Quadriplegia after chiropractic manipulation in an infant with congenital torticollis caused by a spinal cord astrocytoma

Spinal mobilization in infants reconsidered

In this letter to the editor, we discuss additional viewpoints and identify relevant literature to supplement the evidence statement of the authors. We want to make a positive contribution to the discussion about Pediatric Manual Therapy.

Spinal manipulation and mobilisation in paediatrics - an international evidence-based position statement for physiotherapists

INTRODUCTION

An international taskforce of clinician-scientists was formed by specialty groups of World Physiotherapy - International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) & International Organisation of Physiotherapists in Paediatrics (IOPTP) - to develop evidence-based practice position statements directing physiotherapists clinical reasoning for the safe and effective use of spinal manipulation and mobilisation for paediatric populations (<18 years) with varied musculoskeletal or non-musculoskeletal conditions.

METHOD

A three-stage guideline process using validated methodology was completed: 1. Literature review stage (one scoping review, two reviews exploring psychometric properties); 2. Delphi stage (one 3-Round expert Delphi survey); and 3. Refinement stage (evidence-to-decision summative analysis, position statement development, evidence gap map analyses, and multilayer review processes).

RESULTS

Evidence-based practice position statements were developed to guide the appropriate use of spinal manipulation and mobilisation for paediatric populations. All were predicated on clinicians using biopsychosocial clinical reasoning to determine when the intervention is appropriate.1. It is not recommended to perform:• Spinal manipulation and mobilisation on infants.• Cervical and lumbar spine manipulation on children.•Spinal manipulation and mobilisation on infants, children, and adolescents for non-musculoskeletal paediatric conditions including asthma, attention deficit hyperactivity disorder, autism spectrum disorder, breastfeeding difficulties, cerebral palsy, infantile colic, nocturnal enuresis, and otitis media.2. It may be appropriate to treat musculoskeletal conditions including spinal mobility impairments associated with neck-back pain and neck pain with headache utilising:• Spinal mobilisation and manipulation on adolescents;• Spinal mobilisation on children; or• Thoracic manipulation on children for neck-back pain only.3. No high certainty evidence to recommend these interventions was available.Reports of mild to severe harms exist; however, risk rates could not be determined.

CONCLUSION

Specific directives to guide physiotherapists' clinical reasoning on the appropriate use of spinal manipulation or mobilisation were identified. Future research should focus on trials for priority conditions (neck-back pain) in children and adolescents, psychometric properties of key outcome measures, knowledge translation, and harms.

Assessing adverse events associated with chiropractic care in preschool pediatric population: a feasibility study

BACKGROUND

Manual therapies are commonly used by healthcare professionals when caring for children. However, few prospective studies have evaluated their adverse events (AEs). This study aims to assess the feasibility of a pragmatic prospective study aiming to report the immediate and delayed (48-hours post-treatment) AEs associated with manual therapies in children aged 5 or younger. Preliminary data on AEs frequency are also reported.

METHODS

Between July 2021 and March 2022, chiropractors were recruited through purposive sampling and via a dedicated Facebook group for Quebec chiropractors interested in pediatrics. Legal guardians of patients aged 5 or younger were invited to fill out an online information and consent form. AEs were collected using the SafetyNET reporting system, which had been previously translated by the research team. Immediate AEs were collected through a questionnaire filled out by the legal guardian immediately after the treatment, while delayed AEs were collected through a questionnaire sent by email to the legal guardian 48 h after the treatment. Feasibility was assessed qualitatively through feedback from chiropractors and quantitatively through recruitment data.

RESULTS

Overall, a total of 28 chiropractors expressed interest following the Facebook publication, and 5 participated. An additional two chiropractors were enrolled through purposive sampling. In total, 80 legal guardians consented to their child's participation, and data from 73 children were included for the analysis of AEs. At least one AE was reported in 30% of children (22/73), and AEs were mainly observed immediately following the treatment (16/22). The most common AEs were irritability/crying (11 children) or fatigue/tiredness (11 children). Feasibility analysis demonstrated that regular communication between the research team and clinicians, as well as targeting clinicians who showed great interest in pediatrics, were key factors for successful research.

CONCLUSION

Results suggest that it is feasible to conduct a prospective pragmatic study evaluating AEs associated with manual therapies in private practices. Direct communication with the clinicians, a strategic clinicians' recruitment plan, and the resulting administrative burden should be considered in future studies. A larger study is required to confirm the frequency of AEs reported in the current study.

TRIAL REGISTRATION

ClinicalTrials.gov., NCT05409859, Registered on June 3 2022. https://clinicaltrials.gov/study/NCT05409859 .

A taxonomy of risk-associated alternative health practices: A Delphi study

Defining alternative health care and the recording of associated adverse events and harm remains problematic. This Canadian study aimed to establish and classify risk-associated alternative health practices in a Delphi study undertaken with an interdisciplinary panel of 17 health experts in 2020. It provides a new functional definition of alternative health care and an initial taxonomy of risk-associated alternative health care practices. A number of risk-associated practices were identified and categorized into general practices that conflict with biomedical care or largely untested therapies, alternative beliefs systems, physical manipulative alternative therapies, and herbal and nutritional supplements. Some risk significant harms including major physical injuries or even death. The lack of systematic methods for recording adverse events in alternative health care makes establishing the frequency of such events challenging. However, it is important that people engaging with alternative health care understand they are not necessarily risk-free endeavours, and what those risks are.

Physical therapy treatment of a pediatric patient with symptoms consistent with a spinal cord injury without radiographic abnormality: A retrospective case report

BACKGROUND

A spinal cord injury without radiographic abnormality (SCIWORA) is a relatively uncommon event that occurs in children following cervical trauma primarily due to sports-related injuries or physical abuse.

CASE DESCRIPTION

This case report describes an 11-year-old wrestler that developed signs and symptoms consistent with a SCIWORA following neck trauma during competition. Despite all diagnostic tests being inconclusive, the patient demonstrated increased cervical, thoracic, and lumbar paraspinal tone along with pain, loss of sensation, loss of mobility, and weakness of the lower extremities. As a result, the patient was confined to a wheelchair and required maximum assistance to transfer and ambulate with a walker. The patient was referred to physical therapy nine days after the traumatic event, where he received interferential current with moist heat, myofascial release of paraspinal muscles, functional exercise, gait training, and spinal manipulative therapy targeting the cervical, thoracic, and lumbar vertebrae.

OUTCOME

After 13 physical therapy treatments over 5-weeks, the patient was able to ambulate independently and perform all activities of daily living without pain or functional limitation. The following case report outlines this patient's successful journey toward recovery.

CONCLUSION

This case report suggests that spinal manipulative therapy may be a safe and effective intervention when used within a multi-modal treatment strategy for patients with signs and symptoms consistent with SCIWORA. Moreover, spinal manipulative therapy may be considered a beneficial treatment in some pediatric patients. However, this report describes a single patient, and further research is required on the use of spinal manipulation in this patient population.

The safety of spinal manipulative therapy in children under 10 years: a rapid review

INTRODUCTION

The safety of spinal manipulative therapy (SMT) in children is controversial. We were mandated by the College of Chiropractors of British Columbia to review the evidence on this issue.

OBJECTIVES

We conducted a rapid review of the safety of SMT in children (< 10 years). We aimed to: 1) describe adverse events; 2) report the incidence of adverse events; and 3) determine whether SMT increases the risk of adverse events compared to other interventions.

EVIDENCE REVIEW

We searched MEDLINE, CINAHL, and Index to Chiropractic Literature from January 1, 1990 to August 1, 2019. We used rapid review methodology recommended by the World Health Organization. Eligible studies (case reports/series, cohort studies and randomized controlled trials) were critically appraised. Studies of high and acceptable methodological quality were included. The lead author extracted data. Data extraction was independently validated by a second reviewer. We conducted a qualitative synthesis of the evidence.

FINDINGS

Most adverse events are mild (e.g., increased crying, soreness). One case report describes a severe adverse event (rib fracture in a 21-day-old) and another an indirect harm in a 4-month-old. The incidence of mild adverse events ranges from 0.3% (95% CI: 0.06, 1.82) to 22.22% (95% CI: 6.32, 54.74). Whether SMT increases the risk of adverse events in children is unknown.

CONCLUSION

The risk of moderate and severe adverse events is unknown in children treated with SMT. It is unclear whether SMT increases the risk of adverse events in children < 10 years.

Spinal manual therapy in infants, children and adolescents: A systematic review and meta-analysis on treatment indication, technique and outcomes

BACKGROUND

Studies on effectiveness and safety of specific spinal manual therapy (SMT) techniques in children, which distinguish between age groups, are lacking.

OBJECTIVE

To conduct a systematic review of the evidence for effectiveness and harms of specific SMT techniques for infants, children and adolescents.

METHODS

PubMed, Index to Chiropractic Literature, Embase, CINAHL and Cochrane Library were searched up to December 2017. Controlled studies, describing primary SMT treatment in infants (<1 year) and children/adolescents (1-18 years), were included to determine effectiveness. Controlled and observational studies and case reports were included to examine harms. One author screened titles and abstracts and two authors independently screened the full text of potentially eligible studies for inclusion. Two authors assessed risk of bias of included studies and quality of the body of evidence using the GRADE methodology. Data were described according to PRISMA guidelines and CONSORT and TIDieR checklists. If appropriate, random-effects meta-analysis was performed.

RESULTS

Of the 1,236 identified studies, 26 studies were eligible. Infants and children/adolescents were treated for various (non-)musculoskeletal indications, hypothesized to be related to spinal joint dysfunction. Studies examining the same population, indication and treatment comparison were scarce. Due to very low quality evidence, it is uncertain whether gentle, low-velocity mobilizations reduce complaints in infants with colic or torticollis, and whether high-velocity, low-amplitude manipulations reduce complaints in children/adolescents with autism, asthma, nocturnal enuresis, headache or idiopathic scoliosis. Five case reports described severe harms after HVLA manipulations in four infants and one child. Mild, transient harms were reported after gentle spinal mobilizations in infants and children, and could be interpreted as side effect of treatment.

CONCLUSIONS

Based on GRADE methodology, we found the evidence was of very low quality; this prevented us from drawing conclusions about the effectiveness of specific SMT techniques in infants, children and adolescents. Outcomes in the included studies were mostly parent or patient-reported; studies did not report on intermediate outcomes to assess the effectiveness of SMT techniques in relation to the hypothesized spinal dysfunction. Severe harms were relatively scarce, poorly described and likely to be associated with underlying missed pathology. Gentle, low-velocity spinal mobilizations seem to be a safe treatment technique in infants, children and adolescents. We encourage future research to describe effectiveness and safety of specific SMT techniques instead of SMT as a general treatment approach.

What are the risks of manual treatment of the spine? A scoping review for clinicians

Background

Communicating to patients the risks of manual treatment to the spine is an important, but challenging element of informed consent. This scoping review aimed to characterise and summarise the available literature on risks and to describe implications for clinical practice and research.

Method

A methodological framework for scoping reviews was followed. Systematic searches were conducted during June 2017. The quantity, nature and sources of literature were described. Findings of included studies were narratively summarised, highlighting key clinical points.

Results

Two hundred and fifty articles were included. Cases of serious adverse events were reported. Observational studies, randomised studies and systematic reviews were also identified, reporting both benign and serious adverse events.Benign adverse events were reported to occur commonly in adults and children. Predictive factors for risk are unclear, but for neck pain patients might include higher levels of neck disability or cervical manipulation. In neck pain patients benign adverse events may result in poorer short term, but not long term outcomes.Serious adverse event incidence estimates ranged from 1 per 2 million manipulations to 13 per 10,000 patients. Cases are reported in adults and children, including spinal or neurological problems as well as cervical arterial strokes. Case-control studies indicate some association, in the under 45 years age group, between manual interventions and cervical arterial stroke, however it is unclear whether this is causal. Elderly patients have no greater risk of traumatic injury compared with visiting a medical practitioner for neuro-musculoskeletal problems, however some underlying conditions may increase risk.

Conclusion

Existing literature indicates that benign adverse events following manual treatments to the spine are common, while serious adverse events are rare. The incidence and causal relationships with serious adverse events are challenging to establish, with gaps in the literature and inherent methodological limitations of studies. Clinicians should ensure that patients are informed of risks during the consent process. Since serious adverse events could result from pre-existing pathologies, assessment for signs or symptoms of these is important. Clinicians may also contribute to furthering understanding by utilising patient safety incident reporting and learning systems where adverse events have occurred.

Conservative Care of Pediatric Acquired Torticollis: A Report of 2 Cases

Objective

The purpose of this case report is to describe the conservative management of 2 cases of acquired torticollis in children under 3 years of age.

Clinical Features

Both patients awoke with painful, stiff, twisted necks the day after play in a bouncy house. Range of motion was limited, and hypertonic muscles were palpated. Their neurologic and physical evaluation was consistent with a diagnosis of acquired torticollis of musculoskeletal origin.

Intervention and Outcomes

Both children were treated with chiropractic care that consisted of light myofascial release, use of an Activator instrument, and home stretching. Patients improved in pain and range of motion immediately posttreatment and returned to normal ranges in 1 or 2 visits.

Conclusion

Chiropractic care provided relief for these 2 young patients with acquired torticollis.

Clinical Practice Guideline: Otitis Media with Effusion

The clinical practice guideline on otitis media with effusion (OME) provides evidence-based recommendations on diagnosing and managing OME in children. This is an update of the 1994 clinical practice guideline “Otitis Media With Effusion in Young Children,” which was developed by the Agency for Healthcare Policy and Research (now the Agency for Healthcare Research and Quality). In contrast to the earlier guideline, which was limited to children aged 1 to 3 years with no craniofacial or neurologic abnormalities or sensory deficits, the updated guideline applies to children aged 2 months through 12 years with or without developmental disabilities or underlying conditions that predispose to OME and its sequelae. The American Academy of Pediatrics, American Academy of Family Physicians, and American Academy of Otolaryngology- Head and Neck Surgery selected a subcommittee composed of experts in the fields of primary care, otolaryngology, infectious diseases, epidemiology, hearing, speech and language, and advanced practice nursing to revise the OME guideline.

The subcommittee made a strong recommendation that clinicians use pneumatic otoscopy as the primary diagnostic method and distinguish OME from acute otitis media (AOM).

The subcommittee made recommendations that clinicians should (1) document the laterality, duration of effusion, and presence and severity of associated symptoms at each assessment of the child with OME; (2) distinguish the child with OME who is at risk for speech, language, or learning problems from other children with OME and more promptly evaluate hearing, speech, language, and need for intervention in children at risk; and (3) manage the child with OME who is not at risk with watchful waiting for 3 months from the date of effusion onset (if known), or from the date of diagnosis (if onset is unknown).

The subcommittee also made recommendations that (4) hearing testing be conducted when OME persists for 3 months or longer, or at any time that language delay, learning problems, or a significant hearing loss is suspected in a child with OME; (5) children with persistent OME who are not at risk should be reexamined at 3- to 6-month intervals until the effusion is no longer present, significant hearing loss is identified, or structural abnormalities of the eardrum or middle ear are suspected; and (6) when a child becomes a surgical candidate, tympanostomy tube insertion is the preferred initial procedure. Adenoidectomy should not be performed unless a distinct indication exists (nasal obstruction, chronic adenoiditis); repeat surgery consists of adenoidectomy plus myringotomy, with or without tube insertion. Tonsillectomy alone or myringotomy alone should not be used to treat OME. The subcommittee made negative recommendations that (1) population-based screening programs for OME not be performed in healthy, asymptomatic children and (2) antihistamines and decongestants are ineffective for OME and should not be used for treatment; antimicrobials and corticosteroids do not have long-term efficacy and should not be used for routine management.

The subcommittee gave as options that (1) tympanometry can be used to confirm the diagnosis of OME and (2) when children with OME are referred by the primary clinician for evaluation by an otolaryngologist, audiologist, or speech-language pathologist, the referring clinician should document the effusion duration and specific reason for referral (evaluation, surgery), and provide additional relevant information such as history of AOM and developmental status of the child. The subcommittee made no recommendations for (1) complementary and alternative medicine as a treatment for OME based on a lack of scientific evidence documenting efficacy and (2) allergy management as a treatment for OME based on insufficient evidence of therapeutic efficacy or a causal relationship between allergy and OME. Last, the panel compiled a list of research needs based on limitations of the evidence reviewed.

The purpose of this guideline is to inform clinicians of evidence-based methods to identify, monitor, and manage OME in children aged 2 months through 12 years. The guideline may not apply to children older than 12 years because OME is uncommon and the natural history is likely to differ from younger children who experience rapid developmental change. The target population includes children with or without developmental disabilities or underlying conditions that predispose to OME and its sequelae. The guideline is intended for use by providers of health care to children, including primary care and specialist physicians, nurses and nurse practitioners, physician assistants, audiologists, speech-language pathologists, and child development specialists. The guideline is applicable to any setting in which children with OME would be identified, monitored, or managed.

This guideline is not intended as a sole source of guidance in evaluating children with OME. Rather, it is designed to assist primary care and other clinicians by providing an evidence-based framework for decision-making strategies. It is not intended to replace clinical judgment or establish a protocol for all children with this condition, and may not provide the only appropriate approach to diagnosing and managing this problem. (Otolaryngol Head Neck Surg 2004;130:S95.)

Forces of Commonly Used Chiropractic Techniques for Children: A Review of the Literature

OBJECTIVE

The purpose of this study is to review the available literature that describes forces of the most commonly used chiropractic techniques for children.

METHODS

Review of the English-language literature using search terms Chiropract* and technique, protocol, or approach in databases PubMed, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine, and Index to Chiropractic Literature and direct contact with authors of articles and book chapters.

RESULTS

Eleven articles that discussed the 7 most commonly used pediatric chiropractic techniques and the forces applied were identified. Chiropractic techniques reviewed described forces that were modified based on the age of the patient. Force data for mechanically assisted devices were varied, with the minimum force settings for some devices outside the age-specific safe range recommended in the literature when not modified in some way.

CONCLUSION

This review found that technique selection and application by chiropractors treating infants and young children are typically modified in force and speed to suit the age and development of the child.

Perinatal (fetal and neonatal) astrocytoma: a review

INTRODUCTION

The purpose of this review is to document the various types of astrocytoma that occur in the fetus and neonate, their locations, initial findings, pathology, and outcome. Data are presented that show which patients are likely to survive or benefit from treatment compared with those who are unlikely to respond.

MATERIALS AND METHODS

One hundred one fetal and neonatal tumors were collected from the literature for study.

RESULTS

Macrocephaly and an intracranial mass were the most common initial findings. Overall, hydrocephalus and intracranial hemorrhage were next. Glioblastoma (GBM) was the most common neoplasm followed in order by subependymal giant cell astrocytoma (SEGA), low-grade astrocytoma, anaplastic astrocytoma, and desmoplastic infantile astrocytoma (DIA). Tumors were detected most often toward the end of the third trimester of pregnancy.

CONCLUSION

A number of patients were considered inoperable since their tumor occupied much of the intracranial cavity involving large areas of the brain. High-grade astrocytomas were more common than low-grade ones in this review. Fetuses and neonates with astrocytoma have a mixed prognosis ranging from as low as 20 % (GBM) to a high of 90 %. The overall survival was 47/101 or 46 %.

Adverse Events Due to Chiropractic and Other Manual Therapies for Infants and Children: A Review of the Literature

OBJECTIVE

The purpose of this study was to review the literature for cases of adverse events in infants and children treated by chiropractors or other manual therapists, identifying treatment type and if a preexisting pathology was present.

METHOD

English language, peer-reviewed journals and non-peer-reviewed case reports discussing adverse events (ranging from minor to serious) were systematically searched from inception of the relevant searchable bibliographic databases through March 2014. Articles not referring to infants or children were excluded.

RESULTS

Thirty-one articles met the selection criteria. A total of 12 articles reporting 15 serious adverse events were found. Three deaths occurred under the care of various providers (1 physical therapist, 1 unknown practitioner, and 1 craniosacral therapist) and 12 serious injuries were reported (7 chiropractors/doctors of chiropractic, 1 medical practitioner, 1 osteopath, 2 physical therapists, and 1 unknown practitioner). High-velocity, extension, and rotational spinal manipulation was reported in most cases, with 1 case involving forcibly applied craniosacral dural tension and another involving use of an adjusting instrument. Underlying preexisting pathology was identified in a majority of the cases.

CONCLUSION

Published cases of serious adverse events in infants and children receiving chiropractic, osteopathic, physiotherapy, or manual medical therapy are rare. The 3 deaths that have been reported were associated with various manual therapists; however, no deaths associated with chiropractic care were found in the literature to date. Because underlying preexisting pathology was associated in a majority of reported cases, performing a thorough history and examination to exclude anatomical or neurologic anomalies before applying any manual therapy may further reduce adverse events across all manual therapy professions.

A Literature Review of Pediatric Spinal Manipulation and Chiropractic Manipulative Therapy: Evaluation of Consistent Use of Safety Terminology

OBJECTIVE

The purpose of this study was to perform a literature search to identify relevant studies on pediatric spinal manipulation and chiropractic manipulative therapy and to assess if safety terminology was consistent with the International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use (ICH).

METHODS

A literature search was performed in PubMed using the following terms: spinal manipulation pediatric, chiropractic safety pediatric, and manual therapy safety pediatric. PubMed was searched from inception to April 2012 with no language limitations. The international standards included the terminology of the World Health Organization on side effects, adverse reactions, adverse events and the ICH guideline templates that were adapted for manual therapy for this study.

RESULTS

Of the 9 relevant articles identified in this study, 3 reported methodology for classifying safety incidents, and all 9 used safety terminology (adverse effects or adverse events). However, terminology was not used consistently.

CONCLUSION

Most of the articles identified in this literature review did not use terminology consistent with the standards established by the ICH when reporting on safety incidents following pediatric spinal manipulation or chiropractic manipulative therapy. More efforts should be taken to include consistent terminology for studies of spinal manipulation and chiropractic manipulative therapy for children.

IAEA survey of pediatric CT practice in 40 countries in Asia, Europe, Latin America, and Africa: Part 1, frequency and appropriateness

OBJECTIVE

The purpose of this study was to assess the frequency of pediatric CT in 40 less-resourced countries and to determine the level of appropriateness in CT use.

MATERIALS AND METHODS

Data on the increase in the number of CT examinations during 2007 and 2009 and appropriate use of CT examinations were collected, using standard forms, from 146 CT facilities at 126 hospitals.

RESULTS

The lowest frequency of pediatric CT examinations in 2009 was in European facilities (4.3%), and frequencies in Asia (12.2%) and Africa (7.8%) were twice as high. Head CT is the most common CT examination in children, amounting to nearly 75% of all pediatric CT examinations. Although regulations in many countries assign radiologists with the main responsibility of deciding whether a radiologic examination should be performed, in fact, radiologists alone were responsible for only 6.3% of situations. Written referral guidelines for imaging were not available in almost one half of the CT facilities. Appropriateness criteria for CT examinations in children did not always follow guidelines set by agencies, in particular, for patients with accidental head trauma, infants with congenital torticollis, children with possible ventriculoperitoneal shunt malfunction, and young children (< 5 years old) with acute sinusitis. In about one third of situations, nonavailability of previous images and records on previously received patient doses have the potential to lead to unnecessary examinations and radiation doses.

CONCLUSION

With increasing use of CT in children and a lack of use of appropriateness criteria, there is a strong need to implement guidelines to avoid unnecessary radiation doses to children.

Torticollis associated with neonatal brachial plexus palsy

We investigate the incidence of torticollis associated with neonatal brachial plexus palsy, whether the severity of brachial plexus palsy affects outcomes and the rate of recovery. We performed a retrospective review of 128 consecutive neonatal brachial plexus palsy patients evaluated at the University of Michigan from 2005-2009. Patients were followed for at least 3 months, with regular physical examinations and imaging. Forty-three percent presented concurrently with torticollis. Significant differences were evident in mean age at first brachial plexus examination, suggesting that patients with concurrent torticollis present earlier for clinical examination. Recovery from torticollis was evident in 62% of patients by 23 ± 12 weeks with conservative management. No statistically significant differences were evident between torticollis and nontorticollis groups after reviewing their severity of neonatal brachial plexus palsy (Narakas score), recovery from neonatal brachial plexus palsy (biceps function at 6 months), need for nerve repair or reconstructive procedures, or infant, maternal, or other factors associated with labor. Results suggest that although torticollis occurs with increased frequency in children with brachial plexus palsy, its presence is not related to severity and does not affect the probability of recovery from brachial plexus palsy. Conservative management for torticollis yields reasonable recovery.

The chiropractic care of patients with cancer: a systematic review of the literature

BACKGROUND AND SIGNIFICANCE

Cancer is the leading cause of death worldwide and accounted for 7.4 million deaths in 2004. By 2030, deaths from cancer have been estimated at 12 million with 30% being preventable. Complementary and alternative medicine remains popular among cancer patients; particularly with chiropractic services. However, the nature of the chiropractic clinical encounter and its reported benefits remains to be fully investigated. Towards these efforts, we begin with a systematic review of the literature on the chiropractic care of patients with cancer.

METHODS

The following electronic databases were searched: MANTIS [1965-2010]; Index to Chiropractic Literature [1984-2010]; Pubmed [1966-2010]; Medline [1965-2010] EMBASE [1974-2010], AMED [1975-2010], CINAHL Plus [1965-2010], Alt-Health Watch [1965-2010] and PsychINFO [1965-2010]. Key words used were "cancer" and "neoplasm" in Boolean combination with "chiropractic." Primary investigation/reports in peer-reviewed English journals involving chiropractic care were reviewed.

RESULTS

Our review revealed 60 case reports, 2 case series, 21 commentaries, 2 survey studies, and 2 literature reviews. The case reports were diagnostic with commentaries highlighting the importance of recognizing the patient presenting with NMS complaints due to an underlying neoplasm. The chiropractic clinical encounter prior to cancer diagnosis and subsequent medical referral is poorly characterized in the literature.

CONCLUSION

Patients with cancer seek the care of chiropractors. The literature does not reflect or describe the totality of the chiropractic clinical encounter. We encourage further research in this field.

Possible adverse events in children treated by manual therapy: a review

BACKGROUND

Pediatric manual therapy is controversial within the medical community particularly with respect to adverse events. Pediatric manual therapy (Ped MT) is commonly used by a number of professions such as chiropractors, osteopaths and naturopaths for a variety of treatments in children. Ped MT interventions range from advice, light touch, massage, through to mobilisation and high velocity spinal manipulation. However, current evidence related to adverse events associated with Ped MT is not well understood.

OBJECTIVE

To update the clinical research literature from the 2007 report by Vohra, Johnston, Cramer and Humphreys on possible adverse events in children treated by spinal manipulation.

METHODS

A review of the clinical research literature from June 2004 until January 2010 as reported in MEDLINE, PubMed and PubMed Central for adverse events specifically related to the treatment of pediatric cases by manual therapy.

RESULTS

Only three new clinical studies, one systematic review with meta-analysis and one evidence report were identified. Two clinical studies reported on chiropractic care and one on osteopathic spinal manipulation in children. The systematic review investigated all studies of adverse events and manual therapy and was not specific for pediatric patients. The evidence review focused on effectiveness of spinal manipulation in a variety of musculoskeletal conditions. No serious or catastrophic adverse events were reported in the clinical studies or systematic review. However for adults, it has been estimated that between 0.003% and 0.13% of manual therapy treatments may result in a serious adverse event. Although mild to moderate adverse events are common in adults, an accurate estimate from high quality pediatric studies is currently not available.

CONCLUSIONS

There is currently insufficient research evidence related to adverse events and manual therapy. However, clinical studies and systematic reviews from adult patients undergoing manual therapy, particularly spinal manipulation report that mild to moderate adverse events are common and self limiting. However serious adverse events are rare and much less than for medication commonly prescribed for these problems. More high quality research specifically addressing adverse events and pediatric manual therapy is needed.

Comanagement and collaborative care of a 20-year-old female with acute viral torticollis

OBJECTIVE

This case study describes a patient diagnosed with acute viral torticollis and illustrates the relevant aspects of differential diagnosis and the collaborative efforts between the chiropractic and allopathic disciplines in establishing an optimum treatment protocol provided by comanagement of the case.

CLINICAL FEATURES

A 20-year-old female student experienced a sudden onset of neck pain and inability to move her neck in conjunction with an antalgic attitude of her cervical spine in lateral flexion and rotation. Physical examination revealed an elevated temperature indicating the possibility of infection. Associated symptoms included headache, nausea, vomiting, and malaise.

INTERVENTION AND OUTCOME

The patient was initially assessed in a teaching clinic of a university medical health center for acute meningitis. A consultation was requested by the senior attending physician for an opinion by the chiropractic services of the university health center to assess the patient for nuchal rigidity and to provide treatment of the torticollis. After an evaluation of the status of the patient, a diagnosis of acute viral torticollis was established, and chiropractic manual therapy was initiated with a significant improvement in the ability of the patient to execute cervical ranges of motion without undue limitation and pain. Follow-up chiropractic care resulted in resolution of the torticollis without residual symptoms.

CONCLUSION

Acute viral torticollis occurring in a young adult with associated symptoms of fever, headache, nausea, and vomiting presents a diagnostic challenge in excluding the possibility of meningitis. Appropriate clinical and physical examination procedures are essential to exclude the latter while providing the clinician with the confidence to proceed with conservative management of the patient. Comanagement and collaborative care between the medical and chiropractic disciplines offered the patient a treatment plan with prompt resolution of symptoms.

Movement disorder emergencies

Movement disorder emergencies include any movement disorder which evolves over hours to days, in which failure to appropriately diagnose and manage can result in patient morbidity or mortality. It is crucial that doctors recognize these emergencies with accuracy and speed by obtaining the proper history and by being familiar with the phenomenology of frequently encountered movements. These disorders will be discussed based on the most common associated involuntary movement, either parkinsonism, dystonia, chorea, tics or myoclonus, and, when available, review the workup and treatment options based on the current literature.

Holocord pilocytic astrocytoma--case report and review of the literature

Intramedullary glial neoplasms affecting the entire cord from the cervicomedullary junction to the conus are termed "holocord tumors" and those diagnosed as pilocytic astrocytoma are rare. Herein, we present a 13-year-old girl with a tumor extending from the cervicomedullary junction to the conus which was partially resected in a four-stage approach. Histopathological examination of all specimens resulted in diagnosis of a pilocytic astrocytoma. Although no signs of atypia were present, an elevated proliferative activity of endothelial vessels was noted. Residual parts of the tumor showed progress making additional surgery necessary. Therapy and its consequences are discussed and an overview of the literature of these rare longitudinally extensive intramedullary lesions is given.

Adverse events associated with pediatric spinal manipulation: a systematic review

BACKGROUND

Spinal manipulation is a noninvasive manual procedure applied to specific body tissues with therapeutic intent. Although spinal manipulation is commonly used in children, there is limited understanding of the pediatric risk estimates.

OBJECTIVE

Our goal was to systematically identify and synthesize available data on adverse events associated with pediatric spinal manipulation.

METHODS

A comprehensive search was performed of 8 major electronic databases (eg, Medline, AMED, MANTIS) from inception to June 2004 irrespective of language. Reports were included if they (1) were a primary investigation of spinal manipulation (eg, observation studies, controlled trials, surveys), (2) included a study population of children who were aged 18 years or younger, and (3) reported data on adverse events. Data were summarized to demonstrate the nature and severity of adverse events that may result rather than their incidence.

RESULTS

Thirteen studies (2 randomized trials, 11 observational reports) were identified for inclusion. We identified 14 cases of direct adverse events involving neurologic or musculoskeletal events. Nine cases involved serious adverse events (eg, subarachnoidal hemorrhage, paraplegia), 2 involved moderately adverse events that required medical attention (eg, severe headache), and 3 involved minor adverse events (eg, midback soreness). Another 20 cases of indirect adverse events involved delayed diagnosis (eg, diabetes, neuroblastoma) and/or inappropriate provision of spinal manipulation for serious medical conditions (ie, meningitis, rhabdomyosarcoma).

CONCLUSIONS

Serious adverse events may be associated with pediatric spinal manipulation; neither causation nor incidence rates can be inferred from observational data. Conduct of a prospective population-based active surveillance study is required to properly assess the possibility of rare, yet serious, adverse events as a result of spinal manipulation on pediatric patients.

Torticollis secondary to posterior fossa and cervical spinal cord tumors: report of five cases and literature review

Torticollis is either congenital or acquired in childhood. Acquired torticollis is not a diagnosis but rather a sign of an underlying disorder. The causes of acquired torticollis include ligamentous, muscular, osseous, ocular, psychiatric, and neurologic disorders and may be a symptom of significant abnormalities of the spinal cord and brain, such as spinal syrinx or central nervous system neoplasia. Torticollis is rarely considered to be an initial clinical presentation of posterior fossa and cervical spinal cord tumors. We report five cases of pediatric tumors with torticollis at the onset: an astrocytoma originating from the medulla oblongata, another presumptive astrocytoma of the spinal cord located between C1 and C6 cervical vertebrae (not operated), an ependymoma located throughout the whole cervical spinal cord extending into the bulbomedullary junction, an astrocytoma originating from the bulbus and extending into the posterior fossa, and another case of a eosinophilic granuloma located extradurally through the anterior and posterior portions of the vertebral bodies from C3 to C7 producing the collapse of the sixth cervical vertebra. All five cases were seen in children, aged between 3 and 12 years. All these cases reflect the misinterpretation of this neurological sign and the lack of association with the possibility of spinal or posterior fossa tumor. This delay in the diagnosis of these diseases led to progressive neurological deterioration and to the increase in the tumor size, which made surgical intervention difficult and the prognosis unfavorable. Although torticollis secondary to tumors is rarely seen, it is necessary to be kept in mind in the differential diagnosis.

Movement disorder emergencies

For the past 4 years, Dr. Stanley Fahn and I have given a course at the American Academy of Neurology annual meeting on the topic of movement disorder emergencies. The purpose of this review article is to summarize the topic and to present it to readers of this journal. The text of this article has appeared in nearly the same form as the Academy syllabus accompanying our course. It is being presented here so that readers of the journal may review the material.

Complementary therapies in pediatrics: a legal perspective

Increasing use of complementary and alternative medicine (CAM) therapies such as chiropractic, massage therapy, and herbal medicine, raises questions about the clinically appropriate use of CAM in pediatrics. Nonjudicious use of CAM therapies may cause either direct harm or, by creating an unwarranted financial and emotional burden, indirect harm. When advising patients concerning CAM therapies, pediatricians face 2 major legal risks: medical malpractice and professional discipline. Pediatricians can incorporate these considerations into advising and clinical decision-making about CAM therapies to address the best interest of the pediatric patient while helping to manage potential liability risk. This article provides a suggested framework, including asking the following questions: (1) Do parents elect to abandon effective care when the child's condition is serious or life-threatening? (2) Will use of the CAM therapy otherwise divert the child from imminently necessary conventional treatment? (3) Are the CAM therapies selected known to be unsafe and/or ineffective? (4) Have the proper parties consented to the use of the CAM therapy? (5) Is the risk-benefit ratio of the proposed CAM therapy acceptable to a reasonable, similarly situated clinician, and does the therapy have at least minority acceptance or support in the medical literature? Such an approach ideally can help guide the pediatrician toward clinical conduct that is clinically responsible, ethically appropriate, and legally defensible.

A reflective overview of complementary therapies for children 1995–2005

This article considers briefly how and why complementary and alternative medicine has developed in children's care during the last 10 years. Some of the therapies utilised by children are discussed, similarities and differences to trends in CAM for adults highlighted and a potential role for CAM in children's care in the future, suggested.

Otitis media with effusion

The clinical practice guideline on otitis media with effusion (OME) provides evidence-based recommendations on diagnosing and managing OME in children. This is an update of the 1994 clinical practice guideline "Otitis Media With Effusion in Young Children," which was developed by the Agency for Healthcare Policy and Research (now the Agency for Healthcare Research and Quality). In contrast to the earlier guideline, which was limited to children 1 to 3 years old with no craniofacial or neurologic abnormalities or sensory deficits, the updated guideline applies to children aged 2 months through 12 years with or without developmental disabilities or underlying conditions that predispose to OME and its sequelae. The American Academy of Pediatrics, American Academy of Family Physicians, and American Academy of Otolaryngology-Head and Neck Surgery selected a subcommittee composed of experts in the fields of primary care, otolaryngology, infectious diseases, epidemiology, hearing, speech and language, and advanced-practice nursing to revise the OME guideline. The subcommittee made a strong recommendation that clinicians use pneumatic otoscopy as the primary diagnostic method and distinguish OME from acute otitis media. The subcommittee made recommendations that clinicians should 1) document the laterality, duration of effusion, and presence and severity of associated symptoms at each assessment of the child with OME, 2) distinguish the child with OME who is at risk for speech, language, or learning problems from other children with OME and more promptly evaluate hearing, speech, language, and need for intervention in children at risk, and 3) manage the child with OME who is not at risk with watchful waiting for 3 months from the date of effusion onset (if known) or diagnosis (if onset is unknown). The subcommittee also made recommendations that 4) hearing testing be conducted when OME persists for 3 months or longer or at any time that language delay, learning problems, or a significant hearing loss is suspected in a child with OME, 5) children with persistent OME who are not at risk should be reexamined at 3- to 6-month intervals until the effusion is no longer present, significant hearing loss is identified, or structural abnormalities of the eardrum or middle ear are suspected, and 6) when a child becomes a surgical candidate (tympanostomy tube insertion is the preferred initial procedure). Adenoidectomy should not be performed unless a distinct indication exists (nasal obstruction, chronic adenoiditis); repeat surgery consists of adenoidectomy plus myringotomy with or without tube insertion. Tonsillectomy alone or myringotomy alone should not be used to treat OME. The subcommittee made negative recommendations that 1) population-based screening programs for OME not be performed in healthy, asymptomatic children, and 2) because antihistamines and decongestants are ineffective for OME, they should not be used for treatment; antimicrobials and corticosteroids do not have long-term efficacy and should not be used for routine management. The subcommittee gave as options that 1) tympanometry can be used to confirm the diagnosis of OME and 2) when children with OME are referred by the primary clinician for evaluation by an otolaryngologist, audiologist, or speech-language pathologist, the referring clinician should document the effusion duration and specific reason for referral (evaluation, surgery) and provide additional relevant information such as history of acute otitis media and developmental status of the child. The subcommittee made no recommendations for 1) complementary and alternative medicine as a treatment for OME, based on a lack of scientific evidence documenting efficacy, or 2) allergy management as a treatment for OME, based on insufficient evidence of therapeutic efficacy or a causal relationship between allergy and OME. Last, the panel compiled a list of research needs based on limitations of the evidence reviewed. The purpose of this guideline is to inform clinicians of evidence-based methods to identify, monitor, and manage OME in children aged 2 months through 12 years. The guideline may not apply to children more than 12 years old, because OME is uncommon and the natural history is likely to differ from younger children who experience rapid developmental change. The target population includes children with or without developmental disabilities or underlying conditions that predispose to OME and its sequelae. The guideline is intended for use by providers of health care to children, including primary care and specialist physicians, nurses and nurse practitioners, physician assistants, audiologists, speech-language pathologists, and child-development specialists. The guideline is applicable to any setting in which children with OME would be identified, monitored, or managed. This guideline is not intended as a sole source of guidance in evaluating children with OME. Rather, it is designed to assist primary care and other clinicians by providing an evidence-based framework for decision-making strategies. It is not intended to replace clinical judgment or establish a protocol for all children with this condition and may not provide the only appropriate approach to diagnosing and managing this problem.

Complications of cervical spine manipulation therapy: 5-year retrospective study in a single-group practice

OBJECT

The authors report a series of 22 patients in whom major complications developed after cervical spinal manipulation therapy (CSMT). A second objective was to estimate the regional incidence of these complications and to compare it with the very low incidences reported in the literature.

METHODS

During a 5-year period, practioners at a single group neurosurgical practice in Tulsa, Oklahoma, treated 22 patients, who were markedly worse during, or immediately after, CSMT. The details of these cases are reported. The 1995 US Government National Census was used to define the regional referral population for Tulsa. The published data regarding the incidence of serious CSMT-related complications and the rate of CSMTs undertaken nationally were used to estimate the expected number of CSMT-related complications in the authors' region. The number (22 cases) reported in this series was used to estimate the actual regional incidence. Complications in the series included radiculopathy (21 cases), myelopathy (11 cases), Brown-Séquard syndrome (two cases), and vertebral artery (VA) occlusion (one case). Twenty-one patients underwent surgery. Poor outcomes were observed in three, outcome was unchanged in one, and 17 improved. The number of patients in this series exceeded the expected number for the region.

CONCLUSIONS

Cervical spinal manipulation therapy may worsen preexisting cervical disc herniation or cause disc herniation resulting in radiculopathy, myelopathy, or VA compression. In cases of cervical spondylosis, CSMT may also worsen preexisting myelopathy or radiculopathy. Manipulation of the cervical spine may also be associated with higher complication rates than previously reported.

Differential compliance instrument in the treatment of infantile colic: a report of two cases

OBJECTIVE

To report on the novel use of a computer-assisted adjusting device as a potentially safe method for treatment of infantile colic.

CLINICAL FEATURES

Two infants were diagnosed by their pediatrician as having infantile colic, which was characterized by signs of distress, uncontrollable crying, and brief episodes of screaming. Both children had normal growth (despite low birth weight in the second) and no other abnormalities.

INTERVENTION AND OUTCOME

A PulStar Function Recording and Analysis System (PulStar FRAS, Sense Technology, Inc, Pittsburgh, Penn) device was used to administer light impulses (approximately 1.7 joules, which produced a 3 to 4 lb force) at each segmental level throughout the dorsal spine, with probe tips spaced 2 cm apart straddling the spinous processes. Crying was reduced by 50% after a single session of instrumental adjusting in a 6-week old girl and after 4 sessions in a 9-week old boy, according to colic diaries kept by the mothers. Average hours of uninterrupted daily sleep increased from 3.5 to 6.5 hours after a single session. Within 10 days (5 and 8 sessions, respectively), colicky behavior disappeared and average total daily sleep improved to 14.5 hours (an average increase of 4.5 hours). Results continued over a 30-day follow-up.

CONCLUSION

The PulStar mechanical adjusting device appears to have been well tolerated and beneficial in 2 cases of infantile colic. Further research is necessary to determine whether this device can enhance the safety and effectiveness of chiropractic treatment in infants with colic.

Consequences of neck manipulation performed by a non-professional

Case report. Documentation of complication of neck manipulation by an untrained person. Tertiary care referral teaching hospital at Lucknow, India. Clinical evaluation, plain radiography of cervical spine, spinal MRI.A 30-year-old man who fainted after neck manipulation by a barber and developed spinal cord and brainstem dysfunction. His MRI revealed an extramedullary, intradural dumbbell shaped mass on the right side at C1 and C2 level compressing the spinal cord. Public awareness should be increased about the danger of neck manipulation by an untrained person especially in the communities where it is commonly practiced.

Syringomyelic dystonia and athetosis

Two patients with movement disorders associated with syringomyelia are described, one of whom developed unusual torticollis, and the other had choreoathetoid-dystonic movements of the hand and arm. In each case, the movements resolved with decompression of the syrinx. The literature is reviewed and possible mechanisms explored.

Manipulation and mobilization of the cervical spine. A systematic review of the literature

STUDY DESIGN

Cervical spine manipulation and mobilization were reviewed in an analysis of the literature from 1966 to the present.

OBJECTIVES

To assess the evidence for the efficacy and complications of cervical spine manipulation and mobilization for the treatment of neck pain and headache.

SUMMARY OF BACKGROUND DATA

Although recent research has demonstrated the efficacy of spinal manipulation for some patients with low back pain, little is known about its efficacy for neck pain and headache.

METHODS

A structured search of four computerized bibliographic data bases was performed to identify articles on the efficacy and complications of cervical spine manual therapy. Data were summarized, and randomized controlled trials were critically appraised for study quality. The confidence profile method of meta-analysis was used to estimate the effect of spinal manipulation on patients' pain status.

RESULTS

Two of three randomized controlled trials showed a short-term benefit for cervical mobilization for acute neck pain. The combination of three of the randomized controlled trials comparing spinal manipulation with other therapies for patients with subacute or chronic neck pain showed an improvement on a 100-mm visual analogue scale of pain at 3 weeks of 12.6 mm (95% confidence interval, -0.15, 25.5) for manipulation compared with muscle relaxants or usual medical care. The highest quality randomized controlled trial demonstrated that spinal manipulation provided short-term relief for patients with tension-type headache. The complication rate for cervical spine manipulation is estimated to be between 5 and 10 per 10 million manipulations.

CONCLUSIONS

Cervical spine manipulation and mobilization probably provide at least short-term benefits for some patients with neck pain and headaches. Although the complication rate of manipulation is small, the potential for adverse outcomes must be considered because of the possibility of permanent impairment or death.

Radiculomedullary complications of cervical spinal manipulation

Spinal manipulation is commonly used by some therapists for the treatment of cervical pain. Flexion-extension of the cervical spine produces sliding movements of one vertebra over the one below it, which leads to physiological reduction in the antero-posterior diameter of the spinal canal. Spinal manipulation provokes movements that exceed the physiological limits of these articulations and thereby lead to a more significant reduction of the canal diameter. In patients with pre-existing stenosis of the canal or those with vertebral instability, these movements may cause (or aggravate) myelopathy. For this reason, a thorough neurological examination and cervical spine films should be considered mandatory in patients being considered for spinal manipulation. This report describes four patients with cervical myelopathy and/or radiculopathy caused or aggravated by spinal manipulation. In one patient, magnetic resonance scans before and after chiropractic treatment strongly suggests that the disc prolapse syndrome experienced by the patient was provoked by the spinal manipulation.

Torticollis secondary to posterior fossa tumors

Torticollis in childhood may be a sign of many disorders. Five cases, with torticollis as the initial sign of a posterior fossa tumor, are presented. The diagnosis and treatment of the tumor was considerably delayed in all patients because posterior fossa tumor was not considered in the initial differential diagnosis. In two patients, operative procedures on the sternocleidomastoid muscle were performed before discovering the underlying causative tumors. Four of the five patients also had other associated symptoms such as headache, nausea, and vomiting. It is stressed that in acquired torticollis, posterior fossa tumor be considered in the differential diagnosis.

The prevalence of nonmuscular causes of torticollis in children

Torticollis in children may result from a wide variety of pathologic processes. We retrospectively analyzed 288 patients seen in a tertiary care pediatric orthopedic facility for the evaluation of torticollis over a 10-year period to ascertain the frequency of nonmuscular causes of this condition. Fifty-three of these children (18.4% of the study population) had a nonmuscular etiology for their torticollis. Of these 53 patients, Klippel-Feil anomalies were present in 16 (30%), and an underlying neurologic disorder was present in 27 (51%). These neurologic conditions included ocular disorders in 12 (23%) patients, brachial plexus palsies in nine (17%) patients, and lesions involving the central nervous system in six (11%) patients. We conclude that nonmuscular causes of torticollis are collectively not rare. In a child without an identifiable muscular etiology for torticollis, Klippel-Feil anomalies or an underlying neurologic disorder is likely to be the cause of the deformity in the majority of patients.

Torticollis acquired in late infancy due to a cerebellar gangliocytoma

Torticollis in infancy is a common disorder and is typically benign and self-limiting. However, in some instances it is the presentation of serious disease. A critical distinction is whether the condition is congenital or acquired. We present a case of acquired late infantile torticollis caused by a cerebellar gangliocytoma that underscores the importance of making this determination prior to initiating a treatment plan. A gangliocytoma presenting with torticollis has not been previously described.

A risk/benefit analysis of spinal manipulation therapy for relief of lumbar or cervical pain

Approximately 12 million Americans undergo spinal manipulation therapy (SMT) every year. Renewed interest in this method requires an analysis of its reported risks and possible benefits. This review describes two patients with spinal cord injuries associated with SMT and establishes the risk/benefit ratios for patients with lumbar or cervical pain. The first case is a man who underwent SMT for recurrent sciatica 4 years after chemonucleolysis. During therapy, he developed bilateral sciatica with urinary hesitancy. After self-referral, myelography demonstrated a total block; he underwent urgent discectomy with an excellent result 3 months after surgery. The second patient with an indwelling Broviac catheter and a history of lumbar osteomyelitis underwent SMT for neck pain. Therapy continued for 3 weeks despite the development of severe quadriparesis. After self-referral, he underwent an urgent anterior cervical decompression and removal of necrotic bone and an epidural abscess with partial neurological recovery. An analysis of these cases and 138 cases reported in the literature demonstrates six risk factors associated with complications of SMT. These include misdiagnosis, failure to recognize the onset or progression of neurological signs or symptoms, improper technique, SMT performed in the presence of a coagulation disorder or herniated nucleus pulposus, and manipulation of the cervical spine. Clinical trials of SMT have been summarized in several recent articles.(ABSTRACT TRUNCATED AT 250 WORDS)