Published 9 July 2009, doi:10.1136/bmj.b2766
Cite this as: BMJ 2009;339:b2766

Observations

Chiropractic for paediatric conditions: substantial evidence?

Edzard Ernst, professor of complementary medicine, Peninsula Medical School, Universities of Exeter and Plymouth, Exeter

Edzard.Ernst{at}pms.ac.uk

The vice president of the British Chiropractic Association, Richard Brown, writes that there is "substantial evidence for the BCA to have made claims that chiropractic can help various childhood conditions."1 The association made similar statements in a press release,2 because the science writer Simon Singh questioned statements made on the association’s website about childhood asthma, otitis, colic, feeding problems, sleeping problems, and prolonged crying.3 To back up his statement Brown provided 19 references.4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

Several of these references do not contain data relating to chiropractic treatment of the above named conditions.9 10 11 15 (See table.Go) Of the remaining 15, eight articles do not refer to controlled clinical trials but to retrospective analyses, observational studies, questionnaire surveys, and case reports, which tell us little about effectiveness.4 12 14 16 17 19 21 22 Here I will evaluate the remaining seven articles in more detail.5 6 7 8 13 18 20


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  		The 19 articles listed as evidence by the British Chiropractic Association

 
The "pilot study" by Bronfort and colleagues compared regular manipulations with sham manipulations for asthma.5 No effects were noted in lung function or hyper-responsiveness. The observed positive effects on quality of life relate to within-group changes and are, the authors say, "unlikely a result of the specific effects of chiropractic SMT [spinal manipulative therapy] alone."5

The randomised clinical trial by Wiberg and colleagues included 50 children with colic who received either chiropractic or dimeticone.6 In the chiropractic group, less crying was noted by the parents, but, because they "could not be blinded,"6 this might be due to a placebo response or other non-specific effects unrelated to chiropractic itself.

The "pilot study" by Mercer and Nook is available only as an abstract from conference proceedings.7 The data provided in this short summary are insufficient for critical assessment or for drawing meaningful conclusions about the effectiveness of chiropractic for colic.

Hawk et al published a systematic review of chiropractic care for non-spinal conditions, looking at the treatment of asthma, otitis, and colic, among other conditions.8 The authors included "chiropractic care" and studies of spinal manipulation or mobilisation not performed by chiropractors. Their positive conclusion regarding asthma relies on a study of osteopathic mobilisation of the ribs, and their conclusion of benefit for colic relies on the Wiberg study.6 The review does not contain additional positive data from controlled clinical trials of chiropractic for the above mentioned conditions.

The Cochrane review by Glazener et al13 is an evaluation of miscellaneous treatments for bed wetting. The authors found only two trials of chiropractic. These were not of high methodological quality, and the authors referred to them as "weak evidence."

The randomised controlled trial by Browning,18 published after Singh’s disputed commentary,23 compared the effectiveness of two treatments of unknown effectiveness (manipulation and occipitosacral decompression). Similar improvements were noted in the two groups. The authors’ notion that "both treatments appear to offer significant benefit to infants with colic" is arguably unjustifiable, as both treatments might also have been similarly ineffective.

Finally, Reed et al randomised 57 children with enuresis to receive either real or sham manipulations every 10 days for 10 weeks.20 The children in the experimental group had less severe enuresis already at baseline, and intragroup comparison of the number of wet nights failed to show a significant difference.

Although the content of the British Chiropractic Association’s list is important, its omissions are perhaps even more so. At least three relevant randomised controlled trials and two systematic reviews are missing from it.24 25 26 27 28 Arguably, these are the most rigorous papers in this area, but they fail to show that chiropractic is effective. The omissions are all the more curious as the association apparently knew of these articles. The association commented29 on our review30 that was based on this research, and the articles were part of Hawk et al’s review8 cited in the association’s list of evidence.

The association’s evidence is neither complete nor, in my view, "substantial."

Cite this as: BMJ 2009;339:b2766

Competing interests: EE has learnt spinal manipulation as a clinician and has published a book with Simon Singh, Trick or Treatment? Alternative Medicine on Trial.

See editorial by Harvey Marcovitch, BMJ 2009;339:b2759, doi:10.1136/bmj.b2759.

References

  1. Brown R. Chiropractors: clarifying the issues. BMJ 2009;339:b2782.[Free Full Text]
  2. British Chiropractic Association. Third update on BCA v Simon Singh www.chiropractic-uk.co.uk/gfx/uploads/textbox/Singh/BCA%20Statement%20170609.pdf.
  3. Harris E. Science in court. BMJ 2009;338:b2254.[Free Full Text]
  4. Klougart N, Nilsson N, Jacobsen J. Infantile colic treated by chiropractors: a prospective study of 316 cases. J Manipulative Physiol Ther 1989;12:281-8.[Web of Science][Medline]
  5. Bronfort G, Evans RL, Kubik P, Filkin P. Chronic pediatric asthma and chiropractic spinal manipulation: a prospective clinical series and randomized clinical pilot study. J Manipulative Physiol Ther 2001;24:369-77.[CrossRef][Web of Science][Medline]
  6. Wiberg JMM, Nordsteen J, Nilsson N. The short-term effects of spinal manipulation in the treatment of infantile colic: a randomised controlled clinical trial with a blinded observer. J Manipulative Physiol Ther 1999;22:517-22.[CrossRef][Web of Science][Medline]
  7. Mercer C, Nook BC. The efficacy of chiropractic spinal adjustments as a treatment of protocol in the management of infantile colic. In: Haldman S, Murphy B, eds. World Federation of Chiropractic. 5th Biennial Congress, 17-22 May 1999;170-1.
  8. 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 Comp Med 2007;13:491-512.[CrossRef][Web of Science][Medline]
  9. Bockenhauer SE, Julliard KN, Lo KS, Huang E, Sheth AM. Quantifiable effects of osteopathic manipulative techniques on patients with chronic asthma. J Am Osteopathic Assoc 2002;102:371-5.[Abstract/Free Full Text]
  10. Guiney PA, Chou R, Ianna A, Loveheim J. Effects of osteopathic manipulative treatment on paediatric patients with asthma: a randomised controlled trial. J Am Osteopathic Assoc 2005;105:7-12.[Abstract/Free Full Text]
  11. Mills MV, Henley CE, Barnes LL. The use of osteopathic manipulative treatment as adjuvant therapy in children with recurrent acute otitis media. Arch Pediatr Adolesc Med 2003;157:861-6.[Abstract/Free Full Text]
  12. Froehle RM. Ear infection: a retrospective study examining improvement from chiropractic care and analysing for influencing factors. J Manipulative Physiol Ther 1996;19:169-77.[Medline]
  13. Glazener CM, Evans JH, Cheuk DK. Complementary and miscellaneous interventions for nocturnal enuresis in children. Cochrane Database of Syst Rev 2005;2:CD005230.
  14. Nilsson N. Infant colic and chiropractic. Eur J Chiropractic 1985;33:264-5.
  15. Hayden C, Mullinger B. A preliminary assessment of the impact of cranial osteopathy for the relief of infant colic. Complement Ther Clin Prac 2006;12:83-90.[CrossRef]
  16. Hipperson AJ. Chiropractic management of infantile colic. Clin Chiropr 2004;7:180-6.[CrossRef]
  17. Miller J. Cry babies: a framework for chiropractic care. Clin Chiropr 2007;10:139-46.[CrossRef]
  18. Browning M, Miller J. Comparison of the short-term effects of chiropractic spinal manipulation and occipito-sacral decompression in the treatment of infant colic: a single-blinded, randomised, comparison trial. Clin Chiropr 2008;11:122-9.[CrossRef]
  19. Leach RA. Differential compliance instrument in the treatment of infantile colic: a report of two cases. J Manip Physiol Ther 2002;25:58-62.[CrossRef][Web of Science][Medline]
  20. Reed WR, Beavers S, Reddy SK, Kern G. Chiropractic management of primary nocturnal enuresis. J Manipulative Physiol Ther 1994;17:596-600.[Web of Science][Medline]
  21. Blomerth PR. Functional nocturnal enuresis. J Manipulative Physiol Ther 1994;17:335-8.[Web of Science][Medline]
  22. Fallon JM. The role of the chiropractic adjustment in the care and treatment of 332 children with otitis media. Chiropract Paediatrics 1997;2:167-83.
  23. Singh S. Beware the spinal trap. Guardian 2008 April 19 [withdrawn].
  24. Balon J, Aker PD, Crowther ER, Danielson C, Cox PG, O’Shaughnessy D. A comparison of active and simulated chiropractic manipulation as adjunctive treatment for childhood asthma. N Engl J Med 1998;339:1013-20.[Abstract/Free Full Text]
  25. Nielsen NH, Bronfort G, Bendix T, Madsen F, Weeke B. Chronic asthma and chiropractic spinal manipulation: a randomized clinical trial. Clin Exper Allergy 1995;25:80-8.[CrossRef]
  26. Olafsdottir E, Forshei S, Fluge G, Markestad T. Randomised controlled trial of infantile colic treated with chiropractic spinal manipulation. Arch Dis Child 2001;84:138-41.[Abstract/Free Full Text]
  27. Hondras MA, Linde K, Jones AP. Manual therapy for asthma. Cochrane Database Syst Rev 2002;(3):CD001002.
  28. Husereau D, Clifford T, Aker P, Leduc D, Mensinkai S. Spinal manipulation for infantile colic. Ottawa: Canadian Coordinating Office for Health Technology Assessment, 2003.
  29. Lewis BJ, Carruthers G. A biased report. J Roy Soc Med 2006;99:278.[Free Full Text]
  30. Ernst E, Canter PH. A systematic review of systematic reviews of spinal manipulation. J Roy Soc Med 2006;99:192-6.[Abstract/Free Full Text]

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This article has been cited by other articles:

  • Bonneux, L. (2009). The Singh libel case and 'alternative medicine'. Eur J Public Health 19: 574-575 [Full text]  

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Quackery, chiropractic and alternative medicine
Peter C Gøtzsche
bmj.com, 14 Jul 2009 [Full text]
Substantial evidence?
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