Medical Management of Pediatric
and Non-Musculoskeletal Conditions
by Spinal ManipulationThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
Thanks to Dr. Rolf Peters, editor of the Chiropractic Journal of Australia for permission to republish this Full Text article, exclusively at Chiro.Org!
Considering the unpleasant fallout from the Simon Singh Case, this article sheds a unique,
new perspective on manipulative care for non-musculoskeletal conditions.
FROM: Chiropractic Journal of Australia 2013 (Dec); 43 (4): 131–136 ~ FULL TEXT
Peter L. Rome, D.C.
Melbourne, Australia
The Abstract: There is a well established precedent by medical doctors, particularly in Europe, of managing infant, paediatric and other patients for so-called organic conditions by spinal manipulation. There are also claims that chiropractic should not be involved with this form of management for so-called visceral disorders because it does not quite meet the current orthodox theories. This seems contradictory if not hypocritical when there is noted evidence in the medical literature itself of not only the rationale supporting these concepts, but evidence of medical doctors carrying out the same procedures for the same purpose on the same conditions.
Index terms: (MeSH): chiropractic; manipulation, chiropractic; manipulation, orthopedic; manipulation, musculoskeletal; manipulation, spinal; pediatrics; evidence based medicine. (other): medical manipulative therapy.
From the Full-Text Article:
Introduction
Some have questioned the hypotheses justifying chiropractic involvement in the management of paediatric patients, as well as those with so-called visceral conditions. [1–4] This topic was raised recently in a television program by Demasi. [5]
It is acknowledged that chiropractic constructs have been outside the traditional or orthodox models of understanding. However, there is a major contradiction regarding manipulative management of visceral and paediatric care due to the adoption of those very concepts by other areas of medicine – namely manipulative medicine. [6–9]
In particular, European medical doctors have published refereed papers on these very topics involving spinal manipulation in medical journals and medical textbooks for some decades. [10] (see Table 1) In an apparent contradictory development, it is primarily English language medical authors and other sources that seem to have attracted critics who direct their reservations at the principles espoused by chiropractors, but not to their European medical colleagues who are proponents of spinal manipulation. [11] It is also curious that osteopathic manipulative therapy does not appear to attract the same degree of debate and reservations despite the similarities.
There are at least three medical textbooks which include the topics of paediatric manipulative care and the manipulative management of visceral disorders. [6–8] One such medical text is totally devoted to paediatric manual therapy. [6]
INFANTS
Perhaps the most obvious medical evidence supporting the intervention of spinal manipulative care of infants is the textbook edited by Biedermann. [6] First published in Biedermann was originally a surgeon and subsequently moved to “Conservative Orthopedics” (sic). The textbook is dedicated to manipulative care of paediatric patients and comprises over twenty contributing authors including some fifteen medical doctors. He first published papers on the topic in a medical journal in 1995 – over 20 years ago. [12]
Some may question why an infant would require manipulation. However, chapter 8 of this text deals specifically with spinal “Birth trauma and its implications for neuromotor development.” [13]
In addition, in witnessing a birth, one is immediately aware of the potential for cervical spine strains and sprains, even in those where forceps are not used – situations well noted by Sacher. [13]
Another medical doctor, Lewit, has published on the topic of spinal manipulation with specific notes on the manipulation of children. This textbook has been published in at least seven languages following his original Czech edition in 1966. His text notes the importance of the craniocervical junction in new-born babies. [7]
One can assume that infants also suffer headaches, especially cervicogenic ones. An often rapid positive response noted by parents of an unsettled infant to a careful neck manipulation, can be apparent. The chiropractic literature is also replete with such anecdotal observations and case reports. [14–16]
PAEDIATRICS
Not only does Biedermann’s text of 334 pages comprehensively explore the manipulation of children when indicated, he also specifically notes a manipulative role for infants. The contributing authors also cite numerous references covering a wide variety of conditions. [6]
In other references dating back to 1956, Lewit also presents a discussion on the manipulation of children in his text. He a range of medical colleagues in doing so. Among other conditions, he mentions headaches – some of which were “formerly thought to be of psychological origin.” [17]
While the term cervicogenic headache has now been adopted in orthodox medical literature, this does not seem to have changed the orthodox practice approach towards the management of headaches of cervical origin – or perhaps even their clinical recognition. Despite this syndrome being well published in recognised journals, the pharmaceutical approach to managing this common ailment seems to have prevailed.
The term cervicogenic headache first appeared in Pubmed as recently as 1983 [18] – and by chiropractors since at least 1910. [19, 20] However headaches of cervical origin was noted by Braaf and Rosner in 1970 [21, 22] The Braaf and Rosner finding was reported in the media by Professor Stuart Butler that “90% of recurring headaches can be traced to injury induced mechanical derangements in the neck.” [23]
Table 1. Biological Systems Under Which Conditions Are Listed*
As Involving Management by Medical Spinal Manipulation. [10]
Cardiovascular
ENT
Gastrointestinal
Gynaecological
Immune System
Neurological - Headache
Neurological - Vertigo
Paediatric
Respiratory
Thyroid
Psychology
Vision
* This includes some 150 refereed medical papers, plus some 20 on paediatric manipulative care.
VISCERAL CONDITIONS
While there is some controversy as to the role of a vertebrogenic or spine-related factor in visceral dysfunction, there is published medical evidence available supporting this concept and the neurophysiological rationale underpinning it.
Biedermann’s medical text devotes a whole chapter by Theiler on the manipulative management of Attention Deficit Disorder (ADD). [24] This was one of the conditions mentioned controversially on the Catalyst program. [5] There is also a specific section in that book on colic, [25] as well as discussions on mechanical dyspnea syndrome and asthma. [26] These were also mentioned on the Catalyst program.
In a similar vein on medical spinal manipulation, Lewit has a section on vertebrovisceral correlations, where he discusses various published medical papers on numerous ‘visceral’ conditions. His dissertation covers conditions involving the tonsils, heart, lungs and pleura, stomach and duodenum, liver and gall bladder, kidneys, as well as gynaecological disorders. [7]
In his text on spinal manipulative management under the heading of functional disturbances, the once head of the physical medicine department of a Paris hospital – Maigne, lists such conditions as constipation, certain digestive pains, asthma, facial pain, Basedow’s disease, mastodynia, palpitations and pseudo-ulcers, as conditions that have responded to spinal manipulation. [8]
Apart from these independent supportive medical citations, there is ongoing evidence of somatovisceral pathophysiology published in medical journals by both medical doctors and chiropractors. Members of both professions also publish in chiropractic journals. Such studies cover a wide range of evidential levels, including research formats focussing on complex neurophysiological research, as well as randomised controlled trials and case studies. Historically, there was pioneering research involving animal models dating back many years. The Cleveland Chiropractic College conducted experiments using rabbits in the 1960’s. [27] Burns and colleagues conducted extensive osteopathic animal and clinical studies in the 1940’s and 50’s. [28] There has also been considerable neurophysiological and manipulation research involving animal studies published by osteopathic and chiropractic practitioners. [29–31] Both these professions have associated research bodies and their educational institutions conduct active research programs. Indeed, animal manipulation also known as animal chiropractic has become an established part of veterinary care. [32–33]
These observations involving apparent neurovertebral factors as noted by these recognised authorities in the cited cases tend to support the possibility of a role for manipulative management in particular conditions.
THE PHYSIOLOGICAL RATIONALE
To imply that chiropractic hypotheses are not supported by the scientific literature ignores the published evidence. It is simply false in fact and is inconsistent with readily available refereed journal papers, many of which are in medical journals.
Perhaps one of the most significant texts on this subject is a medical one by Sato et al., entitled, The Impact Of Somatosensory Input On Autonomic Functions. [34] This text originated from eminent neurophysiological research laboratories in Japan. It explores the body’s reactions to somatosensory input (somato-autonomic reflexes) to primary organs and systems in the body. It makes special mention of spinal manipulation:“In contrast to the impressive body of knowledge concerning the effects of visceral afferent activity on autonomic functions, there is, generally speaking, much less information available on the reflex regulation of visceral organs by somatic afferent activity from skin, the skeletal muscle and their tendons, and from joints and other deep tissues. The elucidation of the neural mechanisms of somatically induced autonomic reflex responses, usually called somato-autonomic reflexes, is, however, essential to developing a truly scientific understanding of the mechanisms underlying most forms of physical therapy, including spinal manipulation (emphasis added) and traditional as well as modern forms of acupuncture and moxibustion.” [34]
These authors reviewed the “…somato-autonomic reflex responses in the cardiovascular, including cerebral and peripheral nerve blood flow, digestive, urinary, endocrine and immune systems following somatic sensory stimulation in animals anesthetized to eliminate emotional factors.” [35]
They state further that “the decreases in blood pressure and renal activity during manipulation of the spine are thought to be supraspinal reflexes,” and that there were “changes in adrenal nerve activity induced by thoracic spine stimulation in chloralose/urethane-anesthetised rats.” [36]
One cannot help but wonder if critics are aware of the published papers outlining the neurophysiological basis of the manipulative sciences before expressing their opinion. A summary of the role of the ANS and its potential underlying somato-autonomic concepts can be found in the literature. [10] In addition, such authors as Bolton P, [37] Budgell B, [38] Carrick F, [39] Haavik-Taylor H, [40] Henderson C et al., [41] Pickar J, [42] Pollard H, [43] and others, have published widely on the concepts.
There are also many textbooks covering the general principles of chiropractic and osteopathy by such authors as Cramer GD, [44] Gatterman MI, [45] Haldeman S, [46] King HH et al, [47] Korr IM, [48] Kuchera et al, [49] Leach RA, [50] Patterson MM, [51] Redwood and Cleveland, [52] Schafer, [53] and others. Of note is the fact that these published authors essentially base their evidence on available medical references. One could hardly express an informed opinion on the topic of the manipulative sciences without familiarity with these works.
It should also be recognised that chiropractic is not just spinal manipulation. The practitioners generally incorporate into their regime other natural modalities in health management such as exercise, diet, massage, muscle balance, posture assessment, nutritional and life style advice. These are nominated here as incorporating a management and health maintenance supportive care.
CASE REPORTS, EMPIRICAL & ANECDOTAL EVIDENCE
Perhaps one argument about the manipulative sciences is that too great a proportion of its records is not level 1 evidence. Some have argued that in the case of the clinical healthcare sciences, supporting data requires a different form of evidence due to the individuality of patients. [54, 55] There is however, the mounting clinical evidence as well as formal scientific research, especially neurophysiological studies substantiating the manual health professions’ concepts. To date, the writer is not aware of any primary research that contradicts the fundamental hypotheses upon which they are based. Until recent times, the same doubts had been expressed about the value of manipulation for musculoskeletal conditions, and even about the lesion that is addressed by manual procedures – the vertebral subluxation. Events have overtaken these reservations to the extent that SMT for those conditions is now widely sought and adopted within professions other than chiropractic and osteopathy.
Less formal clinical evidence alone may be insufficient to justify a primary contact role in health care. However, that evidence can be seen as positive and supportive as one of the elements in justifying such a role – as in patient-centred care. [55–57] Gatterman emphasises this by stating “Implicit in the worldview of the patient-centred paradigm is the belief that the patient is the most important stakeholder.” [55] It is submitted that if a treatment is scientifically justified but does not work clinically, it should be dismissed. On the other hand, if particular therapeutic procedures are clinically successful, they deserve recognition even if the rationale for them has yet to be fully explored. It seems easier for some to dismiss a particular model of care than to accept a different one – or even to rationally consider research into the underlying premises behind that regimen.
How much of health care is based on the patient response? It is offered here that in practical clinical terms, there is a significant percentage. A patient’s own observations and satisfaction could be nominated as a regular form of efficacy assessment, as this forms a part of practical clinical protocols in everyday practise in all health professions.
To dismiss empirical and anecdotal evidence of aspects of the clinical sciences is difficult to substantiate due to the unique presentation of each patient. [57] It is submitted that all health care professions have been substantially based on anecdotal evidence in clinical practice throughout history. Due to patient variables in the health care sciences, the practicality of establishing a consistent evidence base of clinical observations in health care is important but difficult. Gatterman encapsulates this when she states that:“Evidenced-based medicine that accepts only randomised controlled trials tends to devalue the individuality of patients, shifts the focus of clinical practice away from care of the individual toward the care of populations, with the complex nature of sound clinical judgements not fully appreciated. While RCTs may establish strong causality through the enhancement of internal validity, generalisability is sacrificed.” [55]In underlining the role of anecdotal evidence, Bogen from Stanford University presents the following comment on its web site.“Scientists obtain a great deal of the evidence they use by observing natural and experimentally generated objects and effects. Much of the standard philosophical literature on this subject comes from 20th century logical positivists and empiricists, their followers, and critics who embraced their issues and accepted some of their assumptions even as they objected to specific views. Their discussions of observational evidence tend to focus on epistemological questions about its role in theory testing. This entry follows their lead even though observational evidence also plays important and philosophically interesting roles in other areas including scientific discovery and the application of scientific theories to practical problems.” [59]
In recognition of clinical results, it is suggested that patient safety and satisfaction could be the ultimate forms of anecdotal evidence. [57] This is demonstrated effectively when patient demand and voluntary presentation for care would fundamentally be based on positive clinical outcomes – despite theoretical supportive evidence still emerging.
In 2007, Rees addressed the issue of the suitability of formal fixed EBM for the clinical health sciences. He opined, “Where does this leave us (practitioners – au)? Should we abandon clinical trials? Of course not. They remain a potent way of determining whether interventions work. Should we accumulate trials and look at what a collection of studies says? Of course. What RCTs are not, nor systematic reviews, is an evidential gold standard. Just as we now realize that extrapolation from the bench to the clinic is fraught with hazard, so we are belatedly waking up to the fact that in the treatment of individual patients, all the evidence, from whatever source, needs to be considered. Knowing how to treat the patient in front of you still resists checklists and formalization. For the moment, anyway.” [60]
As raised by Lenzer and Rees, [58, 60] if there are serious questions concerning the suitability of the form that an evidence base should take for clinical medicine, other health professions must review their evidence base criteria as well. Even some aspects of the extensive reviews conducted by the Cochrane Collaboration have been queried by some. [61]
While this discussion is not offered as a form of scientific conclusion, it is intended to offer a plausible comparison by highlighting a blatant contradiction within medicine. It would be hoped that a reasonable, open and scientific mind might determine that there may be elements worthy of constructive discussion, further study and fostered collaboration. Expressed opinion on chiropractic concepts may be explored further, based on all known facets.
The extent of available research may not be as prolific at this stage, but it should be noted that research for the manual professions is essentially self-funded, and not subsidised by a manufacturing industry.
The “Father of American Medicine,’ and as a signatory of the Declaration of Independence Dr Benjamin Rush, must have foreseen the dilemma of containment of other health professions“The Constitution of this Republic should make special provision for medical freedom. To restrict the art of healing to one class will constitute the Bastille of medical science. All such laws are un-American and despotic. ... Unless we put medical freedom into the constitution the time will come when medicine will organize into an undercover dictatorship and force people who wish doctors and treatment of their own choice to submit to only what the dictating outfit offers.” [62]
SUMMARY
It seems quite incongruous that chiropractors should be singled out for criticism based on the questionable claim that chiropractic was based on debatable hypotheses and a dearth of supporting evidence, [63] – in view of the comparable adoption in some quarters of medicine of the very same principles and administering techniques. Further, that osteopathy in Australia seems to have remained below the target area, despite having an almost identical model of care.
The evidence presented here would suggest that opinion expressed on the ABCTV program ‘Catalyst’ appeared to have contradicted readily available published evidence that was not alluded to in the program.
In addition, this refereed material on manipulative management of paediatric patients is available in at least three medical texts and in many published medical papers – primarily in non-English language journals. The range of conditions addressed by manipulative procedures and their positive outcomes, is not only in the chiropractic and osteopathic literature, but also evident in those medical publications.
Case reports, anecdotal and empirical evidence also record observations which reinforce chiropractic hypotheses. They are highlighted by the fact that those forms of evidence are also utilised by orthodox medicine and manipulative medicine. Further, there is growing reservations in the literature about the reliance of meta analyses and randomised controlled studies for the clinical health sciences. [60]
Finally, the claim that there is an absence of sophisticated neurophysiological research, as well as research on animal subjects underpinning these manual therapy concepts, is patently incorrect.
One must conclude that the published medical evidence is not available in English language journals so that the opinions expressed on Catalyst and elsewhere are not adequately informed.
CONCLUSION
A corollary from these observations is that much of the opinion about chiropractic is just that – opinion that is misinformed and not based on available research and facts. One would hesitate to think that it is opinion based on opinion based on misinformed and unsubstantiated opinion. Even an unbiased cursory search would have revealed such evidence.
To pass as authoritative and knowledgeable, such opinion must be fair, accurate, current and fully conversant on the topic.
A claim to the effect that chiropractic is not scientifically based cannot be sustained when its evidence itself is based on established and fundamental published medical science. The continued recognition and incorporation of chiropractic principles and practice into medical domains further contradicts this claim.
Given the evidence of medical utilisation of spinal manipulative therapy for a range of visceral and other conditions, it is difficult to see how claims of an absence of a scientific base for a particular modality could be substantiated, without detracting from practices of medical colleagues. Such medical practices are conducted primarily in non-English speaking countries. There would appear to be a distinct contradiction between those professionals who advocate and employ SMT for a variety of conditions, and those who cannot accept the concepts.
The attitude portrayed by Catalyst is not unanimous within the medical profession. Support for chiropractic is emerging from medical circles in Australia and elsewhere. A recent survey indicated that 31% of general practitioners would ‘seek treatment from a chiropractor.’ [64] Given the traditional policy espoused by some practitioners, that is a surprisingly high percentage.
It would seem that the television program ‘Catalyst’ either overlooked or was not aware of the existing medical evidence on the topic it presented.
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