Johnston BC, Cramer K, Humphreys K, Vohra S.

Adverse events associated with spinal manipulation in children: a systematic review.

CARE Program, Department of Pediatrics, University of Alberta, 4049 Research Transition Facility, 8308 - 114 St, Edmonton, Alberta T6G 2E1, Canada. b.johnston@ualberta.ca

BACKGROUND: Spinal manipulation is a non-invasive manual procedure applied to specific body tissues with therapeutic intent. A variety of different care providers (e.g. physiotherapists, massage therapists) may perform manipulation as part of their practice, but it is most frequently performed by chiropractors. After natural health product use, chiropractic is the most frequently used form of CAM, and chiropractic care is the most established CAM discipline in North America. In adults, estimates of the risk of serious events resulting from chiropractic treatment vary from 1 in 400 000 to 1 in 3.85 million cervical spine manipulations. Little effort has been made to generate similar pediatric risk estimates.

OBJECTIVE: Systematically identify and synthesize available data on adverse events associated with the chiropractic manipulation of children and youth.

METHODS: A comprehensive search was performed of eight major electronic databases (e.g. MEDLINE, AMED, MANTIS) from inception to June 2005. Studies were included if: (i) they were a primary investigation of chiropractic manipulation (i.e. observation studies, controlled trials, surveys); (ii) the study population was 18 years or younger; and (iii) they reported data on adverse events. Adverse events derived from RCTs will be summarized using risk difference (with corresponding 95% confidence intervals) since events are considered rare. For observational studies and surveys, risk estimates will be calculated using numerator (number of adverse events) and denominator (estimated number of pediatric spinal manipulations).

RESULTS: Our search yielded 13916 references. Reviewers identified 164 studies for potential inclusion; 58 references were added by searching the grey literature. Of the 222 articles, 10 were included in our overview. In total we identified 14 cases (abstracted from 10 primary studies included) of adverse events. Ten cases involved serious adverse events (e.g. subarachnoidal hemorrhage, paraplegia), two moderate adverse events (e.g. severe headache) and two involved minor adverse events (e.g. mid-back soreness). Risk estimates will be presented at the meeting. An additional 20 cases concerning adverse events related to delayed or missed diagnoses were also identified.

CONCLUSION: Two major kinds of events were identified. Those associated with harm post manipulation and those associated with delayed or missed diagnoses. As passive surveillance (e.g. case reports) does not provide reliable numerator data (due to under-reporting) or any denominator data (i.e. number of people exposed), it cannot estimate the incidence of AE. Conduct of a prospective population-based active surveillance study to properly assess the possibility of rare, yet serious, adverse events as a result of chiropractic manipulation in children is needed.

 

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