My take home points:
1. The evidence base for spinal manipulation in children is very poor with no good evidence that it benefits any health condition.
2. Chiropractic manipulations and other chiropractic treatments are offered for a wide range of conditions for which it is not reasonable to expect any benefit.
3. It is difficult to draw conclusions about the safety of chiropractic manipulation in children but it is clear that these treatments are not without risk.
4. A significant number of chiropractors who see children are attempting to treat serious conditions that should only fall under the remit of a doctor.
5. There is a need to protect vulnerable patients from being misled into undertaking unsuitable chiropractic treatments.
Overview & purpose
This was an independent review of chiropractic spinal manipulation on children under 12 years. It was not specifically intended to be a review of other aspects of chiropractic treatment. However, it provides an interesting insight into chiropractic treatment in general as some aspects of the review were not specific to spinal manipulation. The review was undertaken in Australia and was initiated by the Victorian Minister for Health. There were 4 components:
- A search for evidence of harm
- A review of evidence of effectiveness
- An online public consultation
- An online consultation with health practitioners
Key recommendations from the review
The review made a total of 10 recommendations. Here I would like to focus on 5 of them (recommendations in italics, my comments in normal font):
- Recommendation 1 – “Spinal manipulation, as defined in Section 123 of National Law, should not be provided to children under 12 years of age, by any practitioner, for general wellness or for the management of the following conditions: developmental and behavioural disorders, hyperactivity disorders, autism spectrum disorders, asthma, infantile colic, bedwetting, ear infections, digestive problems, headache, cerebral palsy and torticollis.” This is a good recommendation. It will be interesting to see how this is enforced as it’s very clear that many practitioners are currently in breach of this new guideline.
- Recommendation 3 – “Prior to treatment, practitioners offering spinal manipulation for children should provide parents or guardians with written information about the proposed benefits and possible risks of care.” (emphasis mine). This is an important change as it requires written information to be provided when previously only verbal consent was needed. It will be interesting to see what this written information contains. These treatments haven’t been shown to offer any benefits and it’s therefore hard to see how any parent given factually accurate information would choose to go ahead with the treatment.
- Recommendation 5 – “Given the lack of Australian-based clinical trial evidence, the practitioner groups permitted to provide spinal manipulation (chiropractic, osteopathy, medical and physiotherapy) urgently undertake research to develop an evidence base for spinal manipulation on children, ceasing practice where the evidence shows no benefit.” This is a reasonable recommendation. However, before undertaking such research it’s important to ask whether there is a plausible biological mechanism of action for spinal manipulation for the particular condition. For some of the conditions listed, such as ear infections or asthma, there is no plausible mechanism by which spinal manipulation could have any effect and therefore it would be unethical to carry out such research. It would be more reasonable to undertake research in, for example, back pain.
- Recommendation 7 – “In the longer term, the post registration training on offer to chiropractors with a special interest in paediatric care should be assessed against the evidence-based guidelines.” I have previously written about some of the inappropriate paediatric training provided to chiropractors and osteopaths in the UK. This is definitely something that needs to be addressed and in the UK at least I expect it will require changes to ALL of the paediatric training currently offered to chiropractors and osteopaths.
- Recommendation 10 – “Health Ministers should consider increasing penalties for advertising offences under Section 133 of the National Law, where a registered practitioner claims benefits of spinal manipulation in children that have no evidence base“. Misleading advertising has been a widespread issue in the chiropractic and osteopathy professions for many years and it continues to be a significant problem that risks deceiving members of the public into taking inappropriate treatments. I have written about this many times on my blog. This is something that definitely needs to be tackled and it would be good to see more significant penalties being applied. As well as Australia, this should happen in the UK (and probably other countries) too.
Although this was a review in Australia, many of the recommendations made are generally applicable and it would be good to see them being implemented in other countries too.
The review about the effectiveness of spinal manipulation for children concluded that the evidence base is very poor. The review found that chiropractic manipulations are widely offered for colic, enuresis, back/neck pain, headache, asthma, otitis media, cerebral palsy, hyperactivity and torticollis in children in spite of a lack of evidence in most of these conditions. In reality it is not surprising that the effectiveness review failed to find evidence to support treatment of these conditions as, in most cases, there is no plausible biological mechanism by which these treatments could provide any benefit. I find it particularly concerning that chiropractors are treating serious health conditions such as asthma and cerebral palsy. In view of recommendation 1 (above) it’s important that regulatory bodies take action to stop these unsuitable treatments.
Many members of the public mistakenly believe that chiropractic treatment is effective as they reported improvement in the condition after the treatment. This highlights how members of the public have very little awareness of how often health conditions improve of their own accord. E.g. Behavioural issues, bedwetting, constipation, colic, reflux, etc cannot plausibly be helped by chiropractic care but do often improve on their own. Therefore the “improvement” that the members of the public reported are very likely to be down to just the natural course of the condition rather than any direct benefit from the chiropractic treatment.
Chiropractors also clearly believe that their treatments are beneficial even when there is no plausible mechanism by which they could be so. For instance, 34% believed their treatments helped babies feed / latch better, 20% thought they improved bowel movements and 16% said treatments resulted in better behaviour. There is simply no mechanism by which treatment from a chiropractor could help with any of these things. This raises serious concerns about some chiropractors understanding of the human body and health. Worryingly, a significant number of chiropractors reported providing treatment for conditions that should only be treated by a doctor. For instance, 2/3 provided treatment for gastrointestinal issues, over 40% for respiratory problems (including asthma and apnoea) and 1/3 for a variety of special needs (including autism, cerebral palsy and prematurity). Some chiropractors also try to give the impression that they are doctors. Let’s be really clear, chiropractors aren’t doctors and their training is in no way comparable to that of a medical doctor.
A concerning 17.4% of people took their child to a chiropractor for “general health and wellbeing / preventative care / alignment”. Some also report using chiropractic as a routine e.g. “As they grow, I consider regular chiropractic checks to be part of our family health regime -just like regular medical and dental checks, I consider it setting a strong foundation for their future health.” There is no evidence that chiropractic treatments provide any general health benefits or prevent any health condition. There is no good reason for anyone to have “regular” chiropractic treatments and these are in no way equivalent to regular medical or dental checks. Also, the treatments that chiropractors provide do not “align” anything, in spite of what some chiropractors may claim. The fact that members of the public hold these erroneous beliefs raises concerns about what they are being told by some chiropractors.
The report found little evidence of direct harm to children from spinal manipulation in children but this was more due to a lack of adequate studies rather than because there isn’t risk: “consistent with the findings of other systematic reviews, due to the paucity of studies and the lack of reported information on the specific treatment techniques employed, it is difficult to draw conclusions about the safety and effectiveness of spinal manipulation in children.” The report noted that “Nonetheless, it is clear that spinal manipulation in children is not wholly without risk. Any risk associated with care, no matter how uncommon or minor, must be considered in light of any potential or likely benefits”. This is important as when assessing suitability of a treatment it’s the risk / benefit analysis that matters. A treatment such as spinal manipulation in children that has no evidence of benefits should not be recommended even if risks are low. The submissions from bodies representing medical or physiotherapy professions are particularly relevant here: “Submissions made by bodies representative of the medical or physiotherapy professions raised concerns related to the potential harm of chiropractic spinal manipulation on children under 12 years. In particular, there was specific concern about potential risks of harm associated with spinal manipulation of very young children, i.e. those under 2 years of age. However, no specific or confirmed instances of proven harm were presented in any submission. Nonetheless, it was the professional view of those groups that in the absence of evidence of benefit, the risks of harm were sufficient to recommend banning chiropractic spinal manipulation of children.”
It’s disappointing that the report didn’t really discuss the potential for indirect risks, in particular the risks of delaying more appropriate care. This is important, and perhaps the biggest risk associated with these treatments, particularly when some chiropractors treat serious conditions like asthma or cerebral palsy.
Medical practitioners clearly have concerns about the suitability of chiropractic care for children under 12. Of the 37 medical practitioners who provided care to a child that had previously received spinal care almost 90% expressed a sentiment that is unsupportive of chiropractic spinal care for children under 12. Concerns were raised about “Delayed / reduced access to appropriate care and non-evidence based / misleading / unethical / inappropriate recommendations”. One example statement from a practitioner was “Fortunately, I am yet to personally have to manage direct physical adverse effects of this treatment. What I have experienced, however, is the infants involved, have generally had unnecessary and unhelpful treatment which has delayed their parents seeking appropriate treatment. Furthermore, this treatment generally feeds the anxiety of their parents.” These are serious issues and it’s important to consider risks like this rather than just direct risks of chiropractic care.
Negative experiences reported by the general public were focused on cost of treatment with no resultant improvement in the condition being treated, excessive use of X-rays, or practitioner pressure to avoid medications or advice previously provided by other health practitioners. The latter points are particularly important and raise concerns about chiropractors advising against proven medical treatments.
The review also raises concerns about the need to protect vulnerable patients from being targeted by chiropractic care. Comments raised included “I feel that vulnerable families are paying large amounts of money to chiropractors/osteopaths who are performing treatments which are not evidence based and may actually harm their child.” and “I also feel that it is morally unconscionable to be purporting to provide “treatment” that is costly and ineffective to vulnerable, worried parents who can be easily taken advantage of.”
It is a legal requirement for any health professional to take informed consent before commencing treatments. This should include a discussion of the benefits and risks associated with the treatment as well as possible alternative treatments. Chiropractors are clearly NOT openly sharing evidence of effectiveness and risks of their treatments otherwise they would be turning away many of these patients e.g. for colic, headache, walking / crawling problems, breastfeeding, bedwetting, asthma, etc. as there is no evidence of benefit and some level of risk. This discussion ought to happen as part of the informed consent process but it is clearly not taking place as chiropractors would otherwise not be continuing to treat these conditions.
Age of children
From this review it is very apparent that most of the children being treated by chiropractors are very young (under 2). Over half (54.5%) of respondents who had accessed care in the past 10 years reported that the care was provided to a child of 0-3 months and nearly three quarters (73.1%) for a child aged 2 years and younger. Of those chiropractors who treat children under 12, the vast majority treat babies under 2 (88.5%). This is a serious concern as there are no infant conditions for which chiropractic or osteopathy treatments have been shown to provide any benefits. This is also the age group for which medical and physiotherapy professions raised the most concerns about these treatments.
This is a very important review of spinal manipulation for children under 12 and also provides a broader insight into chiropractic treatment of babies and children. There is no good evidence that chiropractic treatments provide any benefit for any infant or childhood condition. In many cases there is also no plausible mechanism by which these treatments could provide a benefit and due to a lack of suitable studies, it is not clear whether these treatments are safe. There are undoubtedly some indirect risks such as delaying more suitable treatments and there is also a need to protect vulnerable patients from being targeted for these treatments. The review makes several important recommendations that, if fully implemented, would help to protect members of the public from being misled into undertaking these unsuitable treatments. It will be interesting to see how these recommendations are implemented in practice not just in Australia but also how they are applied around the World.