Infant and Child Chiropractic Care: An Assessment of the Research
 
   

Infant and Child Chiropractic Care:
An Assessment of the Research

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

By Anthony L. Rosner, Ph.D., LL.D.[Hon.], LLC
Foundation for Chiropractic Education and Research
Norwalk, IA. 2003


Dr. Anthony L. Rosner, a 1972 graduate of Harvard University (PhD in biological chemistry/medical sciences), was the Director of Research and Education for the Foundation for Chiropractic Education and Research (FCER), and was then the Director of Research Initiatives at Parker College of Chiropractic.   He is currently the Research Director for the International College of Applied Kinesiology.


OUTLINE:

I.   Pediatric Health Concerns

II.   Theory

III.   Practice

IV.   Managing Pain

     A.   Epidemiological Considerations
             Back Pain
             Neck and Shoulder Pain
             Headache
             Otitis Media
             Infantile Colic and Constipation
             Nocturnal Enuresis
             Asthma

     B.   Outcomes as Demonstrated by Research Reports
             Back Pain
             Headache
             Otitis Media
             Infantile Colic and Constipation
             Nocturnal Enuresis
             Asthma
             Retrolisthesis and Scoliosis
             Neurological Disorders: Epilepsy, Autism, Attention Deficit/Hyperactivity Disorder


     C.   Positioning the Chiropractic Practitioner
             Physical Attributes and Applications
             Chiropractic Paradigms As Guiding Principles


V.   Safety

VI.   Concluding Remarks

Appendix I: Response To Systematic Review on Pediatric Safety

REFERENCES

 
   


I.   PEDIATRIC HEALTH CONCERNS:

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In addition to our parental instincts, consider that the welfare of our children and adolescents is no less than the welfare of our future. That is why we need to pay serious attention to the following pediatric health issues.

  • Pediatric back pain is far more prevalent than was assumed a decade ago. [1]

  • The lifetime prevalence of low back pain among schoolchildren has been reported to be anywhere from 20% to 51%. [2–6]

  • Surveys of 10,000 children conducted in 101 elementary schools indicate that pupils often use chairs or desks that are of inappropriate height or size for their grade level; 30–54% of students carry backpacks significantly exceeding recommended weights; and physical education sessions are inadequate. [7]

  • Backpack use and weight are associated with back pain in children. [8–9]

  • Up to 97% of school children may use backpacks; [9] however, the vast majority of childhood patients in the clinic rarely attribute their back pain to backpacks. [10]

  • In addition to back pain, the use of backpacks has been associated with reduced lung capacity, especially evident in children experiencing adolescent idiopathic scoliosis. [11]

  • Over 20% of adolescent girls and 10% of boys experience chronic, recurrent neck and shoulder symptoms. [12] But in some populations, headache prevalence in schoolchildren during a given year may be as high as 80–90%. [13–14]

  • Otitis media [ear infections], the most common pediatric disorder in the United States, accounts for over 35% of all visits to the pediatrician in the United States, [15] resulting in over 25 M office visits in 1990. [16] Yet the most common means of medical treatment [antibiotics and tympanostomy], have been shown to be woefully inadequate [17–19] with clear risks. [20–21]

  • Infantile colic—unexplainable and uncontrollable crying in infants from 0–3 months old, occurs in 8%–49% of newborns with an average of 22.5%. [22] Yet its cause remains a medical mystery. [23]

  • Nocturnal enuresis—the persistent wetting of the bed at night in the absence of urological and neurological pathology after the age of 4, occurs in a fifth of all 4–5 year olds [24] and persists in 7% of 8–year olds. [25]

  • While the annual incidence of asthma in children in the United States is 7%, [26] the fact remains that it is the most common chronic disease in childhood [27] with its debut during the first year in life in about 30% of infants and in more than 50% before 2 years of age. [28]

As will be pointed out in this monograph, there is evidence that in all of above conditions the conventional, more widely accepted regimes of medical treatment are beset with severe limitations. It is therefore imperative for us to consider alternative treatments which have demonstrated efficacy, cost-effectiveness, and safety. With more children having used chiropractic than any other form of alternative therapy [homeopathy, naturopathy, acupuncture, osteopathy, oligotherapy, others], [29] this should be the form of healthcare intervention given priority as we seek improved pediatric care. This is both apparent and timely since it has been shown that the gaps between what we know and what we need to know and what we know and what we do in pediatric practice is substantial. [30]



II.   THEORY:

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Heiner Biedermann, a German Practitioner in Conservative Orthopedics and Member of the European Workgroup in Manual Medicine, has pointed out that children in early development are subjected to two formidable challenges to their musculoskeletal system. [31] The first is the trauma of passage through the birth canal, one of the most dangerous journeys to be traversed in a lifetime, according to a variety of sources–mostly obstetricians. Here it appears that intracranial structures of apparently healthy newborn individuals display a high percentage of indications of microtrauma of brainstem tissues in the periventricular region, [32] and it is believed that exposed structures of the occipito-cervical junction suffer at least as much as the cranium. [33] In summary, it appears that injury to both the intracranial and subcranial structures is the rule rather than the exception. [31] The second major onslaught to the child’s emerging musculoskeletal system occurs when the infant has to master the transition from a quadruped to a biped, mastering the task of maintaining an upright spine in learning how to walk. Superimposed upon this burdensome task is the fact that the last major growth spurt usually occurs between the ages of 11 and 13, at just the time that such risks to the integrity and alignment of the spinal curve as backpacks, [6–7] and other factors in the elementary school environment are imposed. After all these events, both the complaints and treatment regimens of such individuals become congruent with those of adults.

Prior to adolescence, the infant and the juvenile are highly susceptible to developmental irregularities that may exert a lifetime influence if not properly attended to. At the same time, these same individuals appear to be logical candidate for conservative forms of corrective treatment. This leads to an essential piece of information regarding manipulative therapy for small children: As pointed out by Biedermann, it [spinal manipulative therapy] is not a scaled-down version of the procedures used for adults. [31, 34]

The kinematic imbalances brought on by the suboccipital strain at birth give rise to a concept in which symptoms and signs associated with the cervical spine manifest themselves into two easily recognizable clinical presentations. The leading characteristic is a fixed lateroflexion [called KISS I] or fixed retroflexion [KISS II]. KISS I may be associated with torticollis, asymmetry of the skull, C–scoliosis of the neck and trunk, asymmetry of the gluteal area and of the limbs, and retardation of the motor development of one side. KISS II, on the other hand, displays hyperextension during sleep, occipital flattening that may be asymmetrical, hunching of the shoulders, fixed supination of the arms, orofacial muscular hypotonia, failure to lift the trunk from a ventral position, and difficulty in breast feeding on one side. [34] The leading trademarks of both KISS I and KISS II are illustrated in Figure 1. [31]


In essence, these birth experiences lay the groundwork for rationalizing the wisdom of providing chiropractic healthcare to the pediatric population. What follows is a brief description of practice, followed by descriptions of the evidence supporting chiropractic for managing a wide variety of childhood conditions such that chiropractors have earned the privilege of treating children for a variety of conditions on a first-contact basis without requiring referral.


III.   PRACTICE:

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Manipulation of children appears to date from at least 1727, at which time Nicholas Andry coined the term "Ortho-Paedics" to depict "straightening the young" and became the defining principle of the medical procedures that he published. [31] In this context, the goal of all chiropractic interventions is to alleviate or eliminate perceived asymmetries in spinal structure, posture or gait, as well as reduce symptoms for a variety of conditions which will be described below. No chiropractic adjustment is ever prescribed without evidence of a relative decrease in mobility at a particular articulation.

Examination procedures preceding the chiropractic adjustment include static or motion palpation. It has been suggested by some that radiography may be useful to assess asymmetries and confirm the direction of the impulse to be applied. [31] The elastic properties of the developing spine require that vectors which would introduce extraneous forces into the spine [such as from mobilization or long-lever contacts] should be kept at a minimum. Nonspecific maneuvers which are discouraged include supine, prone or seated rotary break, hyper lateral flexion and rotation, longitudinal traction, extension, flexion, and extension. Instead, the increased flexibility of the child's spine requires a preload tension that is greater than that experienced by adults. This is followed by a high acceleration thrust considerably gentler than that applied to adults. A deceleration period and 1–2 second holding period, increases the effectiveness of the adjustment. [35] Especially with infants, specific contacts are made more often through the fingertips rather than the hypothenar or pisiform applications experienced with adults. Craniosacral procedures primarily limited to non-force indirect methods have also been proposed and implemented. [36] In managing the aforementioned KISS syndromes,

Biedermann describes an impulse manipulation in which the direction of the manipulation may be guided by radiological findings, orientation of the torticollis, palpation of the segmental dysfunction, or the local pain reaction. The intervention itself involves a short thrust of the proximal paland of the medial edge of the second finger, primarily lateral but with the possibility of adding a rotational component. [34] Finally, extensive attention to nutritional matters—including counselling in issues related to vitamin and mineral intake, balanced diets, and food allergies—has long been a component found in most chiropractic practices. [37]


IV.   MANAGING PAIN:

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According to the widely recognized International Association for the Study of Pain, "Inadequate prevention and relief of children's pain are still widespread, a deficiency highlighted during the current IASP Global Year Against Pain in Children." [38] Furthermore, both the physical and psychological responses to pain in children may very well increase their risk of incurring chronic pain in adulthood. [39–41] Research into the nature and assessment as well as treatment of children's pain is said to have grown "exponentially" over the past two decades. [42] It is thus imperative that the most efficacious, cost-effective, and minimally invasive interventions learned from research be put into practice by the most qualified and accessible practitioners available. The purpose of this monograph will be to justify the role of chiropractic as being able to fulfill that need. This should be apparent from [a] epidemiological considerations, [b] outcomes as demonstrated by research reports, and [c] the qualifications of the practitioner.


A.   Epidemiological Considerations:

1.   Back Pain:

It is clear that low back pain can begin in childhood. 10% of children aged 9–10 have been reported to suffer from it with 2% of schoolchildren experiencing disability because of it. [43] In schoolchildren, the lifetime prevalance of low back pain has been estimated to be anywhere from 20% to 51%. [2–6] As shown in Table 1, point, 1-month and 1-year prevalences of back pain in childhood and adolescent populations come close to these figures, ranging from 12–56%. Some 35% of children with low back pain at age 15 participating in one study still were reporting continuous or recurrent pain at 18 and 23 years of age. Furthermore, nearly all [89%] of those who reported pain at all three ages displayed various stages of disc degeneration by MRI at age 15–whereas the aberrant MRI images were evident in only 26% of subjects without recurrent low-back pain. [52]

TABLE 1:   PREVALENCE OF BACK PAIN IN PEDIATRIC AND ADOLESCENT POPULATIONS

NATIONALITY
AGE
PREVALENCE [%]
United States [4]
13–16
30.4, point
United Kingdom [44]
Adolescent
11.5, point
United Kingdom [45]
11–14
24, 1 month
United Kingdom [46]
11–15
12, annual
 
11
22, lifetime
 
15
50, lifetime
Switzerland [47]
Schoolchildren
27, point
Denmark [1]
8–10; 14–16
39, 1 month
Denmark [48]
12
56, 1–year
Turkey [49]
17–20
lifetime
Finland [50]
11.8
53.8, 1–year
Finland [51]
14
8, point [female]
 
14
10, point [male]
 
16
14, point [female]
 
16
11, point [male]
 
18
13, point [female]
 
18
17, point [male]


Ergonomic factors play a major role in this problem. Children in 101 elementary schools revealed that 10,000 children were using chairs or desks of improper height or size for their grade level. [8–9] But the lion's share of back problems has been attributed to the improper use of backpacks. [8–11]

As many as 97% of schoolchildren may be using backpacks. [9] According to a recent news release, this may result in several casualties: [53]
  • Over 75% of adolescents aged 12–18 experience some form of back pain, with the weight of their back pack having been identified as a leading contributor to this pain.

  • One study of Italian schoolchildren revealed that over a third carried more than 30% of their body weight at least once a week, in excess of the limits proposed for adults.

  • The average backpack weight for students has been found to be 17% of their body weight, in excess of the 10% proposed by pediatric chiropractors and orthopedic surgeons.


In other studies:

  • Female students who used backpacks during the day had twice the odds of developing back pain. [8]

  • Back pain was more likely to be reported in students who carried heavier loads or who used backpacks more frequently during the average school day. [8]

  • Students without back pain were more likely to attend a school that banned the use of backpacks between classes. [8]

  • The increased contact pressure and asymmetric shoulder loading apparent with average backpack loads of 22% of body weight were associated with significant pain and injury. [54]

  • In addition to back pain, the use of backpacks has been linked to reduced lung capacity, especially evident in children afflicted with adolescent idiopathic scoliosis. [11]

In active adolescents, spondylolysis has been identified as the most common cause of low back pain. It is seen in 5–6% of the population and usually is triggered by injuries to the posterior elements of the spine, most commonly L–5, L–4 and L–3. Primary causes include sporting activities involving hyperextension combined with rotation such as experienced in gymnastics, wrestling, and weightlifting. [55]

What is of paramount importance is that back pain in childhood and adolescence becomes a risk factor for experiencing back pain in adulthood. Thus its proficient management in the early and formative years would be expected to diminish the pain and disability experienced later in life.

  • One 25-year prospective cohort study showed an increased lifetime prevalence of low back pain in individuals who had incurred low back pain in their adolescence. It was shown that low back pain in the gowth period and familial occurrence of back disease are important risk factors later in life, the increase of probability reaching 88% if both factors are present. [56–57]

  • If back pain becomes chronic, its very nature has shown that it tends to recur again and again over several years. [58–60]



2.   Neck and Shoulder Pain

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From a database of 62,677 12, 14, 16 and 18 year olds and 127,217 14–16 year olds taken from national and classroom surveys in Finland, the prevalence of neck and shoulder pain was found to be increasing from the 1980s steadily through 2001. As shown by Table 2, prevalence increased with age in both genders. Most dramatic was the fact that the authors concluded that, for the low back, neck, and shoulder in adolescents. "This pain suggests a new disease burden of degenerative musculoskeletal disorders in future adults." [51]

TABLE 2:   PREVALENCE OF NECK AND SHOULDER PAIN IN ADOLESCENT POPULATIONS

NATIONALITY
AGE
PREVALENCE [%]
Finland [51]
14
24, point [female]
 
14
12, point [male]
 
16
38, point [female]
 
16
16, point [male]
 
18
45, point [female]
 
18
19, point [male]
Netherlands [61]
12–16
12, point
Canada [62]
Grades 7–9
28, annual


This is not surprising, in that another Finnish study indicated that the risk of neck and shoulder pain increases markedly with computer usage exceeding 2–3 hours per day. The population studied was a sample of 14–, 16–, and 18–year olds. [63] A recent Dutch study, however, attributed the neck and shoulder pain in a similarly aged population to depression and stress, but not computer usage and physical activity. [61] Finally, a study from New Mexico reignites the debate over backpacks discussed above by suggesting from a descriptive study that a correlation exists between backpack weight per body mass index in adolescent girls. [64]

The message to keep in mind is that prevalences are seen to be increasing with age, again suggesting that these conditions can be expected to extend into adulthood without proper management. Yet further evidence supporting this assertion can be found in a South Australian cohort of 13–17 year-old boys and girls in which the prevalence of neck and upper back pain was found to be steadily increasing through 5 years of schooling. [65]


3.   Headache

As shown in Table 3, headache prevalence in pediatric populations are significant, having been reported to be as elevated as 80–90% over the past year in schoolchildren, [66–67] ranging downward to 23% in 10–17 year-olds [68] with a marked elevation [as high as 40%] in girls over boys in Sweden. [73] Classification of headache types has been reported to be difficult due to the fact that there are no specific criteria pertaining to this population. [75] Of the 35% of patients that could be classified in one study, the majority [63%] had chronic tension-type headache according to the International Classification of Headache Disorders. Another 14% were identified due to the probable overuse of medications. [76] From the multivariate regression analysis conducted in another study of Norwegian adolescents aged 12 to 14 years, frequent headaches at 1-year followup could be significantly predicted by:
(1)   numerous headaches at first assessment,
(2)   impairment [reduced leisure time activities],
(3)   high depressive scores, and
(4)   gender–in which girls had a worse outcome. [77]

TABLE 3:   PREVALENCE OF HEADACHE IN PEDIATRIC AND ADOLESCENT POPULATIONS

NATIONALITY
AGE
PREVALENCE [%]
Brazil [66,67]
Schoolchildren
80–90, 1-year period
Netherlands [68]
10–17
23, weekly
Finland [69]
6
15, 1-year period
Finland [70]
6.7–8.7
12, 6-year period
Finland [71]
12
12, point
Sweden [72]
11–17
7 boys, 2-year period
 
 
14 girls, 2-year period
Sweden [73]
7th Grade
29 weekly [female]
 
7th Grade
31 weekly [male]
 
8th Grade
43 weekly [female]
 
8th Grade
11 weekly [male]
 
9th Grade
40 weekly [female]
 
9th Grade
10 weekly [male]
Norway [74]
12.5–15.7
8.1, 1-year period


Family histories of headache are common in children with headache. [68] Two recent studies have shown that anxiety and depressive symptoms are not elevated in children with migraine and tension-type headache as compared to those without these disorders. [78] Regarding tension-type headache, however, shoulder pain, depression, and oromandibular dysfunction have been independently associated with this disorder. [71]


4.   Otitis Media

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a.   Prevalence and Cost:

Otitis media is an inflammation of the middle ear which is seen most commonly in children from birth to the age of 7. As the most common pediatric disorder in the United States, otitis media is responsible for over a third of all visits to the pediatrician in the United States, [15] totalling 25M office visits in 1990 [16] at a national direct cost for management at $5.3 billion [79] with other estimates reaching $8 billion [80] factoring in such indirect expenses as failed treatments or overuse of questionable methods to be discussed below. Acute otitis media is reported to occur in 60% of all children during their first year and in 85% by the age of 3, with 17% of children at one year reporting recurrent episodes. [81] By the age of 3, 50% of children will have had more than three episodes of acute otitis media, [82] and recent studies suggest that its incidence is increasing. [83] Certainly from 1975 to 1990, despite the routine use of antibiotics, the incidence of otitis media with effusion in the United States is estimated to have increased by 250%. [84]

Risk factors for otitis media include allergies [85, 86] attending a daycare center with a large population, [86]   and pacifier use past the age of 10 months. [87] Children whose parents smoke experience 50% more ear infections than children whose parents do not smoke. [88] Potential morbidities include hearing loss or a delay in development. [89, 90] The good news is that otitis media is rarely fatal, with perhaps one patient in 10,000 who would experience such infectious complications as meningitis or mastoiditis leading to serious illness or death. [91]

b.   Rationale:

The approach to managing otitis media should begin with understanding the function of the eustachian tube. Collection of either clear or purulent fluid in this region is the identifying characteristic of otitis media. A likely reason as to why this is so much more prevalent in children than adults has to do with the anatomic variation of the adult and pediatric cranium. The cross-sectional area of the adult eustachian tube, for example, is 2.25–2.75 times larger than that of the 2-year old child. [92] In addition, it’s inclination from the temporal bone to the nasopharynx is 45°   in the adult, but only 10°   in children, impeding natural drainage. Finally, a component of the eustachian tube believed to be critical in its active opening [elastin] is sparse in children as compared to adults. [93] Finally, the muscles responsible for the opening and closing of the eustachian tube are thought to become more developed at ages beyond childhood. [94] As shown in Figure 2, this function is primarily regulated by the tensor veli palatini muscle which in turn is innervated by the trigeminal nerve. [95, 96] Secondary regulation of the tube might also be affected by the levator veli palatini and salphingopharyngeus muscles.


Misalignment of the C1 vertebra and/or occiput, affecting components of the superior cervical sympathetic ganglion, would be expected to influence, in turn, the tonus of the tensor veli palatini muscle, the vagus nerve, the inferior vagal ganglion, and ultimately the levator veli palatini, salhingopharyngeus, and superiorconstrictor muscles. All these sequelae would be presumed to lead to the undesirable construction or closure of the eustachian tube. Treatments such as manipulation in an effort to alleviate this vertebral misalignment would therefore appear to be the most direct and attractive possibility. [97]The other major fact to consider is the case against the premature and indiscriminate use of medical alternatives in treating otitis media.

c.   Risks of Medical Alternatives:

ANTIBIOTICS

As medical practices evolve with our increasing knowledge as well as a changing environment, so must theadvisability of using antibiotics as a first line of treatment for otitis media. To continue the indiscriminate use of such medications in the face of mounting evidence constitutes significant health risks to both the individual patient and the population as a whole. Prescribing antibiotics without even examining the patient is particularly problematical. There are at least 5 reasons to seriously question the use of antibiotics as a first line of treatment for otitis media:

1.   A significant percentage of otitis media cases are not even caused by bacteria

According to numerous studies outlined by Schmidt, anywhere from 20–40% of otitis media cases in which the middle ear fluid has been cultured fail to yield bacterial strains in culture. [98] One would therefore deduct that these represent otitis media cases caused by either viruses or sterile effusions–both of which by definition would not be expected to ever respond to antibiotics. Strong support for this conclusion has been recently provided by Pikaranta, who demonstrated that viruses without pathogenic bacteria were found in the middle ear fluid of the majority of samples taken from children with otitis media with effusion. [99] Should fluid cultures not be obtainable, examination of the ear by otoscopy and/or tympanometry [100] would be expected to yield clear indications of the etiology of the ear infection, helping to segregate those cases which theoretically would be amenable to treatment with antibiotics. The remainder of otitis media cases would have no chance of responding to antibiotics, making their prescription without the direct examination of the patient untenable.

2.   Widespread use of antibiotics for any condition could lead to calamitous bacterial resistance

The remarkable ability of bacteria to develop resistance to antibiotics is well-documented. This would include [i] enzyme mutations which allow bacteria to inactivate beta-lactam drugs, [ii] development of intracellular pumps to remove antibiotics before they can destroy the host cell, [iii] cell wall protein changes which block antibiotics from entry, and [iv] synthesis of substitute proteins which escape the lethal effects of antibiotics. [101] To make matters worse, antibiotic resistance may be transferred via plasmids from a resistant bacterial strain to a nonresistant strain that is not even the same species. [101] Among clinical isolates of some bacterial species, strains resistant to all available antibacterial agents have been identified. [102]   Simply put, each time an antibiotic is used there is the risk that a resistant mutation may develop and proliferate–meaning that the use of antibiotics does not come without a price. Increasing populations of multidrug resistant bacteria from 1995–1998 have been extensively described within the United States. [103]

The consequences of this problem for the world's population could be disastrous. The increased morbidity, mortality, and costs of worldwide resistance of bacteria to antimicrobial drugs is already a matter of record; in fact, a recent article in Forbes reports that drug-resistant infections kill more Americans than AIDS and breast cancer combined. [104] Both the Institute of Medicine in the United States in 1992 [105] and the Centers for Disease Control in 1994 [106] have warned of this growing threat. Remedies linked to a global plan of the World Health Organization [107] include the request to educate parents to avoid asking for antimicrobials when they are not useful and to urge that physicians prescribe them conservatively. [108]

The indiscriminate use of antibiotics appears to have risen to abusive levels. In a lead editorial published ithin the past year, The International Herald Tribune suggests that a major health problem in developed ountries is the overutilization drugs, including the fact that the Centers for Disease Control estimates that one-third of antibiotics taken on an outpatient basis in the United States are unnecessary. Should we continue to use antibiotics at our present level, protection will not be available 50 years from now since almost every major infectious disease is becoming resistant to currently available medicine. [109]

The problem becomes even more acute when one considers otitis media. According to Ambrose Evans-Pritchard, the situation is described as follows:

"In the U.S., there are 24.5 million doctor-visits a year by children with ear infections. They are typically given antibiotics, and in many cases they care kept on a constant, low dosage course for the whole winter. U.S. parents expect no less. But we now know that there is price to be paid for this: more people will die of pneumonia, which is treated with variants of the same drugs. A quarter of all cases of streptomyces pneumoniae in the U.S. are now resistant to know drugs, compared with 0.002 per cent a decade ago." [110]

In this regard, it is important to note that in The Netherlands, where a waiting period of 1–2 days is routinely observed before antibiotics are given for otitis media, occurrence of antibiotic resistance is 1%, compared to the 25% level in the U.S. where antibiotics are given immediately. [111] A 1992 study suggested that more than 90% of the colds and respiratory tract infections for which antibiotic prescriptions were written for adults were viral in origin, rendering these antimicrobial drugs ineffective. In fact, it was presumed that antibiotics are overprescribed by 50% in the United States and Canada. [112]

The take-home message from all the previous arguments would be that antibiotics should be considered as a later [instead of a first] resort.

3.   Side-effects have been linked to the use of antibiotics for otitis media

By destroying bacteria, antibiotics may wreak havoc upon beneficial species as well as those presumed to be causing harm. A perfect example would be their disruption of the ecological balance of intestinal flora. In so doing, the bacteriocidal effects of antibiotics might be expected to allow proteins which are normally blocked from adsorption to pass through the intestinal wall, leading to what is commonly known as a "leaky gut" syndrome. In so doing, antibiotics could allow foreign proteins to be introduced into the bloodstream, leading to the raising of antibodies and the creation of allergic responses within the host. [98]

A recent report is disturbing in that it suggests that there is an increased risk of asthma symptoms with antibiotic use. Specifically, the odds ratio for the risk of asthma rises to 2.7 if antibiotics were ever used, and this risk increases to over 4 if antibiotics were used in the first year of life. Furthermore, the risk increases from 2.3 with 1–2 courses of antibiotics to over 4 if 3 or more courses are used, making the risk appear to be dose-dependent. [113] This phenomenon [an association, not a causation] could well be explained by the aforementioned "leaky gut" phenomenon, in which allergic responses could be manifested by the constriction of bronchial airways and the resulting development of asthmatic symptoms.

A further complication with antibiotics is suggested by the work of Jochen Schacht at the University of Michigan. Animal studies have shown a profound hearing loss [61 db auditory threshold shift at 18 kHz] in in guinea pigs receiving gentamicin, possibly due to a free-radical mechanism of toxicity of aminoglycoside antibiotics [114] which destroys hair cells in the cochlea and the lower turns of the outer ear. [115, 116] L–carnitine, a naturally occurring neuroprotective agent which is required for the transport of long-chain fatty acids across the mitochondrial membrane prior to their oxidation resulting in ATP formation, has been shown to prevent both neonatal mortality and sensorineural hearing loss induced by gentamicin. [117]

Finally one has to note a recent report which indicates that the antibiotic oral erythromycin, sometimes used in treating otitis media, prolongs cardiac repolarization and is associated with case reports of torsades de pointes—a cardiac arrhythmia which causes blackouts. Worse, because erythromycin is ex tensively metabolized by cytochrome P–450 3A [CYP3A] enzymes, commonly used medications which inhibit the effects of CYP3A [nitromidazole antifungal agents, certain calcium-channel blockers, some antidepressants] increase plasma erythromycin concentrations which in turn increase the risk of ventricular arrhythmias with resultant risk of sudden death from cardiac causes. An elevation of sudden cardiac death that could be traced to erythromycin use was, in fact, actually observed in a Medicaid cohort of about 1.2M person-years of follow-up in the state of Tennessee. [118]

All of these findings clearly point out that the use of antibiotics does not come without consequences, the majority of which are unwanted, detrimental, and ultimately preventable if antibiotics are not used inappropriately.

4.   The effectiveness of antibiotic use in treating otitis media has been questioned in the literature

Within the past decade, a reevaluation of a major clinical trial, a second clinical trial, and a meta-analysis all question the effectiveness of amoxicillin in managing middle-ear effusions. The reevaluation suggested that the antibiotic was not effective [119]   and the meta-analysis suggested that to prevent one child from experiencing pain by 2–7 days after presentation, 17 children must be treated with the antibiotic early [suggesting only modest benefits]. [120] The remaining clinical trial not only echoed the findings of the metaanalysis but went so far as to suggest that "this modest effect does not justify prescription of antibiotics at the first visit, provided close surveillance can be guaranteed. [121]

One would imagine that, given this weak evidence regarding the capacity of the routine use of antimicrobials to decrease the duration and severity of otitis media, there should be cries for a revision of this policy. Indeed, requests for such reassessments have appeared recently in the scientific literature, [103] including a review and plea from the International Primary Care Network. [122]

5.   The basis for prescribing antibiotics for pediatric problems may not be based upon scientific principles

To compound the problem of prescribing antimicrobials to treat nonbacterial conditions as suggested in item #1 above, a recent report suggests that when physicians merely thought that the parent wanted antimicrobials to treat their children's illnesses, physicians were significantly more likely to give a bacterial diagnosis. [123] The link between patients' expectations and physicians' prescribing responses has been extensively documented in the literature. [124–128] Patients do seem to expect antibiotics for prescriptions, and their satisfaction rises when these expectations are met. [129, 130]   What is remarkable in these studies is how physicians' diagnostic capabilities as well as their prescriptive responses appear to have been influenced by their perceptions of patients' attitudes.

The question that one would pose in this circumstance is as disturbing as it is elementary: Are sound scientific principles being followed in the current paradigm of prescribing antibiotics?

To conclude, a substantial body of literature now exists to refute the contention that antibiotics should be prescribed as a first line of defense for the treatment of otitis media. It is only through the education of both patients and physicians that one would hope that more efficient, less expensive, and especially less invasive means are developed to manage the patient with otitis media.

TYMPANOSTOMY

In certain instances with persistent otitis media with effusion, tympanostomy tubes have been inserted through the eardrum to attempt to reduce hearing loss caused by the accumulation of fluid or to attempt to lessen the frequency of recurrent bouts of otitis media. In 1988, some 670,000 surgeries were performed in the United States, making it the most common operation for children. [131–133]

It would appear that puncturing the eardrum by such an intervention should be a means of last resort. Potential complications of tube insertion would include prolonged otorrhea, persistent perforation of the tympanic membrane, and scarring of the tympanic membrane which may be associated with low-grade, long-term hearing loss. [131–136] The results from a variety of epidemiological studies have not been encouraging: one study found that one quarter of tube insertions for children were proposed for inappropriate indications and another third for equivocal ones; [137] another indicated that for children younger than three years of age with persistent otitis media, prompt tympanostomies did not measurably improve developmental outcomes. [138]


5.   Infantile Colic and Constipation

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First described in 1894 as dyspepsia, colic has acquired varying sets of diagnostic criteria to the present. The most widely accepted definition is the unexplainable and uncontrollable crying in babies from 0–3 months old, more than 3 hours a day, and more than 3 days a week for 3 weeks or more. This usually occurs in the afternoon or evening hours. [139] The crying is characterized by a higher frequency pitch, [140] and there is frequently motor unrest marked by the flexing of the knees against the abdomen, extension and straightening of the trunk and extremities, and clenching of the fists. Otherwise, the infants affected have been found to be healthy and thriving with normal weight gain. [139]

The incidence of colic among newborns averages 22.5% [ranging from 8–49%]. With 4,058,814 live births having been reported in the U.S. in 2000, [141] that would translate to 913,233 cases of colic every year. Despite the fact that colic has often been described as "benign" and "self-limiting," one observational study has indicated that more than half [53%] of colic cases persist beyond 3 months and that 12% of these continue beyond 6 months. [142] Even though the condition may appear to be short-lived, it runs the risk of damaging the mother-child relationship which could persist for up to 3 years after the disappearance of the symptoms of colic. [143, 144] This condition would also be expected to increase the risk of continuing ill treatment of the child and even death from being shaken. [140, 145]

The cause of colic remains unknown, as [a] radiological studies have shown that the amount of air in the intestines of colicky infants is the same as in normal babies; [139] [b] constriction of the intestines has not been found; [139] [c] gastrointestinal transit time is normal; [139] [d] intestinal hormones and microflora, fecal analysis, occult blood in the stools, hydrogen ion concentration in the breath, and markers of intestinal damage have all shown unremarkable characteristics in infants with colic. [139]

Later in childhood is the problem of chronic childhood constipation, which accounts for 3% of visits to general practitioners and almost 30% of visits to pediatric gastroenterologists. [146] In followup studies, 30–50% of these children continue to have symptoms many years after the initial diagnosis, [147] the symptoms in perhaps 30% being intractable. [147, 148] Contradicting the notion that childhood constipation disappears during puberty was a longitudinal study that revealed no such tendency. [149]
Large quantities of hard, dry feces in the descending colon due to the overabsorption of fluid are the hallmark of constipation. [150] Reduced frequency of defecation, hard stool consistency, and difficult or painful bowel movements are the clinical earmarks of constipation. [151, 152]


6.   Nocturnal Enuresis

According to the Diagnostic and Statistical Manual of Mental Disorders, enuresis has been defined as the involuntary voiding of urine at least twice a month for children aged 5 and 6 and once a month for older children. The most common form of enuresis is nocturnal, in which urine is passed during sleep. [153] This condition is primary if the child has never been consistently dry for more than 1–2 weeks; in secondary enuresis, the child is seen to wet again after an extended period of dryness. [154] The primary form customarily begins by the age of 5, while the secondary variety is experienced between ages 5 and 8. [153]

Nocturnal enuresis is seen in about 15% of 5–year olds, 7% of 8–year olds, and 3% of 12–year olds [155] By the age of 18, it virtually disappears in girls and occurs in 1% of boys. [153] Overall, it is estimated that it affects 5–7 million children in the United States alone. [156]


7.   Asthma

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Asthma is described as a multifactorial condition characterized by spontaneous attacks of wheezing, dyspnea, thoracic constriction and labored breathing. [157] Mild onsets will display symptoms of tachypnea, tachycardia, and wheezing upon expiration, where as more severe forms will present increased breath sounds with pursed lips and the lack of expansion of the rib cage due to intercostal muscle constriction. [157] The hallmark is a thick, white mucous which is produced by the respiratory epithelium of the bronchi, creating an obstruction of the airways with considerable difficulty in breathing. [158]

Estimates of asthma occurrence indicate that it affects 4–5% of the general population in industrialized countries [159] and is the most common chronic disease of childhood. [160] In Australia, its prevalence among children has been calculated to a figure of 20% [161] with one estimate from Victoria running as high as 46%. [162] In the Australian population overall, there are reports that the mortality of asthma has increased from 400 deaths per year in 1979 to around 900 in 1990–with a similar trend having been observed in both the United States and United Kingdom. [163] Direct costs of treatment have ranged from $209 million in New South Wales in 1989 [163] to 400 million pounds in the United Kingdom as calculated by the National Health Service. [164] For children, the prevalence of asthma has been reported to increase more than 50% since 1980 and the mortality more than 70%. [165]

In the United States, the increase in asthma sufferers has risen 75% since 1980 to 1998, while the death rate for children during this period increased by 78%. The year 1995 alone produced 1.8 million visits to the emergency room for asthma. The Centers for Disease Control, in assessing this situation, believed that this problem was due to pollution and other environmental factors. [166]



B.   Outcomes as Demonstrated by Research Reports:

1.   Back Pain:

Despite the wealth of studies regarding low-back pain outcomes in adult populations [167] and the fact that low back pain is the condition most frequently associated with chiropractic care, [168] there have been no con trolled trials to date on the outcomes of chiropractic treatment for low-back pain in pediatric and adolescent populations, according to searches on MEDLINE from 1987–2006 and MANTIS from 1992–2006. As shown ty Table 4, one cohort [169] and three case studies [170–172] involving spinal manipulation by a chiropractor have been reported.

TABLE 4:   SUMMARY OF LEADING OUTCOMES STUDIES INVOLVING
SPINAL MANIPULATION FOR MANAGING BACK PAIN


AUTHOR
DESIGN
# SUBJ
AGE
INTERVENTION
OUTCOMES
RESULTS
Hayden [169] Cohort
54
4–18
SMT Pain [VAS] 87% improved
   
 
 
  Likert 62% improved
Hession [170] CASE
1
16
EMS Pain [VAS] 100% improved
   
 
 
F–D SMT    
   
 
 
R SMT    
Kazemi [171] Case
1
14
S–P Mob ROM Can touch tibia
   
 
 
I Current Tx Pain Pain Free
   
 
 
Cryo Tx    
   
 
 
Lumbar traction    
   
 
 
S–P SMT    
   
 
 
Exercise    
   
 
 
IR Laser Tx    
King [172] Case
1
14
S–P SMT Radiating pain Pain free
   
 
 
Soft tissue Tx Activity limited Unrestricted
   
 
 
I Current Tx    
   
 
 
AIM    
   
 
 
Surgery    

KEY:
EMS = Electrical Muscle Stimulation
F–D = Flexion-Distraction
R = Rotational
S–P = Side-Posture
I = Interferential
IR = Infrared
AIM = Anti-inflammatory medications

This gap in the pediatric low back pain literature fortunately has begun to be addressed with a more recent prospective study of consecutive pediatric patients with low-back pain seeking treatment from randomly selected chiropractors within the cities of Calgary, Alberta and Toronto, Ontario, Canada. Chiropractors were eligible to participate if they were in practice for a minimum of 5 years and saw a minimum average of two pediatric patients per week. A maximum of 5 consecutive cases between the ages of 4 and 18 with a new episode of mechanical low back pain [not previously treated by a chiropractor] were accepted. Low back pain was defined as pain or discomfort in the area bounded by the lowest set of ribs in the patient's back to the lower edge of the buttocks. A total of 15 chiropractors provided data on 54 patients, 61% of which were acute presentations and 47% relating to the onset of a traumatic event. All patients were followed until they reported resolution of the problem, discharge, referral, or discontinuation of treatment. Assessment of low back pain was accomplished by means of two indices: [i] the visual analog scale [VAS], and [ii] a subjective 5-point Likert scale. The mean VAS upon presentation was 5.6.

The most commonly used form of intervention was spinal manipulation, with 95% of follow-up visits including this therapy. Included in additional treatments were passive manual therapy, such as soft tissue treatmentsand mobilization and such modalities as interferential current and ultrasound. Just 7.7% of patients underwent active management, such as patient-directed home exercises, nutrition, and other education.

Within a 6-week course of management, "much improvement" [Grade 4 on the Likert scale] was attained in 62% of the patients, with a median time of 16 days. "Important improvement"" [Grade 3.8 on the VAS] was reported from 87% of the patients with a median time of 28 days. Patients with chronic low back pain were less likely to respond within the median number of treatments. [169]

Given the fact that chronic patients were less likely to respond and that relatively few practitioners employed active management strategies, it appeared to the authors that further education of chiropractors regarding this particular mode of treatment was indicated. Because there was no natural history comparison group, it is not possible to directly implicate cause and effect from this particular study. However, there does seem to be a clear implication that the majority of pediatric patients with low back pain [especially acute] respond positively to chiropractic treatment. [169]

The case studies, all addressing lumbar disc herniation experienced by adolescents, require our further attention. All clearly demonstrate the most prudent course of healthcare, beginning with the most conservative and least invasive modalities and progressing until a positive outcome is attained. [170–172] The study by Hession describes a progression from flexion-distraction to side-posture manipulation, with full recovery experienced by 8 weeks with no recurrence of complaints by 16 months after treatment. [170] Kazemi depicts a far more involved and lengthy course of treatments–all conservative–for 20 weeks, yielding a patient who is pain-free at one year of follow-up. What is even more remarkable is that the patient, a Tae Kwon Do martial artist, was clearly subjected to extreme physical challenge. [171] King's report describes an adolescent who begins treatment conservatively [even with a return referral from a neurosurgical consultation] but ultimately undergoes surgery for disc removal after just 3 weeks of visits to both chiropractic and allopathic providers. [172] Taken together, these three case studies cannot establish cause-and-effect but clearly give us an excellent blueprint as to how pediatric musculoskeletal conditions might best be managed by both the chiropractic and allopathic communities. It is also clear that further clinical research including the more controlled design of randomized clinical trials would add invaluable evidence to further support the chiropractic care of pediatric and adolescent populations with back pain.


2.   Headache:

Despite the multiplicity of outcome studies for adults [173–177] which have gained recognition in a study conducted by Duke University and endorsed by the Agency for Health Research and Quality, [178] there have not been formally constructed manipulation outcome trials with pediatric populations. Rather, there have been numerous case studies and case series, a portion of which have appeared in the peer-reviewed journals. As shown in Table 5, tension-type, cervicogenic, and even migraine headache have been described with positive outcomes. [179–184] Lisi's investigation is noteworthy in that it reports that the cervicogenic headachefrequency decreased to just twice a month after only a single treatment. [184] Other than Hewitt's positive case repor, 180
] no published outcome studies pertaining to neck and shoulder pain specifically in children could be located. For the present, the encouraging results of the adult clinical trials [173–177] can be interpolated and melded with the aforementioned positive pediatric case outcomes [179–184] to suggest that spinal manipulation in the treatment of pediatric headaches enjoys a base of evidence that cannot be ignored.

TABLE 5:   CHIROPRACTIC TREATMENT OF PEDIATRIC HEADACHE

Author
# Subj
Age
Diagnosis
Diagnostic Procedues
Adjustive Procedures
Haney [179]
1
11
Subluxation X-ray, AK muscle Diversified
Hewitt [180]
1
13
TTH Passive MP Diversified
Kastner [181]
12
Unspecified
TTH, M, U Unspecified Unspecified SMT
Cochran [182]
1
10
M X-ray, MP Thompson, diversified
Anderson- Peacock [183]
5
6–15
CEH [2] ROM, M [3] xray, MP Diversified
Lisi [184]
1
8
CEH ROM, MP Diversified
 
 
 
    Modified rotary break
 
 
 
    Side posture mamillary push
 
 
 
    Myofasical release

Legend:  
CEH = cervicogenic headache;
M = migraine headache;
TTH = tension-type headache;
U = unspecific;
ROM = range of motion,
AK = applied kinesiology;
MP = motion palpation;
SMT = spinal manipulative therapy


3.   Otitis Media:

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Although still lacking a randomized clinical trial, arguably the strongest case for chiropractic intervention can be made for managing otitis media. To complement the prevalence, rationale and risks of medical alternatives outlined above in Section IV.A.4. are the results of large cohort and case studies shown in Table 6 supporting the effectiveness of manipulative therapy for treating this condition. [97, 100, 185–197] It can be seen that the majority of otitis media cases treated with spinal manipulation appear to be resolved within 10 days, most responding to fewer than 5 adjustments [100, 186] and many requiring only one or two treatments. [97, 185] Particularly intriguing is the fact that patients with no history of prior ear discomfort were much more likely to show early improvement, avoiding the cost and time of further interventions. [185] Normalization of otoscopic and tympanographic results likely occurred more quickly in cases of acute rather than chronic otitis media as shown in two studies. [100, 186] Fewer surgeries and episodes of acute otitis media were also encountered by patients undergoing osteopathic manipulative treatments. [187]


TABLE 6:   SUMMARY OF LEADING OUTCOMES STUDIES INVOLVING
SPINAL MANIPULATION FOR MANAGING OTITIS MEDIA


AUTHOR
DESIGN
# SUBJ
AGE
INTERVENTION
OUTCOMES
RESULT
Froehle [185] Cohort
46
<5 yr
A SMT Parental decision 93% ep improved
   
 
 
SOT    
   
 
 
AK    
Fallon Case series
332 [100]
<5 yr
RF Otoscopy Resolved
   
401 [186]
 
D, G SMT Tympanography Resolved
Phillips [97] Case
1
23 mo
A SMT Ear drainage, pain Reduction
Mills [187] RCT
57
6 mo
RC AOM episodes Reduction
   
 
6yr
RC + OMT Surgeries Reduction
   
 
 
  Tympanograms More normals

Legend:  
RC = Regular care,
OMT = Osteopathic manipulative therapy,
SMT = Spinal manipulative therapy,
A = Activator,
SOT = Sacro-occipital technique [occasionally],
AK = Applied kinesiology [occasionally],
D = Diversified,
G = Gonstead,
STE = Soft tissue effleurage,
RF = 3o rotation, 5o lateral flexion,
ep = Episodes


The importance of direct examination of the middle ear, such as outlined in extensive detail by a chiropractor who practices in the New York metropolitan area with frequent referrals to and from major hospitals in NewYork, [100] points out the variety of conditions that can be distinguished by tympanography. As shown by the tympanograms in Figure 3, it is possible to distinguish ear conditions which are most likely to respond to antibiotic treatment [positive peak pressure, brought on by purulent bacterial cultures] from those that are not [negative peak pressure, indicative of viral or serous effusions]. This stands in stark contrast to the questionable standards for ordering antibiotics outlined above (Section IV.A.4.c.1]), including the almost surreal bases sometimes chosen for prescribing antimicrobials, as published by Mangione-Smith and her colleagues in the journal Pediatrics. In that particular study, it was shown that physicians both prescribed antibiotics and diagnosed a bacterial origin largely from the mere anticipation of what they believed the parents of affected patients desired in their treatment. [123]



Mastoiditis [the chief complication of otitis media] occurs only 0.2–2% of the time, even without antibiotic treatment; [188] it behooves the physician to not only consider spinal manipulation as a treatment option for otitis media, but as a possible first alternative in light of the more rapid responses achieved in acute cases. Clearly, this strategy serves the patient well also in avoiding the complications attending the medical options discussed above. In none of the studies reported in Table 6 were any side effects or complications reported.

Other than the osteopathic report published by Mills, [187] data from a randomized clinical trial directly comparing the effectiveness of spinal manipulation to standard medical treatment have yet to appear in any of the refereed medical journals. This is an omission that hopefully will be resolved in the near future. In the meantime, there seems to be little reason to deny qualified chiropractors the opportunity to manage this extremely widespread condition with greater efficiency, an absence of side effects, and at lower cost.


4.   Infantile Colic and Constipation:

To buttress years of promising clinical observations, a number of interventions have recently been conducted [Table 7], [189–193] with results that are mostly suggestive. All involve spinal manipulation either applied by fingertip or a computer-assisted solenoid adjusting device. What is most dramatic is the comparison shown with the surfactant dimethicone [Figure 4], which not only produced a considerably lesser effect from 5–10 days after the start of treatment, but showed worsening of symptoms as was apparent in 7 of the medicated group of patients. [189] While the effects of manipulation compared to a hand-held placebo group did not appear to differ statistically, a trend toward superiority in the numbers of patients affected is apparent. Furthermore, greater numbers of the manipulated group indicated "some" or "marked" improvement. [190] Other explanations as to why the latter study did not reveal a statistically significant effect in contrast to the former [in addition to their uses of different control groups] are the following: [i] the infant's mother was blinded; [ii] the former study required infants to cry for more than 3 hours for 5 of the previous 7 days rather than for 3 days per week in the previous 3 weeks; [iii] the intervention in the former study was slightly more intensive [3–5 adjustments over 14 days as opposed to 3 adjustments over 8 days]; and [iv] the latter study required two additional criteria for colic, which could have screened out individuals who displayed an enhanced response in the former investigation. A pilot randomized clinical trial suggested that the complete resolution of symptoms could be found in 93% of the subjects undergoing up to 6 treatment sessions over a 2-week period. [191] What remains unclear is whether Olafsdottir [190] adjusted areas of the spine that were different from the other two investigations, [189, 191] accounting for the differences in results.

TABLE 7:   SUMMARY OF LEADING OUTCOMES STUDIES INVOLVING
SPINAL MANIPULATION FOR MANAGING INFANTILE COLIC


AUTHOR
DESIGN
# SUBJ
AGE
INTERVENTION
OUTCOMES
RESULT
Wiberg [185] RTC
25
4–6 wk
F SMT Crying [hrs] 70% drop in 5 days
   
20
 
Dimethicone Crying [hrs] 20% drop in 5 days
Olasfdottir [190] RTC
32
3–9 wk
F SMT Symptom scale Improvement in 70%
   
24
 
Held 10 min Symptom scale Improvement in 60%
Mercer [191] RTC
15
0–8 wk
SMT Parent diary 93% resolved, 2 wk
   
15
 
Detuned ultrasound    
Klougart [192] Cohort
316
1–5 wk
F SMT Crying [hrs] 75% drop in 14 days
Leach [193] Case
2
6–9 wk
I SMT Crying [hrs] 50% drop after 1–4x

Legend:
F = Spinal manipulation applied with light fingertip pressure,
I = Instrument [PulStar FRAS Sense Technology, Inc.],
x = Number of treatments




While spinal manipulation is usually associated with the treatment of musculoskeletal disorders, these data create two possible interpretations. As indicated by Wiberg, [189] either spinal manipulation has been shown to be effective in the treatment of a visceral disorder or infantile colic is, in fact, a musculoskeletal disorder rather than the visceral condition it is assumed to be. In either case, these data provide a further basis to continue the use of spinal manipulation in treating specified pediatric conditions.

Supported by ONLY case studies at this writing, chiropractors have reported notable success in managing constipation in young children. As shown by Table 8, a wide variety of chiropractic interventions in children aged from 5 months to 8 years have resulted in significant improvements in this condition. [151, 194–196] Particularly noteworthy is the communication from Quist, which reports that the constipation which had plagued an 8-year old child since birth despite allopathic treatments with laxatives and high fluid and fiber intake was resolved after just 3 adjustments with massage. Bowel movements immediately became much more frequent and smaller and softer. After 8 more patient visits within a month, the patient was discharged and bowel function remained normal for at least 13 years after the completion of this course of care. [197]


TABLE 8:   SUMMARY OF CASE STUDIES INVOLVING
SPINAL MANIPULATION FOR MANAGING CONSTIPATION


AUTHOR
AGE
INTERVENTION
Hewitt [151]
7–month
Full-spine, cranial
Eriksen [194]
5–year
Grostic upper cervical
Marko [195]
10–month
Chiropractic biophysics
Quist [196]
8–year
Diversified [drop adjustments], massage



5.   Nocturnal Enuresis:

This condition has been described as having multifactorial origins. [197] It has been proposed that spinal joint dysfunction could disrupt the integration of somatic, spinal, parasympathetic and sympathetic nerve pathways–constituting a significant contribution to the patient's enuretic condition. Thus, a few clinical studies have appeared in the literature [198–200] and suggest that spinal manipulative therapy may play a role in managing this condition [Table 9].

While the majority of cases did not appear to respond in one of the studies, [199] it was felt that more information could have been obtained in the presence of a control group given a sham procedure in a randomized controlled trial. In that particular study, the manipulated group did indeed display a significant improvement over its own baseline values while the placebo group did not. However, the mean pre- to post-treatment night frequency group for the test group compared with that of the control group was not quite statistically significant at the 5% level. [199] A larger sample size would most likely have created a statistically robust difference between the groups. In addition, despite its minuscule n of 1 design, Gemmell's study displayed a time-series improvement following manipulation which defied the natural course of improvement. [200] The one trial that did indicate improvement utilized an adjusting technique developed at the Palmer College of Chiropractic. [201]


TABLE 9:   SUMMARY OF LEADING OUTCOMES STUDIES
INVOLVING SPINAL MANIPULATION FOR MANAGING NOCTURNAL ENURESIS


AUTHOR
DESIGN
# SUBJ
AGE
INTERVENTION
OUTCOMES
RESULT
Reed [198] RTC
31
8–11 yr
P SMT Wet nights/2 wk 16% < baseline
   
15
 
Sham   0% < basline
LeBoeuf [199] Cohort
171
4–15 yr
SMT Wet nights/wk 75% no response
Gemmell [200] Case
1
14 yr
T SMT Dry/damp/wet Trend to dryness

Legend:
P = Spinal manipulation, Palmer Package Adjusting Technique [201],
T = Spinal manipulation, Toggle Recoil,
Sham = Activator at nontension setting


6.   Asthma:

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The typical control of asthma by medication is primarily through antiinflammatory agents [inhaled steroids] or beta-2-agonists [bronchodilators], the last of which when used excessively may actually contribute to an increase of mortality and morbidity. [202] There has thus been a shift toward using anti-inflammatory agents; at the same time, questions have been raised as to whether alternative and less invasive means are available for controlling this condition.

Spinal manipulation has been proposed as an option primarily for two reasons. The first is that vertebral dysfunctions assumed to underlie chiropractic management could produce reflex irritations of the somatic and autonomic nervous system; second, from both a neurological and biomechanical point of view, chestwall function or bronchial airway tone and/or responsiveness might be expected to be adversely affected by such a lesion–leading to a increased risk for an asthmatic attack. [203] Reduction or elimination of these joint aberrations might thus be expected to reduce the incidence of asthmatic events.

A third and perhaps central element to keep in mind is the stress response in the asthmatic. In the attempt to maintain homeostasis, bronchial hyperresponsiveness is the defining characteristic in asthma. What has been ignored for too long until very recently in asthmatic research is the role of the endocrine system; in particular, glucocorticoid secretion from the adrenal cortex in response to adrenocorticoid secretion from the anterior lobe of the pituitary. The role of the adrenal secretions in stress was first described by Hans Selye in 1936, [204] the connection between stressful events and increased cortisol levels being subsequently described. [205–207] The role of the hypothalamic-pituitary-adrenal [HPA] axis as the means by which close communication is established between the central nervous system, the immune system, and hormones–and the means by which this is related to stress and chiropractic has been elegantly presented by Morgan [208] and is depicted in Figure 5A, while Figure 5B indicates in more detail how corticosteroids are produced. [209] The point of this discussion is that interventions which control stress may have a significant palliative effect in the management of asthma, with cortisol appearing to be an important marker.


In terms of actual asthma management, there are some indications from randomized clinical trials that such interventions as acupuncture, yoga, hypnosis, and relaxation are beneficial as adjunctive measures in the management of chronic asthma. [210] A particularly elegant study by Tiffany Field has demonstrated that two groups of asthmatic children, aged 4–8 and 9–16, displayed profound changes in pulmonary functions, attitude and behavior scores, and cortisol levels following massage as compared to a noncontact control group. No other treatments were applied in addition to massage, nor were nighttime symptoms evaluated. [211]

In addition to descriptive or anecdotal data which have reported a positive clinical effect of spinal manipulation for asthma, [212–213] two randomized clinical trials and a cohort study as shown in Table 10 offer qualified support for spinal manipulative therapy in the management of this condition. Lung function improvements per se may not be detectable, [214–215] but quality of life scores improved by 10–28%, led by activity scale changes. [215] The largest randomized clinical trial to date which is attempting to compare different manipulative techniques in the management of asthma is currently underway in Australia; although data on symptoms, quality of life and distress are forthcoming in this study, preliminary cortisol measurements indicate that with manipulation [as opposed to simply visiting the treatment center], levels do decrease. [158] Immunoglobulin A, on the other hand, appears to increase in patients attending chiropractic centers; [158] this result is particularly noteworthy in that transient deficiencies of mucosal and salivary IgA have been shown to lead to the development of bronchial hyperresponsiveness and asthma. [216]


TABLE 10:   SUMMARY OF LEADING OUTCOMES STUDIES
INVOLVING SPINAL MANIPULATION FOR MANAGING NOCTURNAL ENURESIS


AUTHOR
DESIGN
# SUBJ
AGE
INTERVENTION
OUTCOMES
RESULT
Balon [214] RCT
38
7–16 yr
D SMT +S PEF Small rise
   
42
 
Sham FEV No change
   
 
 
  QOL Improved
Bronfort [215] Cohort
22
6–17 yr
SMT Dr PEF N.S. change
   
12
 
  FEV N.S. change
   
 
 
  QOL Significant rise
   
 
 
  Severity Significant drop
   
 
 
  Symptoms No change
Ali [158] RTC
150
 
C AC  
   
 
 
c SF-36  
   
 
 
h DASS  
   
 
 
w Cortisol SMT decreases
   
 
 
  IgA Centers increases

Legend:
D = Spinal manipulation, Diversified,  
S = Soft tissue techniques
Dr = Spinal manipulation with drop table,  
PEF = Peak expiratory flow
FEV = Forced expiratory volume,  
QOL = Pediatric Quality of Life Questionnaire
C = Treatment at centers,  
c = Nontreatment at centers
h = Nontreatment at home,  
w = Nonsymptomatic patients at home
AQ = Asthma questionnaire,  
DASS = Depression and anxiety stress scale


The apparently negative study appearing in The New England Journal of Medicine, stating that "the addition of chiropractic spinal manipulation to usual medical care for four months had no effect on the control of childhood asthma," requires further comment. This statement was based upon the failure of active and sham manipulated patient groups aged 7 to 16 years to be differentiated in terms of their outcomes in both quality of life and airway function. What is indisputable is that there were major improvements from baseline to followup observed in each of the groups. [214] The problem arises when one considers what was actually done in the sham procedures. Prolonged applications to no less than 3 distinct anatomical areas [gluteal, scapular, cranial] to the patient were described. Admittedly, these were not high-velocity contact procedures, but this appears to obscure an important phenomenon. Two pieces of evidence strongly suggest that simple contact with patients through sham procedures may produce significant effects in terms of asthma relief. The first indicates that, with respect to the reflexive inhibition of the alpha-motoneuron pool in human subjects, sham and active manipulative procedures display little difference. This is to suggest that cutaneous receptors, muscle spindles, and joint mechanoreceptors individually or in concert are significantly affected by so-called sham procedures. [217] The second arises from the studies of Field [211] described above, in which low-force massage as opposed to no contact was sufficient to elicit a differential, beneficial response in overcoming asthma symptoms. This more than anything else should indicate that physical contact with the patient is sufficient to trigger a cascade of physiological changes, which Balon erroneously dismissed in the asthma study.

In this particular condition, the reader must take note that chiropractic extends beyond high-velocity, low amplitude adjustments. It encompasses a broad range of both high-velocity and low-force techniques together with ancillary procedures, many of which have obviously been embedded in the sham procedures described. In its attempt to craft a fastidious design, the Balon trial [214] appears to have missed the forest for the trees by attempting to portray the essence of chiropractic care as the lack of differentiation between the sham and manipulated experimental groups.


7.   Retrolisthesis and Scoliosis:

The outcomes for the chiropractic management of these next two sections is of such a preliminary nature that a discussion of the epidemiology of the conditions addressed [retrolisthesis/scoliosis and neurological disorders] has been omitted. As shown by Table 11, very few outcome studies have yet been conducted regarding scoliosis, the obstacles to designing a clinical trial comparing the natural progression of spinal curvature to that seen after a particular intervention being formidable.

Reductions in retrolisthesis were apparent among the 49 consecutive chiropractic patients sampled in Plaugher's investigations. After patients with spondylolisthesis were excluded, patients with retrolisthesis were identified by means of a marking procedure on radiographs of good quality, comparing the positions of the anterosuperior and posterosuperior corners of adjacent vertebral bodies. [218] While Lantz' cohort study did not yield apparent changes after intervention, [219] questions have been raised regarding its [i] inclusion/exclusion/exclusion criteria of patients, [ii] dropouts, [iii] changes in subgroups that may have been overlooked, and [iv] whether there was sufficient statistical power to draw the conclusions reported.

With regard to the subgroup question, a complex reanalysis of Lantz' data by Menke painted a substantially more optimistic picture of responsiveness to chiropractic treatment. Menke indicated that the ratio of patients who improved to those who worsened in their scoliosis was at least 2:1 for the milder curves of 1° , 3°, and 5° as measured by two methods [Risser-Fergusson and Cobb]. Neither the numbers of treatments nor their durationwere associated with improvement. A measure of curve compression–the number of segments below the curve apex–served as a possible indicator of success in that three or fewer intra-apex segments were associated with improvement in scoliosis. The initial Cobb angle as a clinical predictor was not supported. Improvements could be attributed to either a transient type of scoliosis resolving on its own or [more likely] a subgroup of patients actually responding to manipulation. [220]

While cessation of back pain in scoliotic patients has been reported in case studies involving older patients under chiropractic care, [221] this particular outcome is underresearched and has yet to be evaluated in children and adolescents. Also, we need to know whether the progression of curvature observed in scoliosis is to any extent retarded or halted by chiropractic intervention.


TABLE 11:   SUMMARY OF LEADING OUTCOMES STUDIES
INVOLVING SPINAL MANIPULATION FOR MANAGING SCOLIOSIS


AUTHOR
DESIGN
# SUBJ
AGE
INTERVENTION
OUTCOMES
RESULT
Plaugher [218] Case series
49
NS
G SMT Retrolisthesis 34% reduction
   
 
 
  Sacral base angle No change
   
 
 
  Cervical lordosis No change
   
 
 
  Cobb's angle No change
   
 
 
  Scapular base angle No change
Lantz [219] Cohort
42
6–12
D, G SMT Cobb's angle No change
   
 
 
Heel lifts    
   
 
 
Postural counseling    
   
 
 
Lifestyle counseling    

Legend:
G = Gonstead, D = Diversified


8.   Neurological Disorders: Epilepsy, Autism,
       and Attention Deficit/Hyperactivity Disorder:


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Given that the activation of neuronal receptors in the spine might lead to vagus nerve stimulation, known to have antiepileptic effects, [222] it is conceivable that spinal manipulation could limit seizure spread in a particular region of the brain. Numerous case reports of positive effect of manipulation abound in the literature, with one study indicating positive results in all 15 patients administered upper cervical manipulation, [223] and others pertaining to favorable outcomes in individual children in case studies. [224, 225]

A variety of encouraging responses of children with autism having undergone an assortment of manipulativeinterventions have also been reported. [226, 227] Finally, reversal of symptoms associated with attention-deficit hyperactivity have been reported from several children undergoing chiropractic adjustments, with or without nutritional supplements. [228, 229] While these are clearly harbingers to spur further, more rigorous research efforts, the reader must bear in mind that the level of evidence for these neurological disorders is at the present anecdotal only, nor are spinal manipulations yet indicated to replace current and more widely accepted means of treatment. The fact remains that observations such as these warrant further investigation rather than being categorically barred for childhood conditions which remain refractory to conventional medical treatment. It is only with closer investigation that particular strengths and limitations of any proposed healthcare intervention, including chiropractic healthcare, may be properly assessed.



C.   Positioning the Chiropractic Practitioner

1.   Physical Attributes and Applications:

To bring all this research information into today's setting, however, what is that chiropractors have to offer? To begin, in many locales, chiropractic care has been firmly established for children. Both the Kentuckiana and Oklahaven Center are dedicated treatment centers for children with a full spectrum of conditions. [230, 231]   In the Boston area, for example, a cross-sectional descriptive survey of 90 chiropractors revealed that each averaged 13 visits per week from children and adolescents, ranging from 1 to 3 visits weekly for each patient. An estimated 420,000 pediatric visits to chiropractors were made in the Boston area in 1998 at a cost of approximately $14M. [232] In Canada, a survey of 1200 practitioners reveals that almost all are to some degree involved in treating patients under the age of 18. [233]

Regarding musculoskeletal care, chiropractors have taken the offensive in counselling parents and schoolchildren on how to avoid the injuries caused by backpacks, as discussed above in Section IV.A.1. [234–236] The American Chiropractic Association, in particular, provides a checklist of items to assure that the best possible backpack is chosen for children and adolescents: [237]

In terms of preventive measures overall, a study of 88 Norwegian adolescents aged 14–16 has shown that low extension strength is strongly correlated with the development of low-back pain 3 years later. Thus, a preventive measure might be to encourage low-back strengthening exercises, but not activities which simply increase mobility. [238] A second investigation describes the presentation of 11 sessions on correct postural behaviors to a subgroup of 106 third-grade students, the remaining groups either educated on health related themes or receiving no related education at all. The postural behavior instructions included lifting and bending activities at the pupils' homes, classrooms, and physical education classes. In addition to demonstrating far superior posture habits, the experimental group at four years follow-up were found less likely to have developed back problems. [43]

Postural education efforts have been taken a step further with the release of a program in 2003 by Ronald Kirk of a program known as Straighten Up America. [239, 240] This public awareness effort seeks to:
(1) improve posture and function;
(2) to stabilize core musculature;
(3) to enhance spinal and neurological health; and
(4) to prevent spinal subluxations.

Straighten Up America has cooperated with the United States Bone and Joint Decade and is a 50th Anniversary Partner with Get America Moving, an initiative of the President's Council on Physical Fitness and Sports which observed its 50th anniversary in 2006. It maintains a public service website in conjunction with the Congress of Chiropractic State Associations and Life University. The lifestyle choices which it urges both children and adults to follow are shown in Figure 6, with specific exercises for children recommend directly on the program's website. [240]

Separate from posture and musculoskeletal problems is the entire issue of childhood obesity, known in studies in western industrial countries to be rapidly increasing. From 1984 to 1996–1997 to 2003, for instance, the prevalence of obesity in caucasian children in the United Kingdom aged 5–10 years has risen from 1.2% to 3.0% to 6.0%, while in girls it has jumped from 1.8% to 4.5% to 6.6%. [241] In the U.S. for children, the trend for overweight occurrence from 1988–1994 to 1999–2000 was 10.5% to 15.5% for 12–19 year olds, 11.3% to 15.3% for 6–11 year olds, and 7.2% to 10.4% for 2–5 year olds. [242] This trend has extended at least to China and Brazil as well. [243] The cardiovascular risk factors for obesity are well known, pertain directly to children, yet can be reversed with intervention, [244] for which chiropractors have been shown to be well-positioned. [245]

A variety of measures advocated by chiropractors and others which are commensurate with a preventive paradigm of health care rather than a disease-oriented one has been advocated in a recent journal publication from one of the chiropractic institutions. [245] It points out that children should not be dieting to reduce weight but rather should be directed to maintain their current weight with an increase of physical activity, as they are still in a growing stage. [246]


2.   Chiropractic Paradigms As Guiding Principles:

What is essential to keep in mind is that all these strategies for the practice of preventive health for children and adolescents are simply manifestations of what are widely regarded as the tenets of a paradigm of healthcare universally embraced by the chiropractic profession. It is distinctly different from the current disease-oriented model of healthcare which has been found to be lacking to the point of requiring an extensive overhaul if healthcare is to be adequately delivered to the world's population in the next century. [247, 248]

Traditional chiropractic has always viewed the patient as the center of healthcare, the patient's interest taking precedence over all. By influencing function through structure, [249] chiropractic care has embraced a multiplicity of elements identified as vitalism, holism, naturalism, humanism, conservatism, and rationalism. [250–252]   Essentially, the profession and the practitioner are positioned as taking a proactive position in healthcare, attempting to move closer to presumed causes of dysfunction and ill health and thus emphasizing preventive measures.

This orientation is perhaps best articulated by the paradigm adopted in 1996 by the Association of Chiropractic Colleges, designed to identify chiropractors on a course no less significant than the Hippocratic Oath does for allopathic medicine. The position of the drafting body of this document can be best understood by the following excerpt:

"Chiropractic is a health care discipline that emphasizes the inherent recuperative power of the body to heal itself without the use of drugs or surgery. The practice of chiropractic focuses on the relationship between structure [primarily the spine] ad function [as coordinated by the nervous system] and how that relationship affects the preservation and restoration of health. In addition, Doctors of Chiropractic recognize the value and responsibility of working in cooperation with other health care practitioners when in the best interest of the patient."

The chiropractic paradigm itself, as expressed by the ACC, includes:

Purpose:   The purpose of chiropractic is to optimize health.

Principle:   The body's innate recuperative power is affected by and integrated through the nervous system.

Practice:   The practice of chiropractic includes:
  • Establishing a diagnosis;

  • Facilitating neurological and biomechanical integrity through appropriate chiropractic care management; and "Promoting health". [253]



V.   SAFETY:

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The best documented reports indicate that the risk of serious events which result from chiropractic treatment range from 1 in 400,000 [254] to 1 in 5.85 million [255] cervical spine manipulations, with the risk of lumbar complications at 1 per 100 million manipulations. [256] For pediatric populations, the most comprehensive database to date comes from a comprehensive search of 8 major electronic databases including MEDLINE, AMED, and MANTIS from inception to June 2005. It identified a total of 14 cases attributable to intervention and an additional 20 cases related to delayed or missed diagnoses. [257] It is clear from these figures that the risk estimates for pediatric manipulations would be substantially below the 400 deaths per million attributable to the use of NSAID medications, [258] the 700 deaths per million occurring with spinal surgery, [259] the 40 deaths per million seen with venipuncture, [260] or the 13,500 deaths per million reported for appendectomies. [261]

The serious adverse events include subarachnoidal hemorrhage and/or paraplegia [10 cases] and such minor or moderate occurrences as headache or mid-back soreness. Since this was passive surveillance only, a more accurate prospective population-based active surveillance study is needed. [257] A variety of flaws found in this systematic review have compromised its validity to the extent that numerous rebuttals have been written. One such rebuttal [my own] has been provided in Appendix I



VI.   CONCLUDING REMARKS:

Issues regarding the controversies surrounding childhood vaccinations have been capably summarized elsewhere [262] and are beyond the scope of this discussion. The same situation applies to childhood birth trauma. [263] One matter worth mentioning is the recent demonstration that expanding, then removing the mercury preservative thimerosal from pediatric vaccines has been positively correlated with both the increase and then the decrease of both autism and speech disorders. [264]

Evidence from many different types of experimental designs [basic and clinical, the latter comprised of randomized controlled trials and cohort and case studies] has been emerging at a rapid rate over the past two decades and provides a promising basis with which to consider chiropractic management for such childhood conditions as otitis media, colic, enuresis, asthma, and various neurological disorders. Denial of this treatment represents no less than the suppression of important medical information (which in at least one state has been ruled to be a form of medical negligence [265]). Because the frequency of serious side effects associated with spinal manipulation has been reported to be exceedingly low, [258] our continued use and further inquiry into the more detailed aspects of this type of therapy does not appear to constitute any particular health risk to the patient–certainly not any greater and decidedly less than some of the medical side-effects presented in this discussion.

In our review of child healthcare based upon evidence, it is interesting to note that the dosage rates of medications in allopathic medicine for children are routinely calculated from body surface areas, merely representing scaled-down versions of the adult formularies. [266, 267] Direct evidence from outcome studies involving medications and children appears to be lacking. In striking contrast are the manipulative procedures given to children, which as Biedermann had stated at the beginning of this report are not at all simply proportional reductions of the techniques applied to adults. [31, 34] From the evidence at hand, therefore, excluding chiropractic management as a treatment option for infants and children would seem to egregiously violate the overarching principle of providing meaningful risk/benefit ratios of treatment alternatives to the patient, which should be the hallmark of any credible and viable medical practice.



Appendix I: Response To Systematic Review on Pediatric Safety

Safety issues surrounding spinal manipulation have received much attention in recent years. However, there has been very little discussion of this topic as it applies to pediatric patients. A new review recentty published in the journal Pediatrics [257] addresses this very concern, in what has been labelled as a “systematic review”. This is supposed to mean that all the published material In the medical journals been retrieved, with specific articles having passed certain criteria for their more intensive review and analysis.

Because this approach has not been previously followed for pediatric populations who have experienced spinal manipulation, this study pursues an important goal in today's world of assessing risks and benefits of all medical interventions. It also avoids a common limitation in reviews of this type, in that it embraces case and cohort studies which occur in live doctors' offices as well as clinical trials.

Described in the 13 papers accepted for review are 14 cases of direct adverse events following spinal manipulation. These include 9 cases of serious events [subarachnoidal hemorrhage and paraplegia], 2 moderately adverse events requiring medical attention [severe headache], and 3 minor occurrences [mid-back soreness]. Another 20 cases of indirect adverse events involved delayed diagnosis or the inappropriate provision of spinal manipulation for such serious medical conditions as meningitis or rhabdomyosarcoma.

It is both important and commendable that these events have been brought to light In Vohra's report. However, they must be viewed in the larger framework of three factors:

(1)   the total number of treatments administered to children;

(2)   the relative risks of medical procedures for the same conditions treated; and

(3)   the benefits of spinal manipulation in children which have been amply described in the research literature. Lacking these considerations, this review presents a distorted and one-sided assessment of pediatric spinal manipulation.


Unfortunately, the review by Vohra falls short of its goals in its pursuits:

So, the question remains whether the authors have truly accomplished their minimaI objective. Did they actually present an accurate and balanced assessment of the literature addressing the adverse events associated with spinal manipulation? The answer appears to be in the negative.

It is also not at all clear whether all the spinal manipulations described were in fact administered by qualified chiropractors, an important consideration when one considers the risks involved with individuals who have not received complete training in manipulating areas of the neck. Only when the following criteria are met will a truly “accurate and balanced” assessment of the scientific literature have been made:

None of these standards have been met by Vohra's review, such that it can only be greeted with extreme skepticism.



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Assessment of vagus nerve stimulation for epilepsy: Report of the Therapeutics and Technology Assessment.
Neurology 1997; 49(1): 293-297.

223   Pistolese RA.
Epilepsy and Seizure Disorders: A Review of Literature Relative to Chiropractic Care of Children
Journal of Manipulative and Physiological Therapeutics 2001; 24(3): 199-205.

224   Sandefur R, Adams E.
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Chiropractic Journal 1987; 24(12): 21-25.

225   Hyman CA.
Chiropractic adjustments and the reduction of petit mal seizures in a five-year old male: A case study.
Journal of Clinical Chiropractic Pediatrics 1996; 1(1): 28-32.

226   Langley CA.
Epileptic seizures, nocturnal enuresis, ADD.
Chiropractic Pediatrics 1994; 1: 22.

227   Aguilar AL, Grostic JD, Pfleger B.
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Journal of Clinical Chiropractic Pediatrics 2000; 5 (1): 293-304.

228   Giesen JM, Center DB, Leach RA.
An Evaluation of Chiropractic Manipulation as a Treatment of Hyperactivity in Children
Journal of Manipulative and Physiological Therapeutics 1989; 12 (5): 353-363.

229   Tanaka ST, Martin CJ, Thibodeau P.
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230   Barnes T.
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Journal of Chiropractic Humanities 1997; 7 (1): 18-22.

231   Oklahaven celebrates 40 years.
Dynamic Chiropractic September 2002; 20 (18).

232   Lee ACC, Li DH, Kemper KJ.
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Archives of Pediatrics and Adolescent Medicine 2000; 154 (4): 401-407.

233   Verhoef MJ, Papadopoulos C, Durant DL.
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Proceedings of the International Conference on Spinal Manipulation.
Vancouver, British Columbia, CANADA, July 16-19, 1998, pp. 147-149.

234   American Chiropractic Association.
Improper use of backpacks leads to chronic back pain
Journal of the American Chiropractic Association, 1999; 37: 1-2.

235   International Chiropractic Pediatric Association.
Backpacks...your child's spine is at stake
ICPA Newsletter November/December 1998, pp. 1-2.

236   Legg SJ.
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Ergonomics 1997; 40(8): 809-817.

237   http://www.acatoday.org. Downloaded 09/08/06.

238   Sjolie AN, Ljunggren AE.
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239   http://www.cocsa.org/pubs/resources/88_1958_12646.cfm. Downloaded 02/15/07.

240   http://www.straightupamerica.org. Downloaded 02/15/07.

241   Stamatakis, E, Primatesta P, Chinn S, Rona R, Falascheti E.
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242   Ogden CL, Flegal KM, Caroll MD, Johnson CL.
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243   Wang Y, Monteiro C, Popkin BM.
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244   Reinehr T, de Sousa G, Toschke AM, Andler W.
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American Journal of Clinical Nutrition 2006; 84 (3): 490-496.

245   Hall A.
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Topics in Clinical Chiropractic 2001; 8 (4): 8-11.

246   U.S. Department of Health and Human Services.
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247   Zerhouni E. Director of the National Institutes of Health, at the Harvard School of Public Health, April 14, 2005, quoted in the Boston Globe April 19, 2005, pp. D1, D4.

248   Institute of Medicine.
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Washingon, DC: National Academy Press, 2001.

249   Phillips RB, Mootz RD.
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250   Coulter ID,
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Journal of Manipulative and Physiological Therapeutics 1993; 16(5): 319-326.

251   Jamison JR.
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Chiropractic Journal of Australia 1993; 23: 136-140.

252   Phillips RB, Gatterman MI.
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253   The ACC chiropractic paradigm.
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254   Dvorak J, Orelli F.
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Manual Medicine 1985; 2: 1-4.

255   Haldeman S, Carey P, Townsend M, Papadopoulos C.
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Canadian Medical Association Journal 2001; 165(7): 905-906.

256   Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Brook RH.
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Annals of Internal Medicine 1992; 117: 590-598.

257   Vohra S, Johnston BC, Cramer K, Humphreys K.
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258   Dabbs V, Lauretti W.
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Journal of Manipulative and Physiological Therapeutics 1995; 18 (8): 530-536.

259   Deyo RA, Cherkin DC, Loesser JD, Bigos SJ, Ciol MA.
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260   Horwowitz SH.
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Neurology 1994; 44: 962-964.

261   Stremple JS, Boss DS, Davis CH, McDonald GO.
Comparison of post-operative mortality and morbidity in Veterans Affairs and nonfederal hospitals.
Journal of Surgical Research 1994; S6: 4-50416.

262   Colley F, Haas M.
Attitudes on immunizations: A survey of American chiropractors.
Journal of Manipulative and Physiological Therapeutics 1994; 17 (9): 584-590.

263   Forrester JA, Anrig CA.
The prenatal and perinatal period.
In Anrig C, Plauger G [eds], Pediatric Chiropractic. Baltimore, MD: Williams & Wilkins, 1998, pp. 152-160.

264   Geier DA, Geier MR.
Early downward trends in neurodevelopmental disorders following removal of
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Journal of American Physicians and Surgeons 2006; 11 (1): 8-13.

265   Jean Matthies v. Edward D. Mastromonaco, D.O.
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266   Lack JA, Stuart-Taylor ME.
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British Journal of Anaesthesiology 1997; 78 (5): 601-605.

267   Wildhaber JH, Monkhoff M, Sennhauser FH.
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Journal of Pediatric and Child Health 2002; 38 (2): 115-116




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