Is chiropractic care for children being sabotaged by its own research elite?

By Joyce Miller DC, Ph.D.

Children are a significant part of many chiropractor’s practices. There is even a scientific journal dedicated to their practice. According to the International research,¹ 94% of chiropractors treat children who comprise from 5-32% of their practice. There were 103,469 chiropractors in the world in 2017.² If the average chiropractor treats 110 patients per week, then 6-35 patients per week x 50 weeks of the year, the extrapolated number of children patients range from 30 million to 170 million/year world-wide, not insignificant numbers. In large outcome studies, parents report excellent clinical outcomes,^3,4 and high rates of parent satisfaction.^3,4,5 There is even some modest evidence of cost-effectiveness.³

It is clear that parents often seek chiropractic care for their children.^6,7 The safety of this care has likewise been well documented.⁸ There is also no question that research regarding the effectiveness of this care is limited, not least because health care research into the pediatric patient is complex, costly and rare. These simple truths leave chiropractors in the arena of moderate demand and insufficient evidence. It might be expected in this environment that experienced researchers, familiar with the professional issues, might use their expertise to provide more and better research to support the needs of this unique, vulnerable and needy patient group. Instead, it almost seems as there is an impetus to attack the service provided and reiterate all of its weaknesses, already well recorded.

A case in point is the recent publication of the article produced by 50 researchers from 8 countries on a “jolly meetup” (my term) called a “global summit” (their term) designed to critique non-MSK chiropractic research for pediatrics.⁹ Their inevitable conclusion was insufficient evidence. The summit authors actually stated that these conclusions had been reported six times before, and thus, the outcome inevitable. They seemed to be setting up a straw man in order to knock it down. One worders why it took a team of approximately 50 prominent researchers to review and state the same conclusion that has been held for more than a decade. The evidence-base for chiropractic care for children is inconclusive and more evidence is needed. In an article specifically discussing the lack of evidence for non-MSK childhood conditions, I myself, a chiropractor, along with Dr. Randy Ferrance, a Medical Director of Hospital Based Quality stated that specific lack of evidence in 2010, understanding we were not the first or the last to make that statement.¹⁰ There simply and clearly is insufficient evidence for non-MSK disorders (and one may as well include MSK disorders) in the pediatric population. That conclusion did not differ or advance or serve any credible purpose that thinking and working students and clinicians have not stated multiple times before. Their goal seems to have been to destroy the clinical profession. It is not news that more research is needed. The same can be said for virtually all aspects of chiropractic care and in fact, much of medical care. The British Medical Journal recently reported that a mere 18% of medical decisions were based on high quality evidence base.¹¹

In the real world of health care, workers must commit to giving the best and safest health care possible with an insufficient evidence base. Providing safe and effective care in gray areas with insufficient evidence should be applauded, not denigrated. And those with the connections and expertise to do the high-quality research should perform the necessary research rather than simply review and find wanting the past research. It is easy to complain and less easy to provide the research.

Intriguingly, it had previously been suggested by one of the same prominent researchers that child health cannot be ignored, that it may impact long-term quality of life and that chiropractors are well placed to assume the responsibility for the MSK health of children.¹² Although there are a wide range of childhood complaints presented to chiropractors, finding the MSK component has been the goal of chiropractors for time immemorial as the MSK system is the point of entry for manual therapy. In short, chiropractors are musculoskeletalists. This is a term that I coined years ago to help my students understand our entrée to the human body. Chiropractic is a health profession concerned with the diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system.² There is an emphasis on manual therapy including spinal adjustment and other joint and soft-tissue manual treatment.

The process that the researchers chose was to lump all non-MSK conditions together, a non-sensical thing to do from a clinical perspective. Some conditions (often mis-named because no one knows the real etiology, such as infant colic) can be seen as a soft tissue condition, or as a result of autonomic dysregulation. When treated by chiropractors, it is treated through the MSK system. The same is true for the other conditions reviewed. Much of the time, the treatment was not intended to target the complaint (perhaps constipation or enuresis), but to normalize the human body around the complaint. Even the authors in question concede that “Alleviating pain and discomfort originating from the musculoskeletal system can be an important contribution to the care of people with multiple co-morbidities.”⁹ There is medical evidence that touch alleviates infant’s pain.¹³ Parents do understand that chiropractors are musculoskeletalists. They do bring MSK conditions to chiropractors. They also understand that chiropractors are doctors and when not helped by medical doctors, they try the chiropractor. As a pediatrician once told me after presenting her neonate for treatment, “what you guys [chiropractors] do is so helpful because it normalizes and creates comfort throughout the body so that all the systems can improve function. In a baby, when one thing works better, (e.g., sleep) everything works better.”

One must wonder why there was an expensive and concerted effort of knowledgeable colleagues of the profession to pointedly and in a repetitive move negate the work and efforts made by the profession to slowly advance the knowledge base and evidence base for chiropractic care for the pediatric population. The need for further damnation of the professional work was not explained by the authors, except that the previous times (and they named six) that this same research was done, it had, “not had an obvious impact on health care and clinical policies.“

At best, the work was unnecessary as it has all been said before; at worst, the work was meant to be divisive and filled with condemnation and soul-destroying for the work of the practitioner. Even the authors agreed that the previous consensus in the profession was a lack of evidence for non-MSK treatment for children. It remains unclear why the effort and expense were made to repeat what has been known all along: More and better research is needed! More and better condemnation of the research that has been done and previously reviewed and found insufficient is not needed.

Further, one wonders how well these esteemed and respected researchers understand their own field of study. For example, they noted that there were no RCTs in the area of chiropractic care for sub-optimal breastfeeding. Certainly, since they are all active in the arena of chiropractic research, they would understand that babies with this condition cannot be randomized to a non-treatment (control) group because the life-long loss of the benefits of breastfeeding would be too great. Thus, allocating newborns to a non-treatment arm of the trial would be totally unethical. This comment made me wonder if they even understood some of the real issues that plague pediatric research. Were they even in the position to make such a comment?

Is it acceptable for the elite researchers in any profession to take a cheap shot at their colleagues? What are the benefits? What are the risks? What were the costs? What are the real costs? A loss of reputation for those involved? A loss of reputation for the entire profession?

After I began this editorial comment, I came upon an article that I recommend to all practitioners, written by dissenting members of the “summit.”¹⁴ Their thoughtful discussion will give you the scientific realities behind the issues brought up in the “Summiteers” original work. As always, don’t take my word for what these articles state; read both of them yourself and make your own conclusions. I am merely giving you my opinion with this editorial and it is not the opinion of the other editors or the Journal itself.

With the difficulty and expense of RCTs, it is unlikely that we will be able to target all the specific sub-groups that present for care in order to unequivocally declare effectiveness. This doesn’t make chiropractic care for the problems of infants and children any less needed. It doesn’t take away parental requests to obtain help with the routine problems of infants and children. It simply means that we must perform high quality risk/benefit analyses before taking the cases, rule out any potential pathology and enroll all cases into outcome studies so that the parents can state any benefits (or not) that accrue, along with satisfaction levels and opinions on cost-effectiveness (and continue to support high level research as well). This is patient-centered care required by all practitioners and collection of outcomes is known as Real World Data, a practical method to develop research with external validity.¹⁵

One wonders why the researchers, instead of doing practical work to support the profession, spent time and money re-hashing work already widely accepted. Why not do something with that investment to be helpful and give guidance on what can be done to assist professionals, parents and patients? Simple condemnation is undermining of the caring and concern of a real-world professional practice.

References:

1. Doyle, MF & Miller JE. Demographics profile of chiropractors who treat Children: A multinational survey. Journal of Manipulative and Physiological Therapeutics 2019 42(1). org/10.1016/j.jmpt.2018.03.007

2. The National Board of Chiropractic Examiners. The Job Analysis of Chiropractic in Canada. Practice Analysis of Chiropractic 2020. Retrieved September, 2021, from https://www.nbce.org/nbce-news/analysis-canada/

3. Miller JE, Hanson HA, Hiew M, Lo Tiap Kwong DS, Mok Z, & Tee YH. Maternal Report of Outcomes of Chiropractic Care for Infants. J Manipulative Physiol Ther, 2019; 42(3), 167-176. https://doi.org/10.1016/j.jmpt.2018.10.005

4. Keating, GM. Do Children in Australia benefit from chiropractic care? (Order no. 28418243). PhD dissertation 2021. Available from ProQuest dissertations & Theses Global).

5. Navrud IM, Bjornli ME, Feier CH, Haugse T, Miller J. A survey of parent satisfaction with chiropractic care of the pediatric patient. Journal of Clinical Chiropractic Pediatrics 2014;14(3):1167-1171.

6. Black LI, Clarke TC, Barnes PM, Stussman BJ, & Nahin RL. Use of Complementary Health Approaches Among Children Aged 4–17 Years in the United States: National Health Interview Survey, 2007–2012. Natl Health Stat Report 2015., 10(78), 1-19. Retrieved March 12, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4562218/pdf/nihms-720041.pdf

7. Zuzak TJ, Bonkováb,J, Caredduc D, Garamid M, Hadjipanayise A, Jazbec J, Merrick J, Miller J, et.al. Use of complementary and alternative medicine by children in Europe published data and expert perspectives. Complementary Therapies in Medicine 2013;21 Suppl 1:S34-47.

8. Todd AJ, Carroll MT, Robinson A, Mitcjell EKL. Adverse events due to chiropractic and other manual therapies for Infants and children: a review of the literature. J Manip Physiol Ther. 2015;38:699-712.

9. Cote P, Hartvigsen J, Axen I et al. The global summit on the efficacy and effectiveness of spinal manipulative therapy for the prevention and treatment of non-musculoskeletal disorders: a systematic review of the literature. Chiropractic and manual therapies 2021; 29(1):8.

10. Ferrance R and Miller J. Chiropractic diagnosis and management of non-musculoskeletal conditions of infants and children, Chiropractic and Osteopathy 2010; 18:14

11. Ebell MH, Sokol R, Lee A, Simons C, Early J. How good is the evidence to support primary care practice? BMJ Evidence Based Medicine 2017;22(3).

12. Hartvigsen J and Hestbaek L. Children and chiropractic care: a window of opportunity. J Manipulative Physiol Ther 2009, 32: 603-605

13. Honda N, Ohgi S, Wada N, Loo KK, Hagashimoto Y, & Fukuda K. Effect of therapeutic touch on brain activation of preterm infants in response to sensory punctate stimulus: A near-infrared spectropscopy-based study. ADC Fetal and Neonatal Edition 2013;98(3), F244-F249.

14. Goertz C. Hurwitz EL. Murphy BA. Couler ID. Extrapolating beyond the data in a systematic review of spinal manipulation for nonmusculoskeletal disorders: a fall from the summit. JMPT 2021; 44(4):271-279.

15. Katkade VB, Sanders KKN, & Sou KH. Real world data: An opportunity to supplement existing evidence for the use of long-established medicines in health care decision-making. Journal of Multidiscplinary Healthcare 2018;11: 295-304.