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T
HE
S
AFETY AND
E
FFECTIVENESS OF
P
EDIATRIC
C
HIROPRACTIC
:AS
URVEY OF
C
HIROPRACTORS AND
P
ARENTS IN A
P
RACTICE
-B
ASED
R
ESEARCH
N
ETWORK
Joel Alcantara, BSc, DC,
1,2#
Jeanne Ohm, DC,
1,3
and Derek Kunz, BS
1
Background: With continued popularity of complementary
and alternative medicine (CAM) therapies for children, their
safety and effectiveness are of high concern for both CAM and
conventional therapy providers. Chiropractic is the most popu-
lar form of practitioner-based CAM therapies for children.
Objective: The objective of this study was to describe the practice
of pediatric chiropractic, including its safety and effectiveness.
Design: This study used a cross-sectional survey.
Set t i n g: Apractice-basedresearchnetworkwasusedforthisstudy.
Patients/ Part ici pants: Participants were chiropractors and par-
ents of pediatric patients (aged !18 years) attending chiropractic
visits ranging from one to 12 visits.
Intervention: This is a survey study. No interventions were ren-
dered in the completion of this study.
Main Outcome Measures: Demographics, clinical presenta-
tions, treatment-associated aggravations, complications and im-
provements.
Results: The indicated primary reason for chiropractic care of
children was “wellness care.” With respect to condition-based
presentations, musculoskeletal conditions were the most
common, in addition to nonmusculoskeletal conditions of
childhood. The most common techniques used were diversi-
fied technique, Gonstead technique, Thompson technique,
and activator methods. Treatment-associated complications
were not indicated by the chiropractic and parent responders.
Chiropractor responders indicated three adverse events per
5,438 office visits from the treatment of 577 children. The
parent responders indicated two adverse events from 1,735
office visits involving the care of 239 children. Both sets of
responders indicated a high rate of improvement with respect
to the children’s presenting complaints, in addition to salu-
tary effects unrelated to the children’s initial clinical presen-
tations.
Key words: Pediatric, chiropractic, safety, effectiveness
(Explore 2 0 0 9 ; 5 :2 9 0 -2 9 5 . © 2 0 0 9 Pu blished by Elsevier In c.)
INTRODUCTION
Contemporaneous with the ever-expanding use of complemen-
tary and alternative medicine (CAM) by adults is the burgeoning
interest in CAM therapies for children. Eisenberg et al
1
deter-
mined that CAM utilization by adults increased from 34% in the
early 1990s to 42% in the late 1990s. During this same time
period, CAM pediatric utilization increased from 11% to 20%.
2
Of the array of CAM therapies available to children, chiroprac-
tic is the most popular practitioner-based CAM therapy
3,4
and is
referred to as pediatric chiropractic.
5
Pediatric visits for CAM
treatment are for a wide range of disorders, including pain, re-
spiratory and gastrointestinal tract problems, ear infections, en-
uresis, and hyperactivity, among others.
4,6
A study by Lee et al
6
characterizing the chiropractic care of children extrapolated that
30 million pediatric patient visits were made to chiropractors in
1997 at a cost of approximately $1 billion, with parents paying
some $510 million out of pocket.
Given its continuing popularity, pediatric chiropractic there-
fore represents a substantial and significant aspect of CAM ther-
apy for children. In a discussion of the evidence for safety and
effectiveness of manual therapy for children, Huijbregts
7
pointed out that there is no clear evidence of harm to date.
Considering the diversity of approaches in pediatric spinal ma-
nipulative therapy (SMT), research on outcome and harm for
one treatment approach cannot and should not be applied to all.
The safety of chiropractic care in general and the treatment of
children in particular continue to generate controversy and de-
bate.
8,9
The results of this study, and a careful reading of the
literature to date, suggest that in general, SMT for children is
extremely safe.
METHODS
This study was approved by the Institutional Review Board of
Life University, Atlanta, Georgia. The study was approved for
implementation for a period of one year beginning September
2007.
St u d y Sa m p l e
An e-mail invitation was sent out to 2,099 chiropractors to par-
ticipate in the International Chiropractic Pediatric Association
(ICPA) practice-based research network (PBRN) program. The
purpose of this study was to evaluate the safety and effectiveness
1 International Chiropractic Pediatric Association, Media, PA
2 Private practice, Alcantara Chiropractic Wellness Care, San Jose, CA
3 Private practice, Ohm Family Chiropractic, Media, PA
This study was funded by the International Chiropractic Pediatric Asso-
ciation, Media, PA.
#Correspondin g Au thor. Address:
327 N Middletown Rd, Media, PA 19063
e-mail: dr_jalcantara@yahoo.com
290 © 2009 Published by Elsevier Inc. EXPLORE September/ October 2009, Vol. 5, No. 5
ISSN 1550-8307/09/$36.00 doi:10.1016/j.explore.2009.06.002
ORIGINAL RESEARCH
of pediatric chiropractic. Inclusion criteria for participation in
the PBRN were (a) the chiropractor must be in good standing
with the Board of Chiropractic Examiners in his/her state, (b)
they must agree to the terms of participation as an ICPA PBRN
participant (ie, PBRN participation must not be used for practice
building or marketing, in addition to maintaining patient confi-
dentiality and informed consent), and (c) that the subject of
interest (ie, pediatric patients aged !18 years) must have re-
ceived SMT care ranging from one to 12 visits. Furthermore, the
chiropractor was encouraged to invite the parents of pediatric
patients to participate in a similar survey examining the chiro-
practic care rendered to their child.
Su r ve y C on t en t : C h i r op r a ct i c Su r vey
The survey instrument was pilot tested with 15 chiropractors and
changes made as appropriate prior to implementing the study.
Data extracted from the patient file included geographical data
such as gender, age, and the number of visits at the time of file
review. Furthermore, this study examined the presenting com-
plaints and the approach to patient care (ie, the chiropractic
SMT technique applied and the spinal region or regions SMT
was rendered). The chiropractors were also asked to document
treatment-associated changes such as aggravations, complica-
tions, or improvements. Treatment-associated aggravations were
defined as worsening of symptoms or complaints following
treatment. Treatment-associated complications were operation-
ally defined as cerebrovascular accidents, dislocation, fracture,
pneumothorax, sprains and strains, or death as a result of
treatment. Treatment-associated improvements were defined
as improvement in symptoms or other reported perceived
benefits attributed to treatment. The treatment-related aggra-
vations, complications, and improvements were based on
subjective reports by the patient or the patient’s parents/
guardians or from the examination findings on the part of the
chiropractor.
Su r ve y C on t en t : P ar en t Su r vey
The survey instrument was pilot tested with 15 parents/guard-
ians, with changes made as appropriate prior to implementation.
Parent/guardian data include age, gender, and level of educa-
tion. With respect to their child, information extracted includes
gender, age, and the number of visits attended. As in the chiro-
practor survey, this study examined the types of presenting com-
plaints as well as treatment-associated changes such as aggrava-
tions, complications, or improvements.
St at i st i ca l An a l ysi s
Data was entered in a Portable Document Format (PDF) through
Adobe Reader (Adobe Systems, San Jose, CA). From this PDF,
an Extensible Markup Language (XML) file was created contain-
ing the data entered in the original form. Using Adobe Acrobat,
the XML files were converted to a single comma separated value
(.csv) file, which was exported to a spreadsheet (Excel, Microsoft
Corporation, Redmond, WA) and analyzed using descriptive
statistics.
RESULTS
Chiropractor Survey
The data reported herein was derived from a total of 21 chiro-
practors contributing 577 pediatric clinical cases. All patients
received chiropractic SMT at each visit (N !5,438 office visits).
The cohort of pediatric patients ranged in age from less than a
day to 18 years, with an average age of 7.45 years (median age !
seven years; mode age !one year). The gender distribution was
273 females and 304 males. The average number of office visits
completed during the time of the survey was 9.4 (median !12;
mode !12). A majority of the patients reported upon were
existing patients returning for care with new complaints (n !
476; 82.4% of cohort), whereas 94 (16.2% of cohort) were new
patients.
Of the 577 patients, 46% (n !267) were reported as pre-
senting for “wellness care.” Twenty-five percent of these (n !
67) also indicated a concurrent specific complaint (eg, colic)
that was included in the analysis of the various pediatric
clinical presentations. For the 577 patients, the categories for
clinical presentation/care were wellness care (46%); musculo-
skeletal complaints (26%); digestion/elimination problems
(7%); ear, nose, and throat problems (6%); neurological prob-
lems (6%); immune dysfunction (5%); and other (4%).
With respect to the spinal regions addressed, regardless of
clinical presentation, 77 patients received full spine SMT
care, whereas 500 patients received regional spinal care. Full
spin e care denotes that SMT was applied to the cervical, tho-
racic, and lumbosacral spine at each visit. Regional care de-
notes the patient receiving SMT at one or two spinal regions
(ie, cervical and thoracic spine or thoracic and lumbosacral
spine). Additionally, 468 patients received some form of cra-
nial care, regardless of full spine or regional spinal care. When
examining the specific spinal regions rendered SMT (regard-
less of whether a patient received full spine or only regional
care), 509 patients received SMT to the cervical spine, 550
patients received SMT to the thoracic spine, and 524 received
SMT to the lumbosacral region.
The primary and most common chiropractic SMT technique
used by the chiropractors in rendering care were diversified tech-
nique (n !334), Gonstead technique (n !58), Thompson
technique (n !57), activator methods (n !43), cranial tech-
nique (n !23), torque release technique (n !6), and other (n !
55), with n !1, not indicated. Descriptions of these techniques
are provided in Table 1.
With respect to treatment-associated aggravations, compli-
cations, and improvements, these were not mutually exclu-
sive for each patient. From 5,438 visits where SMT was ren-
dered at each visit, there were three separate reports of
treatment-associated aggravations. These were reported as
“muscle stiffness,” “spine soreness through the seventh visit,”
and “stiff and sore” after SMT to the first cervical vertebrae.
The attending chiropractor’s response to the treatment-asso-
ciated aggravations was to address the complaint by follow-
ing a course of care consisting of a reexamination and appli-
cation of a different SMT technique, modification of the
SMT technique rendered, or modification of the spinal seg-
ment that was rendered the SMT. No treatment-related com-
291
Sa f et y an d Ef f e ct i ve n ess o f Pe di a t r i c Ch i r o pr a c t i c EXPLORE September/ October 2009, Vol. 5, No. 5
plications were reported by the patients or their parents/
guardians.
Of the 577 clinical cases, the respondent chiropractors re-
ported 518 patients as experiencing an improvement in their
presenting complaint, attributed to the care they received.
Par ent/ Guar dian Su rvey
The data were provided by 239 parents reporting on a similar
number of children. The parents ranged in age from 20 to 51
years, with an average age of 35.58 years (median !34 years;
mode !33 years). With respect to gender, there were 222 fe-
males and 16 males, with one not indicating. Based on their
reported levels of education, seven had PhDs, 29 had Master’s
degrees, 73 were baccalaureates, 35 had college certification, 61
had “some college,” 26 were high school graduates, three had
“some high school,” and five did not indicate level of education.
Of the 239 children, 113 were female and 119 were male, with
seven genders not indicated. They ranged in age from less than a
day to 18 years. Their average age was 6.16 years (median !
4.67 years; mode !seven years). The patients attended a total
of 1,735 visits, with an average of 7.26 visits (median !11;
mode !12).
With respect to the reasons for seeking chiropractic care, 47%
of patients (n !112) presented for wellness care. Of those pa-
tients indicating a specific complaint, the most common were
musculoskeletal complaints (n !54); ear, nose, and throat prob-
lems (n !10); neurological problems (n !7); colic (n !6);
digestion/elimination problems (eg, constipation and enuresis;
n!9); immune dysfunction (eg, asthma; n !3); birth trauma
(n !7); and others (n !26).
With respect to treatment-related aggravations, complica-
tions, or improvement, these were not mutually exclusive for
each patient. Of the 239 clinical cases, 162 parents reported
treatment-related improvements, two reported treatment-associ-
ated aggravations, and none reported treatment-associated com-
plications. Of the two treatment-associated aggravations, one
was a report of soreness of the knee following care to address a
knee complaint, and the other was stiffness of the cervical spine
following SMT to address cervical spine dysfunction.
Of the types of treatment-associated improvements in relation
to their indicated presenting complaints, the most common re-
ported improvements were decreased pain (n !33), improved
mood (n !18), and increased immune function (n !17). Inter-
estingly, treatment-associated improvements unrelated to the
patients’ initial clinical presentation were reported by many par-
ents. The three most commonly reported improvements were
immune system–related improvements (eg, sick less often; n !
34), improved sleep; n !27), and improved emotional state or
mood (eg, calmer or happier; n !19). In all, 98 patients were
reported as having improvements that were unrelated to their
primary reason for seeking chiropractic care.
DISCUSSI ON
Sa f et y / A dv e r se E f f ec t s
The area of greatest controversy regarding the safety of chiro-
practic care has been that of SMT of the cervical spine. Di
Fabio
12
examined 177 cases involving SMT of the cervical spine
as reported in 116 articles published between 1925 and 1997.
Although the subjects’ age ranged from four months to 87 years,
the majority of the cases involved adult patients (average age !
39.6 years), and those involving children (ie, aged !18 years)
were not well described. The most frequently reported injuries
involved arterial dissection or spasm, lesions of the brain stem,
and Wallenberg syndrome. The “other” category included visual
deficits, hearing loss, balance deficits, and phrenic nerve injury.
Ernst
13
described two cases associated with an adverse reaction
to SMT. One case involved an infant with congenital torticollis
treated with chiropractic spinal manipulation.
14
Within a few
hours of receiving care, the child suffered from respiratory dis-
tress, quadriplegia, and seizures. A holocord astrocytoma with
excessive acute necrosis was found and resected. The second case
involved a three-month-old girl treated by a German physiother-
apist with forced rotation and retraction of the head.
15
As a
result of the care rendered, both vertebral arteries dissected,
causing ischemia of the caudal brain stem with subarachnoid
hemorrhage. The diagnosis was confirmed with magnetic reso-
nance imaging, and the child died.
Table 1. Chiropractic Techniques Utilized in the Pediatric Patient Population
10,11
Technique Description
Diversified technique A generic chiropractic technique characterized as HVLA-type thrust that results in cavitation
Gonstead techniques A segment-specific HVLA-type thrust technique that incorporates the use of x-ray analysis (spinography) and
temperature gradient instrumentation to assist in the clinical decision making (ie, what spinal segments to
perform SMT)
Thompson technique A variation of the diversified technique that utilizes a special table with several “drop-piece” segments;
when the thrust is delivered, the table will drop a small distance; the drop pieces assist the thrust while
minimizing the force used for the delivery of SMT
Activator methods A hand-held, spring-loaded instrument that delivers a site-specific, low-force type thrust
Cranial technique Not a chiropractic technique per se, but a manual therapy that applies a sustained and prolonged force
(non-HVLA) to correct cranial segmental dysfunction
Torque release technique Uses The Integrator,* a torque and recoil release adjusting instrument to deliver the SMT
HVLA, high velocity, low amplitude; SMT, spinal manipulative therapy.
*The Integrator (Jack M. Holder, Miami Beach, FL).
292 EXPLORE September/ October 2009, Vol. 5, No. 5 Sa f et y an d Ef f e ct i ve n ess o f Pe di a t r i c Ch i r o pr a c t i c
Second only to chiropractors in frequency, osteopaths of-
ten perform SMT on patients as part of their treatment ap-
proach. To address the issue of safety of pediatric osteopathic
SMT (OSMT), Hayes and Bezilla
16
performed a retrospective
review of medical records of pediatric patients receiving OSMT.
Treatment-associated aggravations and complication as previ-
ously defined were documented. Of 502 records reviewed, 346
files met their inclusion criteria (ie, patient received two or more
office visits) for analysis. No OSMT-related complications were
documented. Nine percent (n !31) of 346 patients reported an
OMT-associated aggravation; specific reports included worsen-
ing symptoms (n !7), behavior problems (n !5), irritability
(n !5), pain (n !4), soreness (n !4), headache (n !2),
dizziness (n !1), flulike symptoms (n !1), treatment reaction
(n !1), and tiredness (n !1). Based on their findings, Hayes and
Bezilla
16
concluded that OSMT appears to be a safe treatment
modality for the pediatric population.
Vohra et al
17
performed a systematic review of the literature
documenting adverse events associated with pediatric SMT. Us-
ing eight databases and spanning a timeline of 104 years of
scientific publications, Vohra et al
17
found only 14 instances of
adverse events associated with pediatric SMT. The adverse
events include irritability (n !1), loss of consciousness (n !1),
midback soreness (n !1), acute lumbar pain (n !1), headache
and stiff neck (n !1), severe neurological deficits (n !5),
anterior dislocation of the atlas and fracture of the odontoid axis
at C2 (n !1), atlas dislocation (n !1), and death (n !2). Ten
of the 14 cases were attributed to chiropractic. Controversy re-
mains around the interpretation of the findings of this review.
Five of the 10 cases involved adverse events that were minor,
self-limiting, and did not require hospitalization or medical at-
tention. In the cases involving severe neurological loss or spine
fracture or death, the patients had a preexisting medical condi-
tion and/or had a history of neurological trauma, which make it
difficult to clearly attribute the adverse event to the SMT.
Miller and Benfield
18
recently published a three-year retro-
spective analysis of adverse events associated with pediatric SMT
at the Anglo European College of Chiropractic. Based on 697
children attending 5,242 patient visits, the authors reported that
minor adverse reaction is likely to occur at the rate of approxi-
mately one per 100 children, or one reaction reported for every
749 treatments in their patient population. Two potential con-
cerns regarding this review are the fact that an adverse event was
based solely on parental report of excessive crying, and that the
study was performed at a chiropractic teaching clinic with SMT
rendered by chiropractic students. Questions remain regarding
whether excessive crying on parent report is an adequate way to
evaluate adverse effects, and also regarding whether the out-
comes of care rendered by students can be generalized to the
overall practice of pediatric chiropractic.
Our survey of chiropractors reported that 0.51% of the patient
population, or one in 1,812 patient visits resulted in a minor
adverse events. The results from our parent survey indicate
0.83% of the patient population, or one in 867 clinical encoun-
ters, resulted in a minor adverse event. All reported aggravations
(from chiropractor and parent survey) were minor, self-limiting,
and did not require hospitalization or medical attention. More
importantly, the complaints were addressed by the treating chi-
ropractor in subsequent visits and did not dissuade the parent
from continuing care for their child. Based on the National
Cancer Institute’s Common Terminology Criteria for Adverse
Events,
19
the reported adverse events reported herein were mild
(ie, minor, no specific medical intervention, asymptomatic lab-
oratory findings only, radiographic findings only, marginal clin-
ical relevance) in nature.
Minor side effects have been reported in 30% to 55% of adults
receiving chiropractic SMT,
20-23
whereas in this study, less than
1% of the pediatric population experienced minor adverse
events based on chiropractor and parent responders. Several
factors may contribute to the low prevalence of adverse events,
including possible underreporting of adverse events, limitations
in our study design, and selection bias in patients choosing to
participate. It is also possible that chiropractors and other clini-
cians performing SMT in children, aware as they are of the
unique biomechanical features of the pediatric spine,
5
are more
cautious in their approach than some may be in their approach
to SMT in adults. The forces applied during SMT in children are
much less than those applied to adults; contact points are al-
tered, patient and chiropractor positions are modified, and low
force techniques are compared to high-velocity techniques may
be applied less frequently. Also, the malleable and hypermobile
nature of the pediatric spine may confer a greater amount of
adaptability in the pediatric spine as compared with the typical
response seen in adults.
Chiropractic and W ell ness Care
According to Jean and Cyr,
24
pediatric patients use CAM ap-
proaches for a wide variety of health issues, but principally for
chronic conditions involving musculoskeletal, psychological,
and infectious problems. Spigelblatt et al
4
found that the three
most common presenting conditions/reasons for children seek-
ing chiropractic care were respiratory; ear, nose, and throat prob-
lems; and musculoskeletal conditions. Nyiendo and Olsen
25
examined the characteristics of 217 children attending care at a
chiropractic college teaching clinic and found that 42% suffered
from musculoskeletal complaints, 20% from nonmusculoskel-
etal complaints, and 33% attended the clinic for general physical
examination. Verhoef and Papadopoulos
26
examined the treat-
ment of patients aged less than 18 years by Canadian chiroprac-
tors and found that musculoskeletal conditions were the most
common presenting complaints, followed by asthma and head-
aches. The findings of our study support the popularity of mus-
culoskeletal conditions as a presenting complaint in the pediat-
ric population insofar as when there is a specific condition
indicated.
An important finding of our study, however, is the high fre-
quency with which children were brought to the chiropractor
specifically for wellness care. As pointed out by Hawk,
27,28
chi-
ropractic has at its core a vitalistic and holistic theoretical frame-
work and approach to patient care, which incorporates a num-
ber of prevention and health promotion strategies,
27-30
particularly in the training of chiropractors. With the formal-
ization of the model course for public health education in chi-
ropractic colleges
31
and inclusion of public health preventive
measures within the scope of chiropractic practice,
32
chiroprac-
tic is actively moving toward becoming a “wellness profes-
293
Sa f et y an d Ef f e ct i ve n ess o f Pe di a t r i c Ch i r o pr a c t i c EXPLORE September/ October 2009, Vol. 5, No. 5
sion.”
27-31
The findings of our study demonstrate that this evo-
lution is being manifested in the clinical practice of pediatric
chiropractic.
The frequency of wellness care as a motivation for chiroprac-
tic care of children was first documented by Rubin.
33
In exam-
ining the presenting complaints of new patients to his pediatric
clinic, he found that wellness care was a common reason for
presentation, along with spinal, respiratory, stomach, and sleep
problems. Some studies also show a similar phenomenon in
adults; in an international survey of sacro-occipital technique in
adult patients, Blum et al
34
found that 42% of 1,316 patients
presented for care either for wellness, prevention, or to reduce
their risk of illness or injury. Kemper,
35
in addressing the issue of
effectiveness of CAM therapies for children, admonished that to
answer the question of whether or not CAM therapies work, one
of the essential components must be that the families’ goals and
expectations of treatment be elicited systematically. The role of
wellness care in a family’s choice to pursue chiropractic care
should be part of this evaluation.
Limitations
This study has several limitations. One limitation of our study is
the possible underreporting of adverse events by both chiroprac-
tors and parents predisposed to view SMT in a positive light.
Selection bias (ie, volunteer bias) and measurement bias (ie,
attention bias) likely played a role in the results obtained in our
study. The PBRN chiropractors were selected mainly from the
ICPA membership; members of the ICPA are interested in pro-
moting the chiropractic care of children and wellness care.
27,36
Also noteworthy is the bias on the part of the parent population,
as they were recruited from the PBRN. Selection bias may exist
in that only those parents with positive outcomes of care or lack
of adverse events in the care of their child may have been se-
lected. Additionally, studies continue to support the idea that
parent CAM users are more likely to use CAM use for their
children.
24
It is likely that our parent responders were also re-
ceiving chiropractic care under the paradigm of wellness care.
CONCLUSION
To the best of our knowledge, this is the first study of its kind
addressing the safety and effectiveness of pediatric chiropractic
SMT in a practice-based research setting. The results of both our
practitioner surveys and our parent surveys demonstrate a highly
perceived effectiveness for pediatric chiropractic care as well as a
high level of safety. We advocate continued research in this area,
with larger prospective cohorts incorporating the covariates of
safety and effectiveness of pediatric SMT.
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