Research Review by Dr. Shawn Thistle©


Dec. 2008

Study Title:

Adverse effects of spinal manipulative therapy in children younger than 3 years: A retrospective study in a chiropractic teaching clinic


Miller JE, Benfield K

Authors’ Affiliations: Anglo-European College of Chiropractic, Bournemouth, England

Publication Information:

Journal of Manipulative and Physiological Therapeutics 2008; 31: 419-423.


Many manual therapists treat pediatric patients with increasing regularity, and there is some evidence that chiropractic care can benefit pediatric patients (1, 2, 3). As with patients of any age, the risk-benefit ratio of treatment interventions is paramount. To date, very few serious incidents resulting from pediatric spinal manipulative therapy (PSMT) have been reported in the literature. The existing literature suggests that the risk of neurological or vertebrobasilar injury from PSMT is around 1 in 250 million manipulations. However, there have been no studies on a large cohort of these patients to more accurately assess such negative side effects.

This study was a retrospective review of 781 pediatric cases (< 3 years of age) cases presenting to the Anglo-European College of Chiropractic teaching clinic between January 2002 and December 2004. There were no exclusion criteria. Information from each file was extracted by recording the number of treatments received, the type of treatment administered, the outcome of treatment, and any negative or adverse events. The type of treatment was categorized as follows:
  • PSMT to more than one spinal region or pelvis
  • PSMT to the cervical, thoracic, or lumbar spine, respectively
  • PSMT to the pelvis
  • occipital-sacral decompression technique
  • upper extremity treatment
  • lower extremity treatment
  • massage and soft tissue work
  • ”other” – if a treatment did not fit into one of the above categories (the most common here was instrument treatment)
Treatment outcomes were measured by parent report of symptom change (improvement, no change, or worsening). Negative side effects were interpreted from parent comments, and were defined as any adverse reaction that was mild (transient and lasting < 24 hours), moderate (requiring general practitioner/medical intervention), or severe (requiring hospitalization).

Pertinent Results:

  • 697 patients (59% male) underwent 5242 treatments
  • the majority of patients (73%) were 12 weeks of age or younger
  • most infants presented treatment of colic or irritability because of biomechanical disorder, often attributed to birth trauma
  • 89% received treatment, while 11% were referred for other types of care
  • common treatment types: 77% received PSMT to the full spine, 7% occipital-sacral decompression, and 6% PSMT to the cervical spine only
  • 99% reported an outcome of care – most (85%) reporting an improvement in presenting symptoms, 14% reporting no change
  • no parents reported worsening in presenting symptoms, however there were 7 cases in which parents reported adverse reactions (roughly 1%) – upon further examination, 3 of these 7 were not actually adverse reactions and were attributed by the parents to other things aside from the treatment
  • all of the adverse reactions were mild in nature, requiring no medical care – 6 of the 7 involved increased crying, and did not interfere with normal daily function
  • there were no serious complications

Conclusions & Practical Application:

Although the design of this study does not provide insight into the effectiveness of chiropractic care for pediatric patients, it does suggest that adverse events associated with chiropractic care for patients younger than three are rare. This is a positive step forward for the literature in this patient population, who are difficult to study as they are unable to describe adverse reactions themselves.

This study examined a large number of patients, but its results should be interpreted while considering with the following limitations:
  • 3 of the 7 patients who had mild reactions were lost to long-term follow-up
  • parental reporting has inherent limitations – for example, if they are satisfied with the clinical encounter, they may not report adverse reactions even if they occurred
  • patient files may be incomplete in terms of reporting adverse reactions
In adults, a common side effect of manual therapy is temporary soreness, so it is within reason that after PSMT, children may experience the same reaction. Practitioners must ensure that parents understand that increased crying time may be a normal, albeit rare, temporary reaction that can be expected to subside within 24 hours.

Additional References:

  1. Hayden JA, Mior SA, Verhoef MJ. Evaluation of chiropractic management of pediatric patients with low back pain: a prospective cohort study. JMPT 2003; 26: 1-8.
  2. Wiberg JMM, Nordsteen J, Nilsson N. The short-term effect of spinal manipulation in the treatment of infantile colic: A randomized controlled clinical trial with a blinded observer. JMPT 1999; 22: 517-522.
  3. Hughes S, Bolton J. Is chiropractic an effective treatment in infantile colic? Arch Dis Child 2002; 86: 382-384.