A Description of Children and Adolescents in Danish
Chiropractic Practice: Results from a Nationwide Survey

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:    Frankp@chiro.org

FROM:   J Manipulative Physiol Ther. 2009 (Oct); 32 (8): 607–615 ~ FULL TEXT

Lise Hestbaek, PhD, Annette Jørgensen, DC, and Jan Hartvigsen, PhD

Nordic Institute of Chiropractic and Clinical Biomechanics,
Odense, Denmark.
l.hestbaek@nikkb.dk

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OBJECTIVE:   The purpose of this study was to describe Danish chiropractic patients younger than 18 years.

METHODS:   Questionnaires were mailed to all chiropractic clinics in Denmark during a randomly assigned month between September 2007 and September 2008. All patients younger than 18 years or their parents were asked to complete a questionnaire collecting information on age, presenting complaint, duration and consequences of this complaint, referral mode, and use of pain medication.

RESULTS:   Babies were the most common pediatric patients with about one third being between 0 and 4 months of age. Infantile colic was the most common presenting complaint in this age group. For the older children, musculoskeletal problems were the most dominant complaint, ranging from 33% among the preschool children to 75% among the teenagers. These complaints were often chronic and about a third of the children older than 2 years had experienced symptoms for more than 1 year before seeing the chiropractor. These health complaints were reported to restrict activity as well as alter mood, and 39% of the 2- to 17-year olds used analgesics. There was limited referral of patients from other health care professionals.

CONCLUSIONS:   Babies made up most of the Danish chiropractic patients younger than 18 years. Among the older children and the adolescents, musculoskeletal complaints were most common and mostly of a chronic nature. The large number of pediatric patients in chiropractic practices and the paucity of evidence of treatment effectiveness indicate the need for further research in these age groups.

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From the FULL TEXT Article

INTRODUCTION

Surveys from European and North American countries show that chiropractors are almost exclusively providers of musculoskeletal health care, in particular for adult spine-related pain conditions. [1–7] Of course, variations in patient clientele between chiropractic clinics and even between doctors in the same clinic can still be considerable and these variations have been poorly described in the literature. In particular, there appears to be diversity in relation to pediatric patients where some chiropractors almost never treat children and some go as far as to promote themselves as specialists in chiropractic pediatric care. [8]

Recently, there has been an increasing focus on the health of children and adolescents, mainly because lifestyle diseases such as cardiovascular disease and diabetes that affect a large proportion of the population in industrialized countries have been shown to begin early in life. [9–11] This pattern is, however, also seen in musculoskeletal conditions such as back pain where the cumulative lifetime incidence is already at the adult level in late adolescence3 and significant back pain in childhood is a strong predictor of back pain later in life for the individual. [12] It therefore makes sense that chiropractors would be interested in the musculoskeletal health of children and adolescents.

Chiropractic care of children, however, appears not to be limited to conditions of the spine and musculoskeletal system. According to a recent systematic review by Gotlib and Rupert, [13] it has been documented that chiropractors treat vastly different conditions in children ranging from infantile colic, asthma, enuresis, and otitis media to learning disabilities and even jet lag. The rationale for treatment rests primarily with clinical experience and descriptive case reports, as there have been very few randomized controlled trials [13] providing evidence to guide practice. Therefore, high-quality evidence for the effectiveness of the chiropractic treatment of the pediatric patient is almost completely absent.

Detailed descriptions of patients seeking chiropractic care have helped define the domain of the profession for chiropractors themselves, for other health care professions, and for the public. Furthermore, such mapping of patients and their characteristics can help identify areas where there is a particular need for research or increased public awareness. For the reasons mentioned above, it was decided that research into chiropractic pediatric issues would be a priority area at the Nordic Institute of Chiropractic and Clinical Biomechanics, the first initiative being a comprehensive survey of pediatric and adolescent patients in Danish chiropractic clinics. The purpose of this article is to report the results of this survey. Specifically, the age distribution, the types and duration of complaints, mode of referral, consequences of the complaints and use of nonprescription pain medication were of interest.

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DISCUSSION

A large proportion of the pediatric patients in Denmark were younger than 1 year. As expected, the presenting symptoms among the babies were rather diverse, whereas the prevailing symptoms among the older children (older than 2 years) were more similar to those of adult chiropractic patients, namely, musculoskeletal complaints and headaches. Many of the children had been suffering from their primary complaint for more than 1 year, including those with musculoskeletal complaints. About 1 quarter of the schoolchildren felt that their complaint severely influenced their mood and limited their activities and therefore, the complaints did not appear to be trivial. Furthermore, more than a third of all the children used pain medication, of which 16% did so at least weekly. The use of painkillers was highest among headache patients and among those with a low level of physical activity. About 1 quarter of the patients were referred by other health care professionals, most of these being babies referred by health visitors who visit the homes of the newborn babies on a regular basis. Many of the children had parents and siblings who were chiropractic patients.

One of the very prevalent morbidities in childhood is otitis media with effusion with a cumulative incidence of 80% at the age of 4 years. [15] Nevertheless, ear problems only represent 2 percent of the primary complaints in this survey. This indicates that chiropractic is not an obvious choice of care for children with ear problems in Denmark, although it appears to be more common among chiropractors in other countries (personal communication with chiropractors in private practice, United Kingdom and United States). We have no explanations for this apparent discordance, but it could be due to a very widespread use of ventilation tubes in Denmark, making this the obvious solution for parents and general practitioners alike.

The long duration of complaint was to be expected for conditions like asthma, allergy and concentration problems, but it was rather surprising that about 1 quarter of the children with musculoskeletal complaints also suffered for more than 1 year before their first visit to the chiropractor. This means that the child attends the chiropractor for the first time at a point where the condition in an adult patient would be characterized as chronic. The long duration was even more surprising considering that the large majority of the parents of these children was or had been chiropractic patients themselves. This could reflect a strong belief in the myth that children do not suffer from musculoskeletal complaints unless they are seriously injured with fractures or tears or the like. Other types of musculoskeletal pain will thus be regarded as psychosomatic or “growing pains” and thus ignored. It would appear that this attitude seriously needs revision, considering the relationship between musculoskeletal health in childhood and musculoskeletal health in adulthood. Furthermore, this survey shows that the complaints do have consequences for the quality of life of these children (use of medication, alteration of mood, and limitation of activity) and, therefore, might influence their mental and physical development.

The finding that most of the patients were not referred by other health care professionals could indicate that chiropractic was the first choice of care. However, it could also indicate that there are still improvements to be made with respect to interprofessional relationships, even though chiropractic has become an integrated part of the Danish health care system. The high proportion of referred babies is a reflection of a good working relationship between the chiropractors and the health visitors who visit the homes of new families on a regular basis. This relationship is the result of a conscious effort from chiropractors to improve the dialogue with this group and the health visitors being open-minded and searching for new options to help their clients. This might act as a motivator to work even harder for increased knowledge about chiropractic among other health care professions.

The polarizing of physical activity seen with increasing age has been shown previously among Danish adolescents [16] and illustrates the need for information for, and motivation of, teenagers to prevent physical inactivity at this age where acquired health and lifestyle habits may last a lifetime. In addition, the use of nonprescription pain killers among teenagers has been demonstrated in previous Danish surveys where the most commonly used medicine was analgesics for headache and stomach ache, and the proportion of frequent users also increased with age. [17] Holstein et al. [17] also noticed a rising trend in medicine use from 1988 to 1998 and called for more information about the use of medication. Since these problems seem to be similar among chiropractic patients and the rest of the population, these should be areas of focus for the chiropractor, as well as for all other professionals taking care of pediatric patients. The aspect of physical activity might be even more important for the chiropractor than for other professions since musculoskeletal problems might be a barrier for physical activity and a healthy lifestyle. By focusing on the improvement of musculoskeletal health and lifestyle advice, the chiropractor has an important role to play in relation to public health and prevention of lifestyle diseases.

By contacting all clinics in the country and spreading the questionnaires over a full year, sampling bias is minimized with respect to demographic factors and seasonal variations. Furthermore, the questionnaires were targeted to the pediatric population and pilot-tested before use. However, the relatively small sample size may represent a problem. Fortunately, there does not seem to be a systematic bias with regard to age, since the age distribution is similar to that reported from The National Board of Health for 2006. There is no reason to believe that certain complaint categories would be under-represented. Instead, it is more likely that most of the missing sample is simply due to lack of participation in questionnaire collection in busy practices. Indeed, this was confirmed by some chiropractors calling to apologize for their forgetfulness. Furthermore, there were more visits by the end of the month than the beginning, indicating that some clinics did not start their collection by the beginning of the months, but remembered it at some point during their allocated month. We did not become aware of this problem until making the analyses after the end of the data collection. Had we been aware of this problem earlier, we could have extended the collection period for those practices which either forgot the survey completely or started late. We do not anticipate this to skew the result, but it is nevertheless possible and should be kept in mind when interpreting the results.

      Implications for Research

Most of the research related to chiropractic treatment has hitherto been focusing on adult patients. There is very little evidence with regard to chiropractic treatment of children and adolescents. [13] This survey shows that musculoskeletal problems among young chiropractic patients are not trivial and the literature suggests that they have implications for future health. [12, 18] Thus, research must have more focus on this area in order to increase the available evidence regarding treatment of this age group in which primary prevention can be achieved.

Because so many parents seek chiropractic care for their infants, chiropractors have an obligation to provide evidence to support the value of their treatment by conducting research into the etiology, diagnosis, and treatment of excessive crying in infancy.

      Implications for the Chiropractic Profession

Whereas people younger than 20 years constitute 24% of the whole population, in a previous survey, patients younger than 20 years constituted less than 10% of Danish chiropractic patients. [4] If chiropractic is effective for this age group, it is possible that these services are under accessed. However, this would depend on the prevalence of these pediatric conditions. Presently, there is limited attention to pediatric issues in most chiropractic educational and research institutions, and consequently practicing chiropractors too easily rely on charismatic individuals' personal beliefs instead of evidence-based principles. To change this, associations and institutions must pay more attention to the field of pediatrics by supporting and promoting research, and maybe even embrace the idea of pediatrics as a chiropractic sub-specialty. Furthermore, the profession should work towards an increased public awareness about the importance of musculoskeletal health in childhood and the implications for future health.

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CONCLUSION

This survey shows that the 2 largest groups of pediatric chiropractic patients in Denmark are babies with a large variety of symptoms and older children with musculoskeletal complaints. The complaints are often chronic and may have an impact on the children's lives. The survey also showed limited referral from other health care professionals. Research should focus more on chiropractic treatment of infants and babies and the treatment of musculoskeletal problems in children and adolescents.

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Practical Applications:

• The biggest group of pediatric patients in Danish chiropractic practices were babies.
  

• The most common complaints in children older than 2 years related to the musculoskeletal system.
  

• For the children older than 2 years, about one third of the complaints had lasted for more than 1 year
  

• The reported complaints led to restriction of activities and alteration of mood.
  

• Twenty percent of the babies were referred from health visitors. For all other groups, referrals were rare.

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