Chiropractic for paediatric conditions: substantial evidence?BMJ 2009; 339 doi: http://dx.doi.org/10.1136/bmj.b2766 (Published 09 July 2009) Cite this as: BMJ 2009;339:b2766
- Edzard Ernst, professor of complementary medicine, Peninsula Medical School, Universities of Exeter and Plymouth, Exeter
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.⇓) 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
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.