A recent article in the Australian press has once again shone a spotlight on the practice of neonatal spinal manipulation by chiropractors.
Infantile colic can be hard on parents. As Ben points out here there is very little that we can do about it. It occurs in up to 30% of infants and peaks at around 6-8 weeks of age. It can severely impact the ability of both parents to bond with their child as they become progressively more deprived of sleep. Chiropractic therapy has been around since 1895 when Daniel David Palmer performed a manipulation on a partially deaf janitor and reportedly cured him of his affliction.
Is there any evidence that manipulation is of benefit in infantile colic?
A number of studies including this randomised controlled trial, suggest it is of no benefit though a small study by Wiberg et al compared spinal manipulation with dimethicone and noted a statistically significant reduction in hours spent crying in children that had seen the chiropractor. The same has been said to be true of occipital-sacral decompression -another manipulative technique. However, if you look more closely, the trials that show benefits are unblinded and thus open to bias.
The long term follow-up of these children suggested that they are much better two months after the treatment, but one must also consider the natural history of the disease. Colic disappears with time and so parents, who often subjectively report on their child’s symptoms using a crying diary, will always notice a reduction in colic and may falsely attribute it to the therapy. A short cut review by Hughes and Bolton (2002), agreed to the lack of efficacy when compared to placebo in the treatment of infantile colic, but suggested that parents might benefit from the time spent with the chiropractor. In a time-poor traditional health care system, private practitioners with more time to spend may exert a more powerful placebo effect.
Manipulation has also been suggested to be of benefit in a number of other gastrointestinal conditions such as reflux, constipation and inflammatory bowel disease, as well as unrelated disorders such as autism and ADHD.
Commentary in the chiropractic press suggests that given the lack of evidence of benefit for any standard treatment, that manipulation should be also be considered. The evidence there relies on small, single randomized trials coupled with case series and reports.
We often seem to do a lot of things in medicine with no clear evidence of benefit. Is there any evidence of harm with spinal manipulation?
It has been suggested that lack of benefit in some trials may be related to a dosing effect – the negative trial of Olafsdottir used up to three treatments only, whereas the positive trials extended the course of treatment. The theory being that just three treatments was not enough to make a difference but when the ‘dose’ of manipulation was increased to a full course then the benefit becomes more apparent. An audit of practice at a teaching practice in the UK suggested reactions occurred in 1 in 100 children with no serious adverse events reported. A recent literature review by the Journal of Manipulative and Physiological Therapeutics (the journal of the American Chiropractic Association) reported three deaths caused by high-velocity extension and rotational spinal movements. As well as death, a number of other adverse events have been reported including subarachnoid haemorrhage and paraplegia.
A recent article by a medical ethicist suggested that:
With no clear evidence of benefit and certainly evidence of potential harm one wonders what the official bodies think about the manipulation of infant’s spines.
The Chiropractic Board of Australia has the following position statement on its website:
Current research indicates that the incidence of serious adverse events, either directly from manual therapy or indirectly by delayed or misdiagnosis, is rare but real. Given the lack of good quality evidence about chiropractic care of children, more research is required to better understand this issue.
However, this goes against the recommendations of the Chiropractic and Osteopathic College of Australia:-
…COCA expresses concern with respect to chiropractors, osteopaths and others, who employ spinal manipulation when providing care for children with non-musculoskeletal conditions. These non-musculoskeletal conditions include conditions such as colic, asthma, bed wetting and otitis media.
The best available evidence is either inconclusive or does not support the use of manual therapy for the treatment of non-musculoskeletal conditions in children [1,2]. In COCA’s view it is inappropriate to provide treatment that has been shown to be ineffective or where there is insufficient evidence to support its use when other available treatment options have been demonstrated to be beneficial.
And the president of the Australian Medical Association in 2013, Steve Hambleton, stated:-
We know there’s more and more chiropractors treating children for all sorts of things like infantile colic, like bed-wetting, like middle ear infections, all sorts of things for which it’s simply biologically implausible that manipulation…or doing anything with the spine is going to make any difference…You shouldn’t be doing anything with a young person…without significant levels of quality evidence.
Please read some of the literature and draw your own conclusions.
Olafsdottir E, Forshei S, Fluge G, Markestad T. Randomised controlled trial of infantile colic treated with chiropractic spinal manipulation. Archives of disease in childhood. 2001 Feb 1;84(2):138-41. Full text here
Hughes S, Bolton J. Is chiropractic an effective treatment in infantile colic?. Archives of disease in childhood. 2002 May 1;86(5):382-4. Full text here
Ernst E. Chiropractic spinal manipulation for infant colic: a systematic review of randomised clinical trials. International journal of clinical practice. 2009 Sep 1;63(9):1351-3. Full text here
Wiberg JM, 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. Journal of manipulative and physiological therapeutics. 1999 Oct 31;22(8):517-22.
Vohra S, Johnston BC, Cramer K, Humphreys K. Adverse events associated with pediatric spinal manipulation: a systematic review. Pediatrics. 2007 Jan 1;119(1):e275-83.