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FCER News Release

For Immediate Release: January 17, 2007

Contact: Robin R. Merrifield

1304 Perry Ave., Bremerton WA 98310

Phone: 800-343-0549 or 360-471-7837

Fax: 360-478-0834 E-mail: FCERedit@aol.com

FCER Responds to Pediatrics Article

Norwalk, Iowa—It’s a battle that the chiropractic profession is familiar with — a “scientific” article appears in a medical journal decrying the risks of chiropractic cervical manipulation, and newspapers and television news programs spread the conclusions without either comparison to risks associated with common medical treatments or rebuttal from within chiropractic. The latest front in this battle is over the chiropractic treatment of the pediatric population. Published in the January 1, 2007 issue of Pediatrics, the journal of the American Academy of Pediatrics, the article “Adverse Events Associated With Pediatric Spinal Manipulation: A Systematic Review,” has quickly reached the airwaves of the popular media.

In response to this latest media cacophony, the Foundation for Chiropractic Education and Research’s (FCER) Director of Research, Anthony L. Rosner, PhD, drafted a response to the editors of the journal. To provide the practicing chiropractors with the rebuttals necessary to answer patient, medical colleague, and possibly local media questions, a version of that response has been drafted. That response follows:

Safety issues surrounding spinal manipulation have received much attention in recent years. However, there has been very little discussion of this topic as it applies to pediatric patients. A new review recently published in the journal Pediatrics addresses this very concern, in what has been labeled as a "systematic review." This is supposed to mean that all the published material in the medical journals has been retrieved, with specific articles having passed certain criteria for their more intensive review and analysis.

Because this approach has not been previously followed for pediatric populations who have experienced spinal manipulation, this study pursues an important goal in today's world of assessing risks and benefits of all medical interventions. It also avoids a common limitation in reviews of this type, in that it embraces case and cohort studies which occur in live doctors' offices as well as clinical trials.

Described in the 13 papers accepted for review are 14 cases of direct adverse events following spinal manipulation. These include 9 cases of serious events (subarachnoidal hemorrhage and paraplegia), 2 moderately adverse events requiring medical attention (severe headache), and 3 minor occurrences (mid-back soreness). Another 20 cases of indirect adverse events involved delayed diagnosis or the inappropriate provision of spinal manipulation for such serious medical conditions as meningitis or rhabdomyosarcoma.

It is both important and commendable that these events have been brought to light in Vohra's report. However, they must be viewed in the larger framework of three factors: (1) the total number of treatments administered to children; (2) the relative risks of medical procedures for the same conditions treated; and (3) the benefits of spinal manipulation in children which have been amply described in the research literature. Lacking these considerations, this review presents a distorted and one-sided assessment of pediatric spinal manipulation.

Unfortunately, the review by Vohra falls short of its goals in its pursuits:

• Important studies involving pediatric patients who have successfully undergone spinal manipulation in resolving their complaints of ear infections (otitis media) have gone unnoticed.

• Another study in which the authors attribute adverse events to chiropractors in the United States instead involves physical therapists, most likely practicing in Germany.

• Yet another citation of adverse events occurring in a clinical trial describes nothing more than a short period of mid-back soreness and irritability, difficult to distinguish from a period of extended crying in another subject who was not even manipulated but was instead assigned to the placebo group.

• A final group of patients suffered from delayed diagnosis—which the authors erroneously attribute to one study that made no such mention of diagnoses at all but rather focused upon the direct consequences of manipulation per se.

So the question remains whether the authors have truly accomplished their minimal objective. Did they actually present an accurate and balanced assessment of the literature addressing the adverse events associated with spinal manipulation? The answer appears to be in the negative.

It is also not at all clear whether all the spinal manipulations described were in fact administered by qualified chiropractors, an important consideration when one considers the risks involved with individuals who have not received complete training in manipulating areas of the neck. Only when the following criteria are met will a truly "accurate and balanced" assessment of the scientific literature have been made:

• The precise maneuvers applied to the patient;

• The complete qualifications of those administering these treatments;

• The several benefits of manipulations of the cervical area which in the literature have been shown to include the relief of headache, carpal tunnel syndrome, otitis media, colic, and enuresis (bed-wetting).

None of these standards have been met by Vohra's review, such that it can only be greeted with extreme skepticism.

For more information on FCER and its programs, which bolster the chiropractic profession through the support of quality research into the profession and its various modalities, please go to www.fcer.org. FCER is a proponent of evidence-based chiropractic practice and is establishing the Evidence-Based Chiropractic Resource Center. Visit FCER.org on a regular basis for more information on the resources available.

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