Published online June 1, 2007
PEDIATRICS Vol. 119 No. 6 June 2007, pp. 1265-1266 (doi:10.1542/peds.2007-0503)

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LETTER TO THE EDITOR

Adverse Events in the Manipulation of Pediatric Patients: Flaws in a Systematic Review

Richard Brassard, DC
President, American Chiropractic Association
Arlington, VA 22209
Texas Chiropractic College
Pasadena, TX 77505

To the Editor.—

The American Chiropractic Association (ACA) commends Vohra et al¹ for their efforts to learn more about the types and frequencies of adverse reactions associated with pediatric spinal manipulation. We are concerned, however, that the recent study published in Pediatrics does little to add to the scientific literature and will only create undue alarm among parents.

Although Vohra et al found a limited number of reports that identified adverse reactions among pediatric chiropractic patients over the past 60 years, an objective reader could question how these statistics compare to the number of reactions among the same age group that is associated with traditional medical care. Nowhere does the study indicate that analgesics, antibiotics, or any other treatment is safer than spinal manipulation for neuromusculoskeletal conditions. In fact, recent reports suggest that prescription and over-the-counter medications are inherently riskier than conservative spinal manipulation.^2–7

Chiropractic care is always adapted to the individual patient. It is a highly skilled treatment and, in the case of children, very gentle. Even so, doctors of chiropractic routinely inform patients to expect some soreness after their first adjustment. The current literature documents that some patients may experience minor discomfort after spinal manipulation that usually fades within 24 hours.⁸ The chance that chiropractic manipulation will result in a serious reaction in adult patients is remote, ranging from 1 in 1 million to 1 in 5.85 million manipulations.^9,10 For the majority of patients looking for drug-free alternatives, chiropractic manipulation has been shown to be safe and effective for neuromusculoskeletal pain.

Furthermore, the authors’ recommendation for parents to initially consult with their child's medical physician before seeking the professional services of a doctor of chiropractic is unwarranted. Chiropractors are uniquely trained and licensed in every state as primary care providers. They are aware of the types of conditions that will respond to their care, and they can also recognize those conditions that require referral to other health care providers/specialists.

Evidence from many types of experimental studies (basic and clinical, comprised of randomized, controlled trials and cohort and case studies) provides a promising basis with which to consider chiropractic management for such childhood conditions as otitis media, asthma, and enuresis. The current data suggest that further exploration of alternative treatments, such as spinal manipulation, would benefit patients and parents alike.¹¹

It is the ACA's long-standing belief that doctors of chiropractic, in concert with other health care providers, can play an important role in the health of children. The care and treatment of children is included in the chiropractic profession's scope of practice and taught in and through accredited colleges of chiropractic. These colleges teach physical examination, diagnostic procedures, and patient management skills necessary for the quality care of children.

Although chiropractic care has been proven to be beneficial to patients of every age, the ACA believes that doctors of chiropractic are duty-bound to diagnose health conditions brought to their attention and treat the patient if the condition is within their stated scope of practice; otherwise, they should refer the patient for more specialized care.

The ACA encourages additional studies that further evaluate pediatric spinal manipulation and the possibility of a rare adverse event. Unfortunately, the Vohra et al study, although well intended, leaves concerned parents and pediatricians with more questions than answers.

REFERENCES

1. Vohra S, Johnston BC, Cramer K, Humphreys K. Adverse events associated with pediatric spinal manipulation: a systematic review [published correction appears in Pediatrics. 2007;119:867]. Pediatrics. 2007;119(1). Available at: www.pediatrics.org/cgi/content/full/119/1/e275
2. Dabbs V, Lauretti WJ. A risk assessment of cervical manipulation vs. NSAIDs for the treatment of neck pain. J Manipulative Physiol Ther. 1995;18 :530 –536[Web of Science][Medline]
3. Armstrong CP, Blower AL. Nonsteroidal anti-inflammatory drugs and life threatening complications of peptic ulceration. Gut. 1987;28 :527 –532[Abstract/Free Full Text]
4. Babb RR. Gastrointestinal complications of nonsteroidal anti-inflammatory drugs. West J Med. 1992;157 :444 –447[Web of Science][Medline]
5. Fries JF. Assessing and understanding patient risk. Scand J Rheumatol Suppl. 1992;92 :21 –24[Medline]
6. Wolfe MM, Lichtenstein DR, Singh G. Gastrointestinal toxicity of nonsteroidal antiinflammatory drugs [published correction appears in N Engl J Med. 1999;341:548]. N Engl J Med. 1999;340 :1888 –1899[Free Full Text]
7. Gabriel SE, Jaakkimainen L, Bombardier C. Risk for serious gastrointestinal complications related to use of nonsteroidal anti-inflammatory drugs: a meta-analysis. Ann Intern Med. 1991;115 :787 –796[Abstract/Free Full Text]
8. Senstad O, Leboeuf-Yde C, Borchgrevink D. Frequency and characteristics of side effects of spinal manipulative therapy. Spine. 1997;22 :435 –440; discussion 440–441[CrossRef][Web of Science][Medline]
9. Hurwitz EL, Aker P, Adams AH, Meeker W, Shekelle PG. Mobilization and manipulation of the cervical spine: a systematic review of the literature. Spine. 1996;21 :1746 –1760[CrossRef][Web of Science][Medline]
10. Haldeman S, Carey P, Townsend M, Papadopoulous C. Arterial dissection following cervical manipulation: a chiropractic experience. CMAJ. 2001;165 :905 –906[Free Full Text]
11. Rosner A. Infant and Child Care: An Assessment of Research. Norwalk, IA: Foundation for Chiropractic Education and Research; 2003

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PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics

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This Article Extract Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in Web of Science Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Brassard, R. Search for Related Content PubMed Articles by Brassard, R. Related Collections Musculoskeletal System Social Bookmarking                         What's this?