Patient Presentation
A new colleague asked a pediatrician if she knew what was the normative scope of practice for chiropractic physicians in the local area. The new pediatrician had a recent newborn being treated by a chiropractic physician for birth trauma and feeding difficulties and was concerned about the care. “I’ve tried to find some information about this kind of practice but I haven’t been able to find any. Where I practiced before the chiropractors usually took care of adults and occasionally a teenager for back pain. Do you know of any information?” he asked. The senior pediatrician said that it wasn’t uncommon for some families in the area who had a less medical intervention health style to go to one or two chiropractic physicians in the area. “I’ve also not had young infants being treated by them, but one in particular has been helpful with a teenager with chronic headaches and backpain. I’ll see if I can find anything that might help you,” she replied.
Discussion
“Chiropractic is a health care profession concerned with the diagnosis, treatment, and prevention of disorders of the neuromusculoskeletal system and the effects of these disorders on general health.” Some people look at chiropractic care solely as spinal manipulative therapy (SMT) or manipulation. Chiropractic physicians also offer a variety of other treatments including nutritional advice, dietary or herbal supplements, therapeutic exercise, posture correction and behavioral counseling.
Spinal muscle therapy or spinal manipulation is one of the most common complementary, integrative, and alternative medicine practices used by children in the U.S.. Usually care is sought for musculoskeletal complaints but also infant crying/colic, anxiety/stress, sleep problems, asthma, attention problems and upper respiratory infections including otitis media. Another important reason is overall health promotion.
A literature review regarding different forces used for SMT in children found that there was a range of forces used depending on the study and SMT technique used. This paper cites standards for force relative to adults:
- Neonates to 2 month olds = < 10% or 11.2 Newtons (N)
- Children 3-23 month olds = 30% or = 33.6 N
- Children 2-8 year olds = 50% or 56 N
- Children 8-18 years = 80% or 89.6 N
One newton is the force needed to accelerate one kilogram of mass at the rate of one meter per second squared in direction of the applied force. As a reference, gravity exerts a force of about 9.8 Newtons on a 1 kilogram mass.
Learning Point
Authors of a recent expert consensus review noted that despite its use, “…the scientific evidence for the effectiveness and efficacy of chiropractic care and spinal manipulation for treatment of children is not plentiful or definitive.” In their 2016 literature review and Delphi Consensus Panel, the authors came up with a summary of the best practices for chiropractic care in children. Their primacy question was “What is the effectiveness of chiropractic care, including spinal manipulation, for conditions experienced by children (<18 years of age)?"
The authors provide a good overview on the approach to the pediatric patient supporting a detailed history and physical examination with attention to “red flags” that need immediate medical referral, appropriate diagnostic imaging, care planning including counseling for a healthy life style which includes immunization counseling with “…balanced, evidence-based information from credible sources and/or refer the parents to such resources.” They note, if SMT is used, then it should be modified for the individual patient based on size, structural development, flexibility of joints and patient preference. Chiropractic physicians, like all health care providers, should consider if they are the sole manager of the health issue, co-manager with other health care providers, or should provide a referral to an appropriate health care provider. The authors do not provide data to support more detailed scope of practice including evidence for treatment for specific conditions. Initially the authors performed a similar consensus process in 2009 to try to address the gaps in the best practices literature. There was little data therefore expert opinion was used. They sought to update the information again in 2016 and came up with a similar result.
This writer attempted to find guidelines from the Agency for Healthcare Research and Quality which cited 1 guideline from the International Chiropractic Association from 2008. This has been superseded on their website by another guideline which does not address the pediatric age group specifically. This writer also attempted to find guidelines from Chiropractors’ Association of Australia (CAA) reported on 5/23/2016, that were also supported by the American Chiropractic Association on 6/1/2016, but the Internet links went to non-usable pages on the CAA website. A search of the CAA website did not find the resource noted. The National Center for Complementary and Integrative Health Chiropractic care page currently does list clinical practice guidelines for adults with musculoskeletal problems. It does not list any resources under the Scientific Literature section. A Cochrane Collaboration review found that there may be a small benefit from SMT in adults for short term, acute and subacute, low back pain but the differences were small.
Questions for Further Discussion
1. What are the training requirements for chiropractic doctors in your location?
2. What are chiropractic doctors general scope of practice in your location?
3. What is the scope of practice of other non physician health care providers?
4. Define your own scope of practice?
5. How do you integrate complementary and alternative medicine into your practice?
Related Cases
- Symptom/Presentation: Growth Problems
- Age: Infant
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Chiropractice and Complimentary and Integrative Medicine.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Walker BF, French SD, Grant W, Green S. Cochrane Collaboration. Combined chiropractic interventions for low-back pain.
Available from the Internet at http://www.cochrane.org/CD005427/BACK_combined-chiropractic-interventions-for-low-back-pain (rev. 4/14/2010., cited 4/23/18).
Hawk C, Schneider M, Ferrance RJ, Hewitt E, Van Loon M, Tanis L. Best practices recommendations for chiropractic care for infants, children, and adolescents: results of a consensus process.
J Manipulative Physiol Ther. 2009 Oct;32(8):639-47.
Alcantara J, Alcantara JD, Alcantara J. The Chiropractic Care of Infants with Breastfeeding Difficulties. Explore (NY). 2015 Nov-Dec;11(6):468-74.
Todd AJ, Carroll MT, Mitchell EK. Forces of Commonly Used Chiropractic Techniques for Children: A Review of the Literature. J Manipulative Physiol Ther. 2016 Jul-Aug;39(6):401-10.
Pohlman KA, Carroll L, Hartling L, Tsuyuki R, Vohra S. Attitudes and Opinions of Doctors of Chiropractic Specializing in Pediatric Care Toward Patient Safety: A Cross-sectional Survey. J Manipulative Physiol Ther. 2016 Sep;39(7):487-93.
Hawk C, Schneider MJ, Vallone S, Hewitt EG. Best Practices for Chiropractic Care of Children: A Consensus Update. J Manipulative Physiol Ther. 2016 Mar-Apr;39(3):158-68.
Newton. Wikipedia. Available from the Internet at https://en.wikipedia.org/wiki/Newton_(unit) (rev. 4/5/18, cited 4/24/18).
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa
Pediatric Education 