Research Review By Dr. Ceara Higgins©

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Date Posted:

October 2015

Study Title:

Adverse Events Due to Chiropractic and Other Manual Therapies for Infants and Children: A Review of the Literature

Authors:

Todd AJ, Carroll MT, Robinson A, Mitchell EKL

Author's Affiliations:

Private Practice, Victoria, Australia; Dept. of Rural and Indigenous Health, School of Rural Health, Moe, Victoria, Australia; School of Rural Health, Monash University, Australia.

Publication Information:

Journal of Manipulative and Physiological Therapeutics 2015; 38(9): 699-712.

Background Information:

Chiropractic care for pediatric patients is growing. A 2010 survey of chiropractors from Europe and the United States (1) demonstrated that 5-11% of visits were pediatric patients. The research literature on safety and efficacy of chiropractic care (and other forms of manual therapy) for infants and children is in its infancy (no pun intended!), giving critics ample opportunity to strongly and publicly question the reason(s) for the rising popularity.

In order to strengthen the body of literature and update our knowledge in this important area, this review attempted to examine all reported cases of serious adverse events in infants and children receiving manual therapies from a variety of practitioners (i.e. chiropractors, physical therapists, medical physicians, doctors of osteopathy, and other manual therapists). Particular attention was paid to the types of treatment applied, discipline of the treating practitioner and any pre-existing, undiagnosed pathologies present.

Pertinent Results:

31 articles were included in this review. These included 5 systematic reviews, 5 narrative reviews, 4 cross-sectional surveys, 6 randomized controlled trials, 4 practice-based research network (PBRN) trials, 4 case studies, 1 case series, and 2 discussion papers.

Through these articles, a total of 15 serious adverse events were identified. In 10 of the 15, high-velocity, low-amplitude (HVLA) spinal manipulative therapy was applied and in 8 of the 15 it was determined that before the manual therapy was applied, there was a preexisting, unidentified, underlying pathology or existing neurologic symptoms. Three deaths were reported, 2 of which were in previously health infants under 3 months of age. The serious adverse events noted (overall) included:
  • Quadriplegia, which regressed to paraplegia after surgical intervention (23)
  • Progressive neuromuscular deficits in the legs (24)
  • Paraplegia (24)
  • Severe headache with vomiting, left facial weakness, diplopia and ataxia (22)
  • Neck pain with progression to drowsiness and weakness leading to hospitalization (25)
  • Loss of consciousness (21)
  • 7th and 8th posterior rib fractures (15)
  • Anterior dislocation of the atlas and fracture of odontoid at C2 (19)
  • Dislocation of atlas (19)
  • Death (16, 19)
  • Subarachnoidal hemorrhage and death (18)
  • Leg fractures (17)
  • Respiratory failure (26)
  • Hematothorax (14)
A total of 775 mild to moderate adverse events were identified. These included 604 cases of crying, soreness, or transient headache, 1 case of syncope, 35 cases of soreness or transient headache, 50 cases of transient apnea with vegetative responses (returning to normal in 4 breaths), and 87 cases of short lasting (seconds), marked bradycardia. The mild to moderate adverse events noted also included:
  • Soreness (2, 4, 5, 9-13)
  • Stiffness (12)
  • Headache (2, 4)
  • Crying (2)
  • Sleeplessness (2)
  • Increased irritability (5)
  • Severe headache and stiff neck (20)
  • Increased crying < 24 hours (3)
  • Moderate to severe bradycardia (7)
  • Apnea of short duration (6)
  • Increased vomiting (8)
  • Excessive crying (8)
  • Worsening symptoms (4)
  • Behavior problems/irritability (4)
  • Dizziness (4)
  • Flu-like symptoms (4)
  • Treatment reaction (4)
  • Tiredness (4)

Clinical Application & Conclusions:

While this literature review indicates that adverse reactions are possible after manual therapy in a pediatric population, they appear to be rare and may be associated with preexisting pathologies, or the use of inappropriate techniques (or perhaps more accurately, techniques being applied inappropriately).

Details on the 3 cases resulting in death:
The three most severe adverse reaction cases did result in death. These included a three-month-old treated with electrical current and spinal manipulation by a physiotherapist, incorrectly applied craniosacral therapy applied by a craniosacral therapist, and the death of an infant with pneumonia in France in the 1960s, where no details on therapist type or technique were available. In all three cases, the practitioners were in areas where their professions had only recently become regulated.

In cases where adverse events were noted, the most commonly used technique was HVLA thrust manipulation. Further research is needed to determine if this is a result of some aspect of the HVLA thrust technique, the greater frequency with which this technique is applied in general, or due to limitations in the experience or training of the manual therapist applying the treatment. It is interesting to note that although chiropractors apply an extensive number of treatments to children, there were no reported cases of death and only 7 severe adverse events associated with chiropractic care. Of these, 4 were associated with a previously unidentified, preexisting pathology.

During the course of chiropractic training, students are taught to modulate force to suit the needs of the individual patient. Appropriate force modulation should (obviously) always be considered when treating pediatric patients. When surveyed, 956 European chiropractors reported reducing the magnitude of their thrusts by 90% of the level used with adults when treating infants less than 1 year of age (2). This modulation of thrust, combined with a proper examination including pediatrician screening and an appropriate neurologic examination to screen for underlying pathologies, should be helpful in avoiding adverse events.

Based on this review, the authors suggest:
  • Development and implementation of a more comprehensive method of recording adverse events across all manual therapies.
  • Exposing manual medicine clinicians to a broad range of patients, including children, teaching age appropriate techniques in detail.
  • Diligence from clinicians in their history taking, examination, and selection and application of treatment options to ensure the best possible outcomes for their pediatric patients.

Study Methods:

The authors searched EMBASE, AMED, BIOSIS previews, MEDLINE, Maternity and Infant Care, OVID, CINAHL, Psychinfo, PubMed, INDEX to Foreign and Legal Periodicals, SCO-PUS, Science Direct, Index to Chiropractic Literature, and PubMed Central, Google Scholar, the International Chiropractic Pediatric Association, and Journal of Vertebral Subluxation Research. In addition, all seminal articles’ bibliographies were further screened for additional articles.

Inclusion criteria:
  • Events documented by any manual therapy health provider
  • Articles clearly discussed adverse events
  • Articles published in English
Exclusion criteria:
  • Commentaries not reporting case information
  • Details of adverse event data collection were unclear
  • Article included no discussion of adverse events
  • Article did not discuss manual therapy in children
Each included article was analyzed and the nature of the adverse event, practitioner type, technique applied, and evidence of any preexisting, undiagnosed pathology were identified. Adverse events were characterized as mild (transient effects lasting < 24 hours), moderate (requiring medical/general practitioner treatment), or severe (requiring hospital treatment).

Study Strengths / Weaknesses:

Strengths:
  • The authors performed a robust literature search, including a wide range of search terms to identify as many articles as possible.
Weaknesses:
  • Only articles published in English were included in the review.
  • When used in the literature, the term spinal manipulation can vary widely, from very light touch to use of a mechanical instrument to HVLA thrusts. This makes it difficult to determine the exact technique used in many cases, which is difficult to fully elucidate in a project of this nature.

Additional References:

  1. Hestbaek L, Stochkendahl MJ. The evidence base for chiropractic treatment of musculoskeletal conditions in children and adolescents: the emperor’s new suit? Chiropr Osteopat 2010; 18: 15.
  2. Marchand AM. Chiropractic care of children from birth to adolescence and classification of reported conditions: an Internet cross-sectional survey of 956 European chiropractors. JMPT 2012; 35: 372-380.
  3. Miller JE, Benfield K. Adverse effects of spinal manipulative therapy in children younger than 3 years: a retrospective study in a chiropractic teaching clinic. JMPT 2008; 31: 419-423.
  4. Hayes NM, Bezilla TA. Incidence of iatrogenesis associated with osteopathic manipulative treatment of pediatric patients. JAOA 2006; 106: 605-608.
  5. Sawyer CE, Evans RL, Boline PD, et al. A feasibility study of chiropractic spinal manipulation versus sham spinal manipulation for chronic otitis media with effusion in children. JMPT 1999; 22: 292-298.
  6. Koch LE, Biedermann H, Saternus KS. High cervical stress and apnea. Forensic Sci Int 1998; 97: 1-9.
  7. Koch LE, Koch H, Graumann-Brunt S, et al. Heart rate changes in response to mild mechanical irritation of the high cervical spinal cord region in infants. Forensic Sci Int 2002; 128: 168-176.
  8. Philippi H, Faldum A, Schleupen A, et al. Infantile postural asymmetry and osteopathic treatment: a randomized therapeutic trial. Dev Med Child Neurol 2006; 48: 5-9.
  9. Rowe DE, Feise RJ, Crowther ER, et al. Chiropractic manipulation in adolescent idiopathic scoliosis: a pilot study. Chiropr Osteopat 2006; 14: 15.
  10. Alcantara J, Ohm J. The safety and effectiveness of pediatric chiropractic: results from a practice-based research network. International Chiropractic Pediatric Association. 2006.
  11. Alcantara J, Ohm J, Kunz D. The safety and effectiveness of pediatric chiropractic: a survey of chiropractors and parents in a practice-based research network. Explore (NY) 2009; 5: 290-295.
  12. Alcantara J, Ohm J, Kunz D. Treatment-related aggravations, complications and improvements attributed to chiropractic spinal manipulative therapy of pediatric patients: a practice-based survey of practitioners. Foc Alt Comp Ther 2007; 12: 3.
  13. Alcantara J, Ohm J, Kunz D. Treatment-related aggravations, complications and improvements with pediatric chiropractic SMT: a survey of parents. International Chiropractic Pediatric Association. 2006.
  14. Struewer J, Frangen TM, Ziring E, et al. Massive hematothorax after thoracic spinal manipulation for acute thoracolumbar pain. Ortho Rev 2013; 5: 120-122.
  15. Wilson P, Greiner M, Duma E. Posterior rib fractures in a young infant who received chiropractic care. Pediatr 2012; 130: 1359-1362.
  16. Holla M, Ijland MM, van der Vliet AM, et al. Death of an infant following “craniosacral” manipulation of the neck and spine. Nederlands Tijdschrift voor Geneeskunde 2009; 153: 828-831.
  17. Simonian PT, Staheli LT. Periarticular fractures after manipulation for knee contractures in children. J Pediatr Orthop 1995; 15: 288-291.
  18. Jacobi G, Riepert T, Kieslich M, Bohl J. Fatal outcome during physiotherapy (vojta’s method) in a 3-month old infant. Case report and comments on manual therapy in children. Klinische Padiatrie 2001; 213: 76-85.
  19. Rageot E. Complications and accidents in vertebral manipulation. Les Sahiers du College de medicine des hopitaux de Paris. 1968; 9: 1149-1154.
  20. Leboeuf C, Brown P, Herman A, et al. Chiropractic care of children with nocturnal enuresis: a prospective outcome study. JMPT 1991; 14: 110-115.
  21. Klougart N, Leboeuf-Yde C, Rasmussen LR. Safety in chiropractic practice. Part II: treatment to the upper neck and the rate of cerebrovascular incidents. JMPT 1996; 19: 563-569.
  22. Zimmerman AW, Kumar AJ, Gadoth N, Hodges FJ. Traumatic vertebrobasilar occlusive disease in childhood. Neurology 1978; 28: 185-188.
  23. Shafrir Y, Kaufman BA. Quadriplegia after chiropractic manipulation in an infant with congenital torticollis caused by a spinal cord astrocytoma. J Pediatr 1992; 120(2 Pt 1): 266-269.
  24. Ziv I, Rang M, Hoffman HJ. Paraplegia in osteoenesis imperfecta. A case report. J Bone Joint Surg (Br) 1983; 65: 184-185.
  25. L’Ecuyer JL. Congenital occipitalization of the atlas with chiropractic manipulations: a case report. Nebraska State Medical Journal 1959; 44: 546-550.
  26. Held JP. Dangers of cervical manipulation in neurology. Annals of Physical and Rehabilitation Medicine (Lille). 1966; 251-259.