cases where adverse events were noted were attributed to SMT that was not cared for by chiropractors.

While we encourage any study into the efficacy and safety of chiropractic, we do need to truly observe what is being said by the data.

If, in fact, we were to calculate the number of pediatric visits to chiropractors over 117 years – where true adverse events requiring emergency care would have a high likelihood of being reported –  we can see our safety record remains strong. All things remaining equal, there is perhaps insufficient evidence to indicate that chiropractic care of children is, in any way, harmful.

If, however, any adverse event did occur, it would be one too many – and so we need to continue to be diligent in our recommendations for children. A prudent rule of thumb is to co-manage always on the side of caution to the level of your experience and within your comfort zone.

As with any skill, knowledge and practice experience require commitment and time. Reflecting on each day in practice with the attitude of  “what can I continue to improve upon” generally keeps us on our toes.

Finally, we want to encourage, and strive for, more evidence and funding for research. We are now seeing this materialize, but although our evidence base grows and improves, we need to remember a lack of evidence does not mean evidence of lack.  As Sackett et al. note, “The practice of evidence-based medicine means integrating the individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical experience we mean the proficiency and judgment that individual clinicians acquire through clinical experience and practice.”10

The key in this interaction continues to be you, the doctor, and your commitment to making the best decisions for your patient.

References
  1. Gracovetsky S.A. The Spinal Engine. 1988 Springer Vienna
  2. Biedermann H. Manual Therapy in Children. Churchill Livingstone-Elsevier Limited. 2004
  3. Melillo R. Disconnected Kids. 2009. Perigee Book. Penguin Group 375 Hudson St. New York, NY. USA
  4. Melillo R. Reconnected Kids. 2011. Perigee Book. Penguin Group 375 Hudson St. New York, NY. USA
  5. Spigelblatt L. et al. The Use of Alternative Medicine by Children on the Rise. Pediatrics 1994. 94:811-814.
  6. Spigelblatt L. Alternative Medicine: A Pediatric Conundrum. Contemporary Pediatrics.1997. 14(8): 51-64.
  7. College of Chiropractors of Ontario website http://www.cco.on.ca./english/Members-of-the-Public/How-CCO-Protects-thePublic%20Interest/Policies-and-Guidelines
  8. Vohra S, BC Johnston, K Cramer, K Humphreys. Spinal Manipulation: A Systematic Review. Pediatrics 119 (1) Jan 2007 e275-283 www.pediatrics.org/cgi/content/full/peds.2006-1392v1
  9.   Alcantara J. A critical appraisal of the systematic review on adverse events associated with pediatric spinal manipulative therapy: A chiropractic perspective. J Pediatr Matern & Fam Health - Chiropr 2010 Win;2010(1):22-29
  10. Sackett DL, W Rosenberg, JA Gray, RB Haynes. Evidence Based Medicine: what it is and what it isn’t. BMJ 1996 312:71


Dr Liz Anderson-Peacock’s extensive background includes a multi-decade chiropractic practice that ranks, globally, in the top percentile in terms of volume and best practices; articles in peer reviewed journals; membership on academic panels; and involvement with regulatory boards. She has taught pediatrics for numerous colleges and groups throughout the world and graduated first in the ICA/ACA pediatric diplomate program in 1996. She‘s the recipient of numerous awards and currently delivers keynote lectures and workshops, as well as coaches professionals in the co-operative model.

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