Chiropractic + Naturopathic Doctor

RESEARCH REVIEW: December 2008

By Shawn Thistle   

Features Research

Adverse effects of spinal manipulative therapy in children younger than
three years: a retrospective study in a chiropractic teaching clinic.

Study Title: Adverse effects of spinal manipulative therapy in children younger than three years: a retrospective study in a chiropractic teaching clinic.
Author(s): Miller JE, Benfield K
Publication information:  Journal of Manipulative and Physiological Therapeutics 2008; 31: 419-423.
Summary:  Below

Many manual therapists treat pediatric patients with increasing regularity, and there is some evidence that chiropractic care can benefit pediatric patients1,2,3. As with patients of any age, the risk-benefit ratio of treatment interventions is paramount. To date, very few serious incidents resulting from pediatric spinal manipulative therapy (PSMT) have been reported in the literature. The existing literature suggests that the risk of neurological or vertebrobasilar injury from PSMT is around 1 in 250 million manipulations. However, there have been no studies on a large cohort of these patients to more accurately assess such negative side effects.
This study was a retrospective review of 781 pediatric cases (all under three years of age) presenting to the Anglo-European College of Chiropractic teaching clinic between January 2002 and December 2004. There were no exclusion criteria. Information from each file was extracted by recording the number of treatments received, the type of
treatment administered, the outcome of treatment, and any negative or adverse events. The type of treatment was categorized as follows:

  • PSMT to more than one spinal region or pelvis
  • PSMT to the cervical, thoracic, or lumbar spine, respectively
  • PSMT to the pelvis
  • Occipital-sacral decompression technique
  • Upper extremity treatment
  • Lower extremity treatment
  • Massage and soft tissue work
  • “Other” – if a treatment did not fit into one of the above categories (the most common here was instrument treatment)

Treatment outcomes were measured by parent report of symptom change (improvement, no change, or worsening). Negative side effects were interpreted from parent comments, and were defined as any adverse reaction that was mild (transient and lasting less than 24 hours), moderate (requiring general practitioner/medical intervention), or severe (requiring hospitalization).

Pertinent results of this study include:

  • 697 patients (59 per cent male) underwent 5242 treatments
  • The majority of patients (73 per cent) were 12 weeks of age or younger Most infants presented treatment of colic or irritability because of biomechanical disorder, often attributed to birth trauma
  • 89 per cent received treatment, while 11 per cent were referred for other types of care
  • Common treatment types: 77 per cent received PSMT to the full spine, seven per cent occipital-sacral decompression, and six per cent PSMT to the cervicalspine only
  • 99 per cent reported an outcome of care – most (85 per cent) reporting an improvement in presenting symptoms, 14 per cent reporting no change
  • No parent reported worsening in presenting symptoms, however there were seven cases in which parents reported adverse reactions (roughly one per cent) – upon further examination, three of these seven were not actually adverse reactions and were attributed by the parents to other things aside from the treatment
  • All of the adverse reactions were mild in nature, requiring no medical care – six of the seven involved increased crying, and did not interfere with normal daily function
  • There were no serious complications

Although the design of this study does not provide insight into the effectiveness of chiropractic care for pediatric patients, it does suggest that adverse events associated with chiropractic care for patients younger than three are rare. This is a positive step forward for the literature in this patient population, who are difficult to study as they are unable to describe adverse reactions themselves.
This study examined a large number of patients, but its results should be interpreted while considering with the following limitations:

  • Three of the seven patients who had mild reactions were lost to long-term follow-up
  • Parental reporting has inherent limitations – for example, if they are satisfied with the clinical encounter, they may not report adverse reactions even if they occurred
  • Patient files may be incomplete in terms of reporting adverse reactions

In adults, a common side effect of manual therapy is temporary soreness,
so it is within reason that after PSMT, children may experience the same reaction. Practitioners must ensure that parents understand that increased crying time may be a normal, albeit rare, temporary reaction that can be expected to subside within 24 hours. •

Additional References: 

  1. Hayden JA, Mior SA, Verhoef MJ. Evaluation of chiropractic management of pediatric patients with low back pain: a prospective cohort study. JMPT 2003; 26: 1-8.
  2. Wiberg JMM, Nordsteen J, Nilsson N. The short-term effect of spinal manipulation in the treatment of infantile colic: A randomized controlled clinical trial with a blinded observer. JMPT 1999; 22: 517-522.
  3. Hughes S, Bolton J. Is chiropractic an effective treatment in infantile colic? Arch Dis Child 2002; 86: 382-384.

Dr. Shawn Thistle is the founder and president of Research Review
Service, Inc., an online, subscription-based service designed to help
busy practitioners to integrate current, relevant scientific evidence
into their practice.  Shawn graduated from CMCC and holds an Honours
Degree in Kinesiology from McMaster University.  He also holds a
certificate in Contemporary Medical Accupuncture from McMaster
University, and is a Certified Active Release Techniques (ART)
Provider.  For more information about the Research Review Service,

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