Adverse events associated with pediatric spinal manipulation: A systematic review

aap.jpg  This systematic review was published online in the journal Pediatrics on December 18. It will appear in print in the January 2007 issue. The review was produced by members of the Complementary and Alternative Research and Education Program at the University of Alberta (Edmonton).

On January 18 the FCER (Foundation for Chiropractic Education and Research) has issued a response to this article,  and has just published it on the FCER Web site.  An excerpt:

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.

Vohra S, Johnston BC, Cramer K et al. Adverse events associated with pediatric spinal manipulation: A systematic review. Pediatrics 2007;119 (1):e275-e283. [Published online December 18 2006] PubMed Record

BACKGROUND: Spinal manipulation is a noninvasive manual procedure applied to specific body tissues with therapeutic intent. Although spinal manipulation is commonly used in children, there is limited understanding of the pediatric risk estimates.
OBJECTIVE: Our goal was to systematically identify and synthesize available data on adverse events associated with pediatric spinal manipulation.
METHODS: A comprehensive search was performed of 8 major electronic databases (eg, Medline, AMED, MANTIS) from inception to June 2004 irrespective of language. Reports were included if they (1) were a primary investigation of spinal manipulation (eg, observation studies, controlled trials, surveys), (2) included a study population of children who were aged 18 years or younger, and (3) reported data on adverse events. Data were summarized to demonstrate the nature and severity of adverse events that may result rather than their incidence.
RESULTS: Thirteen studies (2 randomized trials, 11 observational reports) were identified for inclusion. We identified 14 cases of direct adverse events involving neurologic or musculoskeletal events. Nine cases involved serious adverse events (eg, subarachnoidal hemorrhage, paraplegia), 2 involved moderately adverse events that required medical attention (eg, severe headache), and 3 involved minor adverse events (eg, midback soreness). Another 20 cases of indirect adverse events involved delayed diagnosis (eg, diabetes, neuroblastoma) and/or inappropriate provision of spinal manipulation for serious medical conditions (ie, meningitis, rhabdomyosarcoma).
CONCLUSIONS: Serious adverse events may be associated with pediatric spinal manipulation; neither causation nor incidence rates can be inferred from observational data. Conduct of a prospective population-based active surveillance study is required to properly assess the possibility of rare, yet serious, adverse events as a result of spinal manipulation on pediatric patients.

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