J Can Chiropr Assoc. 2016 (Sep); 60 (3): 212–219 ~ FULL TEXT
Jocelyn Cox, BPhEd, DC,
Christine Davidian, DC, MSc,
Silvano Mior, DC, FCCS, PhD
Graduate Education and Research Department
of Canadian Memorial Chiropractic College
Introduction: Spinal pain in the pediatric population is a significant health issue, with an increasing prevalence as they age. pediatric patients attend for chiropractor care for spinal pain, yet, there is a paucity of quality evidence to guide the practitioner with respect to appropriate care planning.
Methods: A retrospective chart review was used to describe chiropractic management of pediatric neck pain. Two researchers abstracted data from 50 clinical files that met inclusion criteria from a general practice chiropractic office in the Greater Toronto Area, Canada. Data were entered into SPSS 15 and descriptively analyzed.
Results: Fifty pediatric neck pain patient files were analysed. Patients’ age ranged between 6 and 18 years (mean 13 years). Most (98%) were diagnosed with Grade I–II mechanical neck pain. Treatment frequency averaged 5 visits over 19 days; with spinal manipulative therapy used in 96% of patients. Significant improvement was recorded in 96% of the files. No adverse events were documented.
Conclusion: pediatric mechanical neck pain appears to be successfully managed by chiropractic care. Spinal manipulative therapy appears to benefit pediatric mechanical neck pain resulting from day-today activities with no reported serious adverse events. Results can be used to inform clinical trials assessing effectiveness of manual therapy in managing pediatric mechanical neck pain.
Key words: chiropractic, neck pain, pediatric, spinal manipulative therapy, case series
From the Full-Text Article:
Spinal pain is common amongst the pediatric population (including children and adolescents). It is a significant health issue [1, 2], where 52% of pediatric patients report musculoskeletal (MSK) symptoms over a one-year period.  Neck pain is the most common spinal pain in pediatric patients [3, 4] with 60% reporting neck pain persisting at two years after this study began.  A survey of Finnish school children reported neck pain experienced at least once during the week. 
Children with neck pain seek complementary and alternative medicine (CAM) interventions, of which the most common is chiropractic care. [2, 6, 7] pediatric patients comprise between about 8% and 13% of a chiropractor’s practice. [7–10] A recent National Institute of Health report suggested that 3.3% of children in the United States (1.9 million) saw a chiropractor or osteopath between 2002 and 2007.  Although surveys report pediatric patients visit chiropractors, little is known why they visit, how often, and whether or not there is a favourable response.
In addition to these unknown variables, there is also a paucity of evidence of effectiveness of spinal manipulative therapy (SMT) in the management of musculoskeletal (MSK) pain in children; what evidence is available is of low quality.  This is important to note, as SMT is one of the tools chiropractors use to address and manage MSK complaints. Currently the only standard of treatment for children with MSK pain can be found in a recent consensus-based clinical practice guideline.  Unfortunately, due to lack of available quality evidence of treatment effectiveness, consensus led to a generic recommendation of using a therapeutic trial within an evidence based framework. Similarly, systematic reviews [14, 15] have reported that much of the evidence into MSK care for the pediatric population is limited due to insufficient sample size, research design and expert opinion.
Much of the evidence on pediatric care for MSK neck pain is exploratory, relying on single case studies and expert opinion. [14–16] Exploratory studies within the IDEAL framework  can be used to help identify appropriate trial design and feasibility.  They can set the stage for explanatory studies that assess effectiveness, quality assurance and safety of an intervention. [18, 19] Given the infancy of the research regarding the management of pediatric neck pain , foundational work is required to inform the future design for more robust explanatory studies, e.g. randomized controlled trials. The IDEAL framework provides a guide to inform research when there are gaps in knowledge.  This paper aims to contribute to the exploratory stage of the IDEAL framework by documenting the clinical presentation and outcomes of pediatric patients presenting with neck pain to a chiropractic office.
This study was granted ethics approval by the Institution’s
Research Ethics Board. We conducted a retrospective patient
chart review. Patient charts were included if
(i) the patient was between 6–18 years,
(ii) had a chief complaint of neck pain, and
(iii) received treatment (See Table 1).
The first episode of neck pain in the file was selected for
data abstraction. Neck pain was defined as pain originating
from musculoskeletal tissues in the region from the
occiput to the first thoracic vertebrae. Minor injury was
described as mild to moderate limitation in physical activity
of mechanical origin, i.e. sport participation, roughhousing,
motor vehicle collisions, or falls. The definition
of Grade I and Grade II mechanical neck pain was adopted
from the Neck Pain Task Force.  It did not include
primary complaints of headaches, shoulder or arm pain;
however, subjects with secondary headaches to neck pain
were included. Clinical files were sequentially drawn in
alphabetical order and the first 50 patient charts meeting
our inclusion criteria were selected for review.
Two researchers abstracted records from a general
practice chiropractic clinic in the Greater Toronto Area,
Canada. The office had three practicing chiropractors. The
data were collected using a standardized intake form. The
intake form was adapted from a similar form previously
used for abstraction in a low back pain study,  though
it was not validated for neck pain. The intake form was
revised by changing related low back pain references to
neck pain, including location and examination protocols.
Revisions were reviewed for content validity.  The data
intake forms included patient demographics, information
regarding the history and examination, the diagnosis, the
treatment(s) used and the outcome of care (see Table 2).
Any discrepancy in the coding of information was
dealt with by consensus of the two researchers. If consensus
could not be reached, then the senior author (SM)
made the final decision. Treatment was considered complete
when a patient presented on two consecutive visits
with no reported complaint of neck pain or was deemed
recovered and discharged from care.
All patient information was coded to prevent any direct
identification, thus ensuring confidentiality of the patient
records. Information linking the patient ID number and
their file was recorded in a reference booklet and stored in
a locked cabinet in the practitioners’ office. Once all data
had been entered and checked for accuracy, the booklet
All data were entered into an Excel spreadsheet, and
later exported into SPSS Version 15 for statistical analysis.
Data were descriptively analysed.
The age range of the patients was 6 to 18 years, with a
mean age of 13 years. There was an equal distribution of
males and females. The majority of patient referrals were
from parents, with few from other sources [chiropractor
(2%), medical doctor (2%), or other (8%)]. The source
of referral was not reported in 70% of subjects. Most patients
presented with acute pain following a minor injury.
The character of the pain was commonly described as
localized sharp/stabbing in 46%, dull/achy in 20%, and
without specific description in 34% of cases. Associated
referred pain was reported in 30% of patients either to
the head (10%), upper back (10%), or one or both arms
(10%). Headaches were reported in 58% (See Table 3).
First incidence of neck pain was reported in 64% of
cases. Prior neck complaints were present in 28% of patients,
while no data were available for 8%. Only 14%
of patients reported previously receiving SMT. Plain film
imaging was reported in 12% of charts. About 30% reported
receiving prior treatment for their neck pain (e.g.
analgesics, muscle relaxants, and bed rest) with no reported
Examination findings were positive for primarily Grade
I or Grade II mechanical neck pain (i.e. joint restrictions
with localized tenderness on palpation of the facet or apophyseal
joints of the neck with no distal radiation) (See
Table 3). The most frequently reported level of painful
dysfunction was the mid-cervical spine (C4–C6) (56%).
Associated muscle tenderness on palpation was primarily
found in the cervical paraspinal muscles (70%) and trapezius
(56%). Ranges of motion were visually assessed to
be mildly to moderately reduced in all directions. Neurological
examination was unremarkable, except in one
case where unilateral diminished biceps reflex was found
and attributed to a previous upper limb surgery.
The most common treatment provided was manual
therapy (see Table 4). SMT provided was high-velocity,
low-amplitude thrust manipulation, delivered supine with
a rotary thrust directed at the painful segments. The most
common form of adjunctive therapy was soft tissue therapy
(STT), followed by the use of passive modalities.
The average number of patient visits was 5 (sd=3) with
a range between 1 and 15 and a median of 3 visits. The
patient visits were distributed over a range of 2 to 80 days,
with the average being 19 days (±15 days, median 17).
In 96% of cases, patients were discharged after self-reporting
feeling very much improved or deemed recovered
by the chiropractor. There was no recorded worsening of
symptoms nor adverse events
In our study, the typical patient was 13 years old and presented
with acute neck pain with associated headaches due to minor injury. This age range is similar to that reported
in other studies where spinal pain was common
amongst those between the ages of 11 and 15 years. 
frequency of reported headaches was interesting but consistent
with findings of a cross-sectional study of Swedish
preadolescents.  About 54% of these cases reported minor,
unintentional childhood injuries.
Children typically sustain unintentional childhood injuries
in their daily lives while developing, learning and
growing (e.g. riding a bicycle, running and playing, participating
in sports).  It is not uncommon for a child to
experience pain after a fall and then to not perceive such
an incident as an injury. Despite neck pain being attributed
to an injury, this association may not necessarily be
causal as suggested in an observational study by Hellstenius
et al. , wherein no significant relationship was
found between occurrence of trauma and neck pain and/or
headaches. A similar conclusion was reported in another
study that identified only 3% (9 of 264) of adolescents
with neck pain had a previous injury to the neck. 
In our study, examination findings were generally considered
to be uncomplicated and mechanical in nature.
The most frequent examination findings suggested localized,
painful intersegmental joint movement restrictions
and muscle tenderness on palpation. Although ranges of
motion were visually assessed, we did not consider this a
concern given that visual assessment has been reported to
be reliable and valid when quantifying ranges of motion. 
The most commonly reported level of cervical joint pain
was the middle cervical region; unlike Hellstenius et al. 
who indicated the upper cervical region was more commonly
reported. In consideration of the uncomplicated nature
of the pain, imaging amongst our sample was uncommon
(12%).  Such a low rate suggests radiographs are not
as commonly requisitioned in children as in adults. 
We found that chiropractic treatment primarily included
SMT and STT, along with patient education and
home exercises. The SMT performed was a supine rotary
cervical and was most commonly directed at the painful
joint restrictions. This appears to be consistent with other
pediatric practices.  Follow-up with study chiropractors
suggested that modulated manipulative forces were used
during the treatment (personal communication). Such
modulation is in agreement with Best Practice Guidelines
that suggest forces and loads used during SMT be relative
to the patient’s size and modified to address the development
of the immature skeleton. [27, 28] Similar conclusions
were noted in a survey where the majority of chiropractors
reported modifying their therapeutic techniques for
We found relatively few treatments were provided for
an episode of care. The average frequency of visits was
five over the course of 19 days. Of these patients, 96%
reported a favourable outcome. A similar frequency was
reported by Marchand (2012), who found the length of
treatment varied by patient age and condition treated;
however, for those between 13 and 18 years, the average
number of treatments was 4.6 for neck pain.  For
context, Hurwitz et al.’s  retrospective analysis of chiropractic
treatments for neck pain and headaches for adults
reported the average number of visits for adults with neck
pain, per episode of care was 10 visits (median 6 days).
Another study suggests that adults improved in pain after
three weeks of treatments.  Based on our work, children
with neck pain appear to respond favourably and quickly
to chiropractic care.
There were no adverse events recorded in the patient
charts. While minor adverse events such as transient increased
soreness are commonly reported after manual
therapy , serious adverse events are exceedingly rare.
One study reported nine adverse events published in the
literature over 100 years of publications32, of which six were related to delayed or mis-diagnosis, rather than to
the intervention. Studies exploring the safety profile of
chiropractic care (spinal manipulation, soft tissue therapy,
passive modalities, exercise, and education) have reported
minimal risk in the management of musculoskeletal complaints. [13, 28, 33–35]
Our study supports findings in other studies that have
found the majority of pediatric patients are referred to
CAM providers by parents  but few are referred by physicians. 
This may be due to the strongest predictor of the
use of complementary health approaches by children is
use by their parents  or it may be due to medical physicians
being hesitant to refer to a chiropractor.  Such
hesitation may be related to limited exposure to the roles
and understanding of the requirements and indications
for chiropractic care. [40, 41] Results from exploratory studies
may provide preliminary evidence supporting the use of
chiropractic care in the management of common pediatric
MSK conditions to help support the role of interprofessional
There are a number of limitations of our study. The
study is a retrospective case series that has inherent design
limitations , including small sample size, subjective
coding, relying on documented findings, inability to collect
missing/unreported data, and no randomization nor
blinding. However, the results can help inform inclusion,
frequency and duration of care, and outcome criteria for
future explanatory studies. Further, the assessment of patient
self-rated improvement was subjective, including
the use of terms ‘better’ and ‘much improved’. The term
‘better’ implied recovery but was not pre-defined; however,
we considered it a reasonable proxy given patient
discharge and evidence of clinical improvement. Asking
patients to self-rate their recovery is increasingly being
used as a valid and reliable measure of their progress. 
We are also aware that low quality studies tend to present
an overly optimistic view of effectiveness compared to
larger assessment and evaluation studies. [44, 45] Furthermore,
given no control group, the results may have been
due to the placebo effect, therefore more rigorous studies
are needed. Finally, we did not track the total number of
files reviewed during abstraction, thus we’re unable to estimate
the percentage of files searched in order to achieve
our total sample.
This study provides exploratory data suggesting mechanical
neck pain in pediatric patients responds favourably
and quickly to chiropractic care. It also provides a
developmental frame from which to progress the field of
pediatric MSK pain management research. Our data can
be used to design more robust controlled trials providing
more realistic measures of the effectiveness of SMT in the
management of neck pain in pediatric patients.
In our study, 50 pediatric patients between 6 and 18 years
(average 13 years) were found to have evidence of mechanical
neck pain. Treatment was provided on average of
5 visits over an average of 19 days. These patients were
successfully managed primarily using SMT. There were
no worsening of symptoms nor adverse events recorded.
This exploratory study provides data to help inform
the role, indication and dose of manual therapy in the
management of pediatric mechanical neck pain. It highlights
a treatment option with minimal risk and reported
successful pain management for a commonly experienced
MSK condition by many pediatric patients. The results
can be used in designing more robust explanatory studies.
Jeffries LJ, Milanese SF, Grimmer-Somers KA.
Epidemiology of adolescent spinal pain: a systematic overview of the research literature.
Spine. 2007;32(23): 2630–2637.
Ndetan, H, Evans, MW, Hawk, C, and Walker, C.
Chiropractic or Osteopathic Manipulation for Children in the United States:
An Analysis of Data from the 2007 National Health Interview Survey
J Altern Complement Med. 2012 (Apr); 18 (4): 347–353
Mikkelsson M, Salminen JJ, Kautiainen H.
Non-specific musculoskeletal pain in preadolescents. Prevalence and 1-year persistence.
Pain. 1997; 73:29–35.
El-Metwally A, Salminen JJ, Auvinen A, Macfarlane G,
Risk factors for development of nonspecific musculoskeletal pain in preteens and early adolscents: a prospective 1-year follow-up study.
BMC Musculoskeletal Disord. 2007;8:46.
Aartun E, Hartvigsen J, Wedderkopp N, Hestbaek L.
Spinal Pain in Adolescents: Prevalence, Incidence, and Course: A School-based
Two-year Prospective Cohort Study in 1,300 Danes Aged 11-13
BMC Musculoskelet Disord. 2014 (May 29); 15: 187
Spiggelblatt L, Liane-Ammara G, Pless B, Guyver A.
The use of alternative medicine by children.
Kemper KJ, Vohra S, Walls R.
The use of complementary and alternative medicine in pediatrics.
Hawk C, Long CR, Boulanger KT.
Prevalence of Nonmusculoskeletal Complaints
in Chiropractic Practice:
Report From a Practice-based Research Program
J Manipulative Physiol Ther 2001; 24 (3) March: 157–169
Waalen JK, Mior SA.
Practice patterns of 692 Ontario chiropractors.
J Can Chiropr Assoc. 2005;49(1):21.
Chiropractic Care of Children from Birth to Adolescence
and Classification of
Reported Conditions: An Internet Cross-Sectional Survey of
956 European Chiropractors
J Manipulative Physiol Ther. 2012 (Jun); 35 (5): 372–380
Clarke TC, Black LI, Stussman BJ, Barnes PM, Nahin RL.
Use of Complementary Health Approaches Among
Children Aged 4–17 Years
in the United States: National Health Interview Survey, 2007–2012
National Health Statistics Report 2015 (Feb 10); (78): 1–19
Hestbaek L, Stochkendahl MJ.
The Evidence Base for Chiropractic Treatment of Musculoskeletal Conditions
in Children and Adolescents: The Emperor's New Suit?
Chiropractic & Osteopathy 2010 (Jun 2); 18: 15
Hawk C, Schneider MJ, Vallone S, Hewitt EG.
Best Practices for Chiropractic Care of Children:
A Consensus Update
J Manipulative Physiol Ther. 2016 (Mar); 39 (3): 158–168
Hill JJ, Keating JL.
A systematic review of the incidence and prevalence of low back pain in children.
Phys Ther Rev. 2009;14(4): 272–284.
Hill JJ, Keating JL.
Risk factors for the first episode of low back pain in children are infrequently validated across samples and conditions: a systematic review.
J Physiol. 2010;56:237–244.
Gleberzon BJ, Arts J, Mei A, McManus EL.
The Use of Spinal Manipulative Therapy For Pediatric
A Systematic Review of the Literature
J Can Chiropr Assoc. 2012 (Jun); 56 (2): 128–141
A Call to the IDEAL.
J Can Chiropractic Assoc. 2010; 53(3).
McCulloch P, Cook JA, Altman DG, Heneghan C.
IDEAL Framework for surgical innovation 1: The idea and development stages.
Brit Med J. 2013;346:f3012.
Ergina PL, Barkun JS, McCulloch P, Cook JA, Altman DG.
IDEAL Framework for surgical innovation 2: observational studies in the exploration and assessment stages.
Brit Med J. 2013; 346:f3011.
Guzman J, Hurwitz EL, Carroll LJ, Haldeman S, Côté P, Carragee EJ.
A New Conceptual Model Of Neck Pain:
Linking Onset, Course, And Care
J Manipulative Physiol Ther. 2009 (Feb); 32 (2 Suppl): S17–28
Shekelle PG, Coulter I, Hurwitz EL, Genovese B, Adams AH.
Congruence Between Decisions To Initiate Chiropractic Spinal Manipulation
for Low Back Pain and Appropriateness Criteria in North America
Annals of Internal Medicine 1998 (Jul 1); 129 (1): 9–17
Mokkink LB, Terwee CB, Patrick DL, Alonso J, Stratford PW.
The COSMIN study reached international consensus on taxonomy, terminology, and definitions of measurement properties for healthrelated patient-reported outcomes.
J Clin Epidemiol. 2010;63:737–745.
Weber Hellstenius SA (2009)
Recurrent Neck Pain and Headaches in Preadolescents Associated with Mechanical Dysfunction
he Cervical Spine: A Cross-Sectional Observational Study With 131 Students
J Manipulative Physiol Ther 2009 (Oct); 32 (8): 625—634
World Health Organization.
Unintentional Childhood Injuries. WHO Training Package for the Health Sector. 2010.
Lee AC, Li DH, Kemper KJ.
Chiropractic Care for Children?
Arch Pediatr Adolesc Med 2000 (Apr); 154 (4): 401–407
Pohlman KA, Hondras MA, Long CR, Haan AG.
Practice Patterns of Doctors of Chiropractic
With a Pediatric Diplomate:
A Cross-sectional Survey
BMC Complement Altern Med. 2010 (Jun 14); 10: 26
Hawk C, Schneider M, Ferrance RJ, Hewitt E, Van Loon M.
Best Practices Recommendations for Chiropractic Care
for Infants, Children,
and Adolescents: Results of a Consensus Process
J Manipulative Physiol Ther. 2009 (Oct); 32 (8): 639–647
A literature review of pediatric spinal manipulation and chiropractic manipulative therapy: evaluation of consistent use of safe terminology.
J Manipulative Physiol Ther. 2012;1–7.
Hurwitz EL, Coulter ID, Adams AH, et al.
Use of chiropractic services from 1985 through 1991 in the United States and Canada.
Am J Public Health. 1998; 88:771–776.
Hurwitz EL, Morgenstern H, Harber P, Kominski GF, Yu F.
A randomized control trial of chiropractic manupulation and mobilization for patients with neck pain: clinical outcomes from the UCLA Neck-pain study.
Am J Public Health. 2002; 92(10):1634–1641.
Carnes D, Mars TS, Mullinger B, Froud R, Underwood M.
Adverse events and manual therapy: a systematic review.
Manual Therapy. 2010;15(4):355–363.
Vohra, S, Johnston, BC, Cramer, K, and Humphreys, K.
Adverse Events Associated with Pediatric Spinal Manipulation: A Systematic Review
Pediatrics. 2007 (Jan); 119 (1): e275–e283
Dagenais S, Gay RE, Tricco AC, Freeman MD, Mayer JM.
NASS Contemporary Concepts in Spine Care:
Spinal Manipulation Therapy for Acute Low Back Pain
Spine J. 2010 (Oct); 10 (10): 918–40
Carlesso LC, Gross AR, Santaguida PL, Burnie S.
Adverse events associated with the use of cervical manipulation and mobilization for the treatment of neck pain in adults: a systematic review.
Man Ther. 2010;15:434–444.
Adverse Effects of Spinal Manipulative Therapy in Children
Than 3 Years: A Retrospective Study in a Chiropractic Teaching Clinic
J Manipulative Physiol Ther 2008 (Jul); 31 (6): 419–423
Hayden JA, Mior SA, Verhoef MJ.
Evaluation of Chiropractic Management of Pediatric Patients with
Low Back Pain: A Prospective Cohort Study
J Manipulative Physiol Ther 2003 (Jan); 26 (1): 1–8
Hestbaek L, Jorgensen A Hartvigsen J.
A Description of Children and Adolescents in Danish
Results from a Nationwide Survey
J Manipulative Physiol Ther. 2009 (Oct); 32 (8): 607–615
Black LI, Clarke TC, Barnes PM, Stussman BJ, Nahin RL.
Use of Complementary Health Approaches Among
Children Aged 4–17
Years in the United States: National Health Interview Survey, 2007–2012
National Health Statistics Report 2015 (Feb 10); (78): 1–19
Allareddy V, Greene BR, Smith M, Haas M, Liao J.
Facilitators and barriers to improving interprofessional referral relationships between primary care physicians and chiropractors.
J Ambul Care Manage. 2007; 30(4): 347–354.
Wong JJ, DiLoreto L, Kara A, Yu K, Mattia A et al.
Assessing the attitudes, knowledge and perspectives of medical students to chiropractic.
J Chiropr Educ. 2013; 28(2):112–122.
Wong LY, Toh M, Kong KH.
Barriers to patient referral for complementary and alternative medicines and its implications on interventions.
Complementary Therap Medicine. 2010;18(3):135–142.
Retrospective case studies and chart reviews.
Respir Care. 2004;49(10):1171–1174.
Ngo T, Stupar M, Cote P, Boyle E, Shearer H.
A study of the test–retest reliability of the self-perceived general recovery and self-perceived change in neck pain questions in patients with recent whiplash-associated disorders.
Eur Spine J. 2010;19(6):957–962.
Hempel S, Miles J, Suttorp MJ, Wang Z, Johnsen B et al.
Detection of associations between trial quality and effect sizes [Internet].
Rockville (MD): Agency for Healthcare Research and Quality (US); 2012.
Craig P, Dieppe P, MacIntyre S, Michie S, Nazareth I
Developing and evaluating complex interventions: the new Medical Research Council guidance.
Brit Med J. 2008;337:a1655.
Return to the PEDIATRICS Section