Rosen M, Blum CLWFC’S 10th Biennial Congress. International Conference of Chiropractic Research |  Montreal, Canada. Apr 30 – May 2, 2009: 319-21


Introduction: A call has been made for more rigorous scientific inquiry to examine the value of manipulative therapy in the treatment of pediatric conditions [1]. Simultaneously there have also been inquiries by our scientific community attempting to isolate what subset of patients with nonmusculoskeletal conditions might respond to chiropractic care [2]. Due to the scarcity of published literature relating to the chiropractic treatment of nonmusculoskeletal conditions [3], particularly of pediatric patients, this paper attempts to facilitate a glimpse into a clinical practitioner’s office where these conditions are routinely being treated. There are some specific difficulties with performing research with children, this is because: (1) Information is usually gathered second hand from their parents or via parent/doctor observation; and (2) randomized controlled studies have limitations since children by nature of their age are not considered competent to give consent to participate in experimental studies. While randomized controlled studies are the preferred option for investigative studies, observational studies may also offer valuable information [4]. Case reports (series) have a tendency to represent a positively biased presentation of selectively chosen patients by a doctor, yet still in some instances they may offer an important window into what is taking place in chiropractic clinical practice.

Methods: Cases were identified by reviewing the files of active patients under age 12 who presented for treatment of nonmusculoskeletal complaints. Data were abstracted from the identified charts and were entered into an SPSS (v. 14.0) database. All pediatric patients were treated by the same clinician. In all cases active chiropractic care consisted of sacro occipital technique and cranial pediatric treatments, with ancillary procedures to improve neurological function, when clinically indicated. These included cross patterning, biofeedback, early intervention, targeted exercise, nutritional support or homeopathic allergy desensitization.

Results: Of the 36 (16 male, 20 female) nonmusculoskeletal pediatric patients identified for this case series, 5 had presenting complaints of immune function, 7 for developmental delays/dysfunction, 9 for birth trauma, 1 for seizure activity, 3 for learning problems, 3 for endocrine problems, 3 for migraines, 2 gastrointestinal issues, 2 for fussiness/agitated/anxiety, and 1 for enuresis. Immune function presentations (n=5, 3_, 2_) consisted of children (1.2-6 years old) with allergies, asthma, ear infections, eczema, chronic congestion, and chronic recurring coughs, needing between 5-20 (average 11.4) office visits until significant improvement was noted. Developmental delays/dysfunction presentations (n=7, 4_, 3_) consisted of children (5 months-6 years old) with difficulties with verbal skills, motor skills/coordination, ambulation, visual dysfunction, and tics – vocal and physical, needing between 5-14 (average 10.1) office visits until significant improvement was noted. Birth trauma presentations (n=9, 5_, 4_) consisted of children (3 days-1.8 years old) with secondary birth difficulties due to c-section, vacuum delivery, premature birth, and nursing difficulties, needing between 1-12 (average 5.5) office visits until significant improvement was noted. Seizure activity presentations (n=1_) consisted of a child 3.8 years old until significant improvement was noted after one treatment. Learning problem presentations (n=3, 2_, 1_) consisted of children (2.4-13.4 years old) with ADD, ADHD, Asperger’s Syndrome, and verbal issues, needing between 1-9 (average 6) office visits until significant improvement was noted. Endocrine problem presentations (n=3_) consisted of children (8.6-14 years old) with low HGH/ stature, menarche symptoms, and thyroid dysfunction, needing between 3-18 (average 13) office visits until significant improvement was noted. Migraine headache presentations (n=3, 1_, 2_) consisted of children (8.3 – 14 years old) needing between 1-6 (average 3.3) office visits until significant improvement was noted. Gastrointestinal dysfunction presentations (n=2, 1_, 1_)) consisted of children (2 weeks and 1 year old) needing between 2-6 (average 4) office visits until significant improvement was noted. Patients (n=2_) seen for fussiness/agitated/anxiety were 2 and 3 months old needing between 1-5 (average 3) office visits until significant improvement was noted. One female patient (9.4 year old) presented with enuresis needing 14 office visits until significant improvement was noted.

Discussion: A challenge in evidence based healthcare is integrating historically successful clinical practice with current published research. Developing a pediatric chiropractic evidence base, particularly one for nonmusculoskeletal conditions, for practicing doctors [2,3] would likely start with expanding the doctor’s knowledge of pediatric diagnosis and treatment options.  This process could involve a certification process such as one by the International Chiropractic Pediatric Association (ICPA) which has postgraduate 180 hour certification and 360 hour diplomate programs. Implementing chiropractic adjustive techniques on newborns, infants, and young children is completely different from dealing with the adult patient so learning appropriate chiropractic therapeutic interventions to mitigate any adverse response to treatment [5] may be important. Sacro occipital technique (SOT) has protocols that are indicator based and offers low force techniques may be better applied to a young child. Cranial techniques, which are part of SOT’s system of analysis and treatment maybe indicated to address some newborn and developmental conditions. The Sacro Occipital Technique Organization – USA (SOTO-USA) like the ICPA also has a certification program to ensure that practitioners treating pediatric patients have appropriate training. It seems reasonable that chiropractic pediatric practitioners who are using SOT and cranial procedures are adequately trained in pediatrics and SOT/cranial care, possibly through certification programs. Part of this training should be to know when it is appropriate to refer patients for both emergency care and allopathic cotreatment. It is anticipated that the success in treatment for nonmusculoskeletal pediatric patients in this case series was high since cases were identified among active patients currently participating in wellness/maintenance care.

Conclusion: Since it does appear from this case series that pediatric nonmusculoskeletal conditions may benefit from SOT and cranial pediatric adjustive techniques, there is a greater need to investigate whether these responses to care can be generalized. Studies incorporating comparison groups may be warranted. In order to build an evidence base that accurately reflects real-life practice, it is essential that successful chiropractic clinical practices treating pediatric patients with nonmusculoskeletal conditions collaborate with the chiropractic research community.

References:

  1. Gotlib, A.; Rupert, R.; Chiropractic manipulation in pediatric health conditions – an updated systematic review. Chiropr Osteopat. 2008 Dec; Vol. 16(4): 11.
  2. Hawk C, Khorsan R, Lisi AJ, Ferrance RJ, Evans MW. Chiropractic care for nonmusculoskeletal conditions: a systematic review with implications for whole systems research. J Altern Complement Med. 2007 Jun;13(5):491-512.
  3. Hawk C, Long CR, Boulanger KT. Prevalence of Nonmusculoskeletal Complaints in Chiropractic Practice: Report from a Practice-based Research Program. J Manip Physio Therap. Mar-Apr 2001; 24(3):157-69.
  4. Concato J, Shah N, Horwitz RI. Randomized, controlled trials, observational studies, and the hierarchy of research designs. N Engl J Med. 2000 Jun 22;342(25):1887-92.
  5. Vohra S, Johnston BC, Cramer K, Humphreys K. Adverse events associated with pediatric spinal manipulation: a systematic review. Pediatrics. 2007 Jan;119(1):e275-83.

A case study of a 38-year-old female with chronic otitis media and loss is presented. The symptoms subsided and hearing was restored through chiropractic care with an emphasis on cranial adjustments. Chiropractic treatment of chronic otitis media of adults and children as an alternative to tympanotomy and ventilation tubes is discussed.

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