ICPA Response

Adverse Events Associated With Pediatric Spinal Manipulation: A Systematic Review. What Does the Data Really Show?

Abstract

Background: In a recent issue of the journal Pediatrics, Vohra and her colleagues 1 published the results of their systematic review of the literature on the adverse events associated with the use of spinal manipulative therapy (SMT) in children. Chiropractic, grounded on a holistic and vitalistic approach to patient care, remains a popular choice among parents for the conservative care of their children 2. Some 30 million visits were made by children to chiropractors in 1997 and indications are that these visits continued to increase with subsequent years 3. While Vohra et.al. 1 are to be commended for their efforts to fill the “virtually non-existent” database on this aspect of children’s care, a critical appraisal of their article brought forth issues germane to the practice of pediatric chiropractic 4 – the least of which are their findings that chiropractic care of children have resulted in misdiagnosis and/or inappropriate provision of chiropractic and adverse events may be associated with spinal manipulation therapy in children.

Methods: Vohra et.al. 1 searched the following electronic databases: Central [Second Quarter, 2004], Medline [1966-2004], PubMed [1966-2004], Embase [1988-2004], CINAHL [1982-2004], AltHealth [1990-2004], MANTIS [1900-2004] and ICL [1985-2004]. Their initial search identified a total of 13,916 articles for consideration. An initial screening defined 164 articles for full review from the above pool with another 68 articles from a review of the reference lists and by contacting authors of included reports and experts in the field. Their predetermined study selection criteria consisted of (a) The study was a primary investigation/report (i.e., case report, case series, case-control, randomized controlled trials, and survey or surveillance studies) (b) Part or all of the study population was 18 years or younger and (c) Adverse events were reported were applied and identified 13 studies – 10 from the English language, 2 French and 1 German article. According to Vohra et.al. 1, 2 of the articles were RCTs, 4 case series, and 7 case reports. From this list, 14 cases of direct adverse events were identified.

Of the 14 cases reporting direct adverse events associated with pediatric spinal manipulation, 10 were attributed to chiropractic. It is these 10 events that are re-examined with the findings described using descriptive statistics. Furthermore, Vohra et.al. 1 identified 20 cases leading to a delayed diagnosis and/or inappropriate provision of chiropractic care that resulted in indirect adverse events. The literature base from which these cases were derived was also re-examined. The results are described using descriptive statistics.

Results: Of the 10 cases attributed to a direct adverse event attributed to chiropractic care, 9 were immediately retrievable for this study. The results of the re-analysis are provided in Table 1. What becomes obvious is that due to the lack of quantity and quality of the spontaneous reports re-examined and with due consideration of confounding variables (i.e., pre-existing morbidity and history of trauma), cause and effect inferences by Vohra and her colleagues were unsupported and lead to suspect their conclusion that adverse events may be associated with SMT as attributed to chiropractic care.

A re-examination of the 20 cases leading to a delayed diagnosis and/or inappropriate provision of chiropractic care that resulted in indirect adverse events is provided in Table 2. What becomes apparent after a thorough examination of the literature base from which these cases were derived indicates a violation of the selection criteria. Of the three references cited for these 20 cases, 2 were retrievable for examination and found to be Letters to the Editor while the referenced textbook with anti-chiropractic sentiments was not.

The authors' further comment on risk factors associated with spinal manipulation of children were poorly supported with 4 cited references. These did not involve clinical trials or longitudinal studies, etc. that address risk, are not appropriate for the pediatric population and/or poorly translate to the cervical spine. Vohra et.al. comment throughout their article that SMT is some homogenous procedure demonstrating their naiveté on the myriad of techniques available on the use of SMT in children.

Conclusion: In the article by Vohra and colleagues, cases attributing direct adverse events associated with pediatric spinal manipulation as a result of chiropractic care were inappropriate and cases leading to a delayed diagnosis and/or inappropriate provision of chiropractic care were unsubstantiated.

Table 1. Cases Associated with Direct Adverse Event Attributed to Chiropractic

Table 2. Case involving misdiagnosis and/or provision of inappropriate chiropractic care.

References

1. Vohra S, Johnston BC, Cramer K, Humphreys K. Adverse events associated with pediatric spinal manipulation: a systematic review. Pediatrics. 2007 Jan;119(1):e275-83. Epub 2006 Dec 18
2. Spigelblatt L, Liane-Ammara G, Pless B, Guyver A. The use of alternative medicine by children. Pediatrics. 1994;94:811–814
   Lee AC, Li DH, Kemper KJ. Chiropractic care for children. Arch Pediatr Adolesc Med 2000 Apr;154(4):401-7
3. Alcantara J, Plaugher G, and Anrig C. Pediatric chiropractic. In: Redwood D and Cleveland C. Fundamentals of Chiropractic. Mosby Inc. 2003

Joel Alcantara, BSc, DC 1

1. Research Director, International Chiropractic Pediatric Association, Media, PA, USA and Private Practice of Chiropractic, San Jose, CA, USA

Presented at WFC Annual Conference. Portugal, May 2007.