J Altern Complement Med. 2017 (Dec 20) [Epub] ~ FULL TEXT
Joel Alcantara, DC, Andrea E. Lamont, PhD, Jeanne Ohm, DC, and Junjoe Alcantara, DC
The International Chiropractic Pediatric Association,
327N Middletown Road
Media, PA 610-565-2360
OBJECTIVES: To characterize pediatric chiropractic and assess pediatric quality of life (QoL).
DESIGN: A prospective cohort. Setting/Locations: Individual offices within a practice-based research network located throughout the United States.
SUBJECTS: A convenience sample of children (8-17 years) under chiropractic care and their parents.
EXPOSURE: Chiropractic spinal adjustments and adjunctive therapies.
OUTCOME MEASURES: Survey instrument measuring sociodemographic information and correlates from the clinical encounter along with the Patient Reported Outcomes Measurement Information System (PROMIS)-25 to measure QoL (i.e., depression, anxiety, and pain interference). Sociodemographic and clinical correlates were analyzed using descriptive statistics (i.e., frequencies/percentages, means, and standard deviations). The PROMIS-25 data were analyzed using scoring manuals, converting raw scores to T score metric (mean = 50; SD = 10). A generalized linear mixed model was utilized to examine covariates (i.e., sex, number of visits, and motivation for care) that may have played an important role on the PROMIS outcome.
RESULTS: The original data set consisted of 915 parent-child dyads. After data cleaning, a total of 881 parents (747 females, 134 males; mean age = 42.03 years) and 881 children (467 females and 414 males; mean age = 12.49 years) comprised this study population. The parents were highly educated and presented their child for mainly wellness care. The mean number of days and patient visits from baseline to comparative QoL measures was 38.12 days and 2.74 (SD = 2.61), respectively. After controlling for the effects of motivation for care, patient visits, duration of complaint, sex, and pain rating, significant differences were observed in the probability of experiencing problems (vs. no reported problems) across all QoL domains (Wald = 82.897, df = 4, p < 0.05). Post hoc comparisons demonstrated the children were less likely to report any symptoms of depression (Wald = 6.1474, df = 1, p < 0.05), anxiety (Wald = 20.603, df = 1, p < 0.05), fatigue (Wald = 22.191, df = 1, p < 0.05), and pain interference (Wald = 47.422, df = 1, p < 0.05) after a trial of chiropractic care.
CONCLUSIONS: The QoL of children improved with chiropractic care as measured by PROMIS.
KEYWORDS: chiropractic; pediatrics; prospective study
From the FULL TEXT Article:
Complementary and alternative medicine (CAM)
use in the pediatric population continues to remain
popular, particularly for children living with chronic and
recurrent conditions.  In 2000, Lee et al.  published the first
characterization of the chiropractic care of children based on
a survey of Boston chiropractors. The investigators extrapolated
that *30 million pediatric visits were made to chiropractors
annually in the United States. They estimated the
total cost for care at $1 billion with costs split approximately
in half between third-party payers and families paying directly
out-of-pocket. In 2010, Alcantara et al.  published a
more comprehensive characterization of pediatric chiropractic
using a practice-based research network (PBRN).
Using calculations similar to Lee et al.,  these investigators
approximated 86 million pediatric visits were made annually
to chiropractors in 2007, leading Alcantara et al.  to conclude
that the chiropractic care of children represents a significant
aspect of not only the practice of chiropractic but also pediatric
healthcare in general. Indeed, of the various practitioner-based
CAM therapies, chiropractic has been found to be popular. [4–6]
The treatment of musculoskeletal disorders such as neck pain
and lowback pain  as well as the promotion of health and wellbeing [8, 9] has been reported to be common motivations for
seeking chiropractic care of children. However, studies that
evaluated the frequency of, reasons for, and factors influencing
CAM use and specialty pediatrics within the same geographic
locale have also found evidence of the utilization of chiropractic
care for children with chronic disease, including cancer, [10, 11] gastrointestinal disorders,  cardiac problems,  and
neurological  problems.
In this era of evidence-informed practice, there is a need
by all healthcare providers to document and demonstrate
safety and effectiveness. No more is this true than in the care
of infants and children. Despite the popularity and high
utilization of chiropractic by the pediatric population, to the
best of the authors knowledge, no study has examined the
quality of life (QoL) of children under this paradigm of care.
To address this deficit, the QoL of children under chiropractic
care in a PBRN was examined, regardless of coexisting
medical impairment or concurrent medical care.
study has two purposes:
(1) to understand the utilization of
patterns of pediatric populations who receive chiropractic
(2) to understand how QoL changed in a population
of children who self-select into chiropractic care.
This study was approved by the Ethics Review Board of
Life University (Marietta, GA) and uses a convenience
sample of practicing chiropractic physicians and a normative
sample of children naturally receiving care from these
doctors. Doctors of chiropractic (DCs) (N = 280) enrolled in
a postgraduate course in pediatric chiropractic were invited
to participate in a QoL study of children under chiropractic
care (i.e., spinal adjustments and adjunctive therapies). In
addition to direct involvement in the care of children, inclusion
criteria for DC participation in this PBRN have
previously been described. [3, 8, 15] The participating DCs were
encouraged to invite parents and their children under chiropractic
care as respondents for this study.
Parent and child
inclusion criteria for participation were
(1) the parents provided consent and children (i.e., age 8–17 years) provided assent,
(2) the children were currently under chiropractic care, and
(3) both parent and child have the ability to speak and read English.
Exclusion criteria included
(1) lack of consent or assent and
(2) the child has a coexisting medical, psychiatric, or cognitive impairment(s) that presented
a contraindication to chiropractic care or their ability to comprehend the survey instruments.
Parent responders in this study provided sociodemographic
information for themselves (i.e., age, gender,
level of education, and experience with chiropractic care)
and their child (i.e., age and gender). In addition, clinical
correlates/covariates of the history and physical examination
were examined (i.e., motivation for care or presenting complaints,
medical care, visits to the Emergency Room, and
effectiveness of medical care).
For the pediatric responders, the Patient Reported Outcomes
Measurement Information System or PROMIS was
utilized for this purpose. PROMIS was a National Institutes
of Health initiative to create patient reported outcomes
(PROs) to assess domains of physical, psychological, and
social health, and QoL.  The PROMIS instruments were
developed using rigorous qualitative and quantitative methods  and standardized to a reference population.  To date,
the pediatric PROMIS instruments have been implemented in
various pediatric populations, including those with cleft lip
palate,  systemic lupus erythematosus,  cancer,  obesity, 
asthma,  Crohn’s disease,  and nephrotic syndrome. 
The instrument is a 25–item survey consisting of a fixed
collection of short forms for physical functioning mobility,
anxiety, depressive symptoms, fatigue, peer relationships,
pain interference, and pain based on a numeric rating scale
(NRS) (0 = no pain; 10 = worst pain you can think of). The
survey instrument was pilot tested with 10 pediatric respondents
without difficulty. The PROMIS pediatric short forms
have been found to correlate well with the Pediatric Quality
of Life Inventory and demonstrates similar accuracy but with
better readability and efficiency.  In addition, the PROMIS
measures for children have been found to have demonstrated
feasibility, internal consistency, construct validity, and responsiveness
to change in a clinical setting. [21, 26]
Upon consent and assent, study participants (i.e., parents
and their children) were asked to complete a baseline survey
consisting of the parent survey (i.e., parent and child sociodemographics,
motivation for care, or presenting complaints)
and pediatric survey (i.e., PROMIS-25 survey) as
already described. After a trial of care, the children were
then asked to complete a comparative survey consisting of
the PROMIS-25 instrument. Study participants involved
children at various stages of care (i.e., new patients and
existing patients/long-term patients). It was left to the
judgment of the participating chiropractor the duration or
number of visits from baseline to comparative measures.
The only stipulation was that a minimum of 7 days must
have elapsed from baseline to comparative measurement as
the PROMIS instrument had a 7–day recall.
Responses were entered into an online data processing
center created specifically for the purpose of this study and
exported to an Excel spreadsheet (Microsoft Corp., Portland,
OR) for analysis. The sociodemographic and clinical
correlates were analyzed using descriptive statistics. These
were provided as frequencies and percentages, means, and
standard deviations. The PROMIS-25 data were analyzed
using scoring manuals provided by the PROMIS Assessment
CenterSM.  For each PROMIS short form (i.e.,
physical functioning mobility, anxiety, depressive symptoms,
fatigue, peer relationships, pain interference, and pain
intensity), a scoring table was developed to associate the
raw scores to a T score metric with a mean of 50 and
standard deviation of 10. The greater the T score, the greater
the measured QoL domain.
Since the study will involve chiropractors across the
United States, this clustering of individual patients from
various chiropractic practices can create residual correlations
due to systematic differences across the practitioners
(i.e., differences in chiropractic technique, skill or clinical
experience, or other capacities). To take this variation into
account, a generalized linear mixed model with random
intercept and logit link was estimated. Each model additionally
included a set of covariates that authors theorized
might play an important role on the PROMIS outcome.
Specifically, the effects of the reason for the visit (i.e.,
musculoskeletal condition, wellness, or another reason),
number of visits, time lapse between baseline and comparative
data collection, chronicity of condition, biological sex,
and pain ratings were controlled for. All covariates were
centered before analyses and entered into the regression
model. Within this statistical framework, significant change
was assessed through a Wald test of the difference in the
thresholds between each baseline and comparative mean
T scores for each QoL domain. The parameter of interest
was whether the probability of endorsing a problem in each
QoL domain changed from baseline to comparison (i.e., at
follow-up) in a repeated measures design.
In the event that the distribution of the mean T scores for
the various domains (i.e., anxiety, depression, and physical
functioning) is highly skewed and leads to non-normality of
residuals and violations of typical parametric (i.e., ordinary
least squares) model assumptions, the mean T scores for each
QoL domain will be dichotomized to reflect whether the
children reported having any problems in the domain (e.g.,
any symptoms of depression or anxiety) versus no symptoms.
To protect against erroneous error due to multiple comparisons,
the omnibus test that all thresholds were equal was
first tested, then held the false discovery rate at p = 0.05
using the Benjamini–Hochberg procedure for all protected
post hoc comparisons. All analyses were conducted in
Mplus version 7.28
Of the 88 PBRN chiropractors, sociodemographic and
practice characteristics were available for 63 DCs (44
female, 19 males). Their average age was 32.27 years
(SD = 6.03) with an average practice experience of 5.36
years (SD = 4.59). Their primary chiropractic techniques
were indicated as diversified technique (N = 43), Thompson
technique (N = 17), activator methods (N = 14), sacrooccipital
technique (N = 11), Gonstead technique (N = 4),
chiropractic biophysics (N = 2), and ‘‘other’’ (N = 10). In
these data, it was found that between 5% (i.e., for pain NRS)
and 8.8% (i.e., for fatigue) of the variability in the outcome
was attributable to differences across DCs, which was interpreted
to be small to moderate in size.
The original data set consisted of a total of 915 parent–
child dyads. After data cleaning, a total of 881 parents (747
females; 134 males; mean age = 42.03 years) and 881 children
(467 females and 414 males; mean age = 12.49 years)
comprised the study population. The parents had an average
age of 42.03 years (range = 25–71 years; SD = 6.58) and
were highly educated. Eighty-five percent (N = 755) had
some college or higher level of education (i.e., 2% PhDs,
15% Masters, 36% Bachelors, 32% some college education),
whereas 13% (N = 113) were high school graduates
with 1% (N = 13) having some high school education. Eighty
percent (N = 702) of the parents were concurrently under
chiropractic care along with their child.
The pediatric responders (N = 881; 467 females and 414
males) had a mean age of 12.49 years (range: 8–17 years;
SD = 2.82). Baseline measurement took place at the first
chiropractic appointment for 45% of the youth, during early
stages of care (visits 2–9) for 27% of them and during an
established patient visit (‡10th visit) for 28%. The mean
number of days and patient visits from baseline to comparative
QoL measures was 38.12 days and 2.74 (SD= 2.61), respectively.
What are the utilization patterns of children in the PBRN?
The first aim in this study was to understand the utilization
patterns and constellation of healthcare services with
this sample of children. All children in the sample were
under chiropractic care with a chiropractor participating in
this PBRN as an inclusionary criterion. This population of
interest were children under chiropractic care. When inquired
about their motivation for this chiropractic care for
their child, almost half (49%) of the parents were motivated
with wellness care for their child, followed by a clinical
presentation involving the musculoskeletal system (27%)
and ‘‘another reason’’ (23%). When asked to indicate a
duration of suffering that their child may be experiencing (if
any), those parents responding indicated the following durations:
days (21%; N = 187), weeks (12%; N = 105), months
(17%; N = 152), or years (49%; N = 430).
Fifty-eight percent of the parents reported that their
family medical physician (MD) was not aware of the chiropractic
care their child received, whereas 40% reported
that their MD was aware of their child’s chiropractic care
with 2% (of total respondents) indicating their MD referred
their child for chiropractic care (2% did not respond to this
item or had errors in data entry).
In terms of medical care received, the majority of parents
(75%) indicated that their child did not receive prior medical
care as it relates to their chiropractic presentation, whereas
15%of children receivedmedical attention prior but no longer,
and 10% of the children had on-going medical care in conjunction
with chiropractic. Medical care received involved
prescription medication (N = 66), prescribed over-the-counter
medication (N = 48), or care that was described as ‘‘other’’
(N = 29). Of the 25% (N = 218) of parents indicating previous
or ongoing medical care for their child, 55% provided an effectiveness
rating (i.e., very ineffective, ineffective, neutral,
effective, very effective) of their child’s medical care. Note
that the word ‘‘effectiveness’’ was not defined nor was a validated
tool to rate effectiveness used. This question wasmerely
asked simply to determine the degree or extent that medical
care produced the desired results (i.e, improvement of symptoms)
the parents were seeking. Of 120 parents, 24% rated
their child’s medical care as ineffective/very ineffective, 30%
provided a neutral rating, and 46% rated their child’s medical
care as effective/very effective.
In terms of the need for emergency care services for their
child in the previous 3 months, the majority of parent responders
(84%) indicated that their child did not require
visit(s) to the ER, whereas *3% of the parents indicated
taking their child to the ER. The remainder of the parents
(13%) indicated that their child’s chiropractic care was not
related to any medical condition requiring visits to the ER.
Parents were asked about previous or concurrent use of
other CAM therapies for their child. Forty-seven percent of
the parents indicated the ongoing use of vitamins and other
nutritional supplements, 31% indicated previous use of
herbal remedies, and 3% indicated ongoing use of herbal
remedies. Nine percent of parents indicated previous use of
and 5% with ongoing use of homeopathic remedies. Eleven
percent of the parents indicated previous use of acupuncture,
whereas only 2% had ongoing use of acupuncture. One
percent of parents indicated previous chiropractic care
elsewhere for their child, whereas 15% had no previous
experience or use with CAM therapies for their child.
How did chiropractic care change for pediatric chiropractic patients?
The baseline and comparative mean T score values for the
QoL domains of this study are provided in Table 1. The
frequencies for the indicated numeric pain ratings (NRS) are
provided in Table 2. Distribution of the T scores for the
various QoL domains was very highly skewed. There was a
preponderance of children who indicated very low T scores
for anxiety, depression, pain interference, fatigue, and high
T scores for peer relationship and mobility. Transformations
were unsuccessful at improving this non-normality. Descriptive
statistics and correlations for all observed variables
are given in Table 3.
At comparative measures, the frequencies of children with
the following number of visits were determined as follows: 1
visit (N = 436; 49.48%), 2 visits (N = 134; 15.21%), 3 visits
(N = 75; 8.51%), 4 visits (N = 64; 7.26%), 5 visits (N = 39;
4.43%), 6 visits (N = 18; 2.04%), 7 visits (N = 17; 1.93%), 8
visits (N = 14; 1.59%), 9 visits (N = 10; 1.13%), and 10 or more
visits (N = 55; 6.24%). Children attending visits ranging from 2
to 9 comprised less than half of this study population (N = 371;
44.11%). Data from 19 children (2.15%) were deleted from
analyses due to inconsistent or impossible values on number of
visits (e.g., comparative dates preceding baseline dates). The
mechanism of missingness was assumed to be missing completely
at random, and, therefore, not biased from listwise
deletion. There was no other missingness in the data set.
After controlling for the effects of motivation for care, the
number of visits at baseline (i.e., visit 1, visits 2–9, visits ‡10),
the number of visits between measurement occasions, duration
of complaint (i.e., days, weeks, months, and years), patient sex,
and pain NRS, this analysis demonstrated significant differences
in the probability of experiencing problems (vs. no reported
problems) across all QoL domains (Wald = 82.897,
df = 4, p < 0.05). Model-implied probabilities of indicating at
least one symptom of each QoL domain values would indicate
the predicted probability of youth reporting any of the problems
on the PROMIS-25 questionnaire. Post hoc comparisons
demonstrated that patients were less likely to report any symptoms
of depression (Wald = 6.1474, df = 1, p < 0.05), anxiety
(Wald = 20.603, df = 1, p < 0.05), fatigue (Wald = 22.191, df = 1,
p < 0.05), and pain interference (Wald = 47.422, df = 1, p < 0.05)
at comparison than at baseline. Peer relationship and mobility
were not analyzed due to the preponderance of children with
very high T scores.
In addition to determining the QoL of children under
chiropractic care, this study also provided some interesting
insights into the patterns and utilization of chiropractic
services by this patient population. In the interest of brevity,
discussions on the study findings are focused as they pertain
to QoL changes concomitant with chiropractic care. The
sociodemographic findings with parent responders in terms
of age, sex, and educational level are consistent with the
literature characterizing adult chiropractic patients [29–32] and
previous studies characterizing the chiropractic care of
children. [3, 8]
To date, this is the largest characterization of children
receiving chiropractic care. When the focus of healthcare
shifts to value-based care rather than fee-for-service, PROs
take on new meaning and importance in documenting patient
outcomes. The strength of PROs lies in their ability to
provide outcomes with personal and social context that are
meaningful on a day-to-day basis for patients. To the authors
knowledge, this is the first use of the PROMIS instrument
in the pediatric chiropractic population. These
findings are such that after a trial of chiropractic care, the
overall QoL of the pediatric subjects improved. Mean
T scores in physical functioning and peer relationships increased,
whereas mean T scores in anxiety, depressive
symptoms, fatigue, and pain interference decreased. These
changes in mean T scores were statistically significant, regardless
of the covariates of time lapse, the number of visits,
chronicity, motivation for care, patient sex, and pain NRS.
A major concern with generic health-related QoL measures
such as the PROMIS-25 has been that such measures
may not be as responsive to changes in symptoms in
disease-specific patients, measure specific disease symptoms,
and treatment side-effects germane to a particular
population of patients. Disease-specific QoL measures may
be more sensitive to specific clinical changes in diseasespecific
patients (i.e., asthma) than a generic measure and as
such may have greater use in individualized care such as
chiropractic. However, as it applies to a chiropractic PBRN,
disease-specific instruments are unable to provide comparisons
among patients with the plethora of clinical presentations
addressed by DCs in everyday practice, including
noncondition-based care (i.e., wellness care). A major
challenge to performing QoL research in a chiropractic
PBRN has been the dependence of a number of QoL measures
that are disease dependent (i.e., Bournemouth questionnaire  and Oswestry questionnaire ). In addition, the
plethora, heterogeneity, and inconsistency of use of these
disease-dependent outcome measures in chiropractic care
make cause and effect inferences with respect to effectiveness
of care very challenging.  As was found in this PBRN
study, children have a plethora of clinical presentations
motivating chiropractic care.  The application of the
PROMIS-25 instrument was found to be promising in chiropractic
practice and research. The use of the PROMIS
instrument confirmed its comparability (i.e., outcome comparisons
were possible despite heterogeneity in clinical
presentation and/or motivation), flexibility (i.e., PROMIS
was administered online and paper and pencil), and inclusiveness
(i.e., PROMIS was administered in a chiropractic
PBRN). Furthermore, the PROMIS-25 questionnaire demonstrated
its utility for screening of children with or without
clinical presentations/motivations, facilitated benchmarking
with asymptomatic populations, and provided a means to
measure health promotion types care. [36–38] Ongoing efforts
to use both generic and disease-specific QoL measures in
pediatric healthcare were supported for a more comprehensive
Similar to this study, the studies by Arvanitis et al.  and
Gipson et al.  utilized the short forms for the indicated QoL
domain. When comparing the mean baseline T scores of
chiropractic patients with children with Crohn’s disease
(Table 1), the following was observed. Comparable anxiety
and pain interference scores were found, whereas depressive
symptoms and peer relationships are higher and fatigue
mean T scores as lower in this pediatric population. Overall,
the children presenting for chiropractic care have comparable
if not worst QoL measures than those children with
Crohn’s disease. After a trial of chiropractic care, the QoL
scores of the chiropractic patients were found as improving
relative to baseline measures as well as compared with
children with Crohn’s disease. Anxiety and pain interference
decreased in mean T scores, whereas peer relationships
mean T score increased. When comparing the mean baseline
T scores of the chiropractic children with the overall mean
T scores of children with nephrotic syndrome, very similar
QoL measures in all domains were observed. After a trial of
chiropractic care, mean T scores in anxiety, depression, fatigue,
and pain interference relatively decreased in the chiropractic
population whereas peer relationships relatively
increased when compared with the children with nephrotic
syndrome. Crohn’s disease and nephrotic syndrome are
debilitating illnesses. With comparable QoL measures to
this pediatric population, the need for chiropractic care of
children should not be underestimated.
This study has a number of strengths including high external
validity. This study utilized convenience sampling to
obtain a naturalistic sample of children under chiropractic
care by many different chiropractors with varying clinical
experience applying a variety of chiropractic techniques.
This sample presented with varying conditions and histories
of treatment, reflective of the type of children who seek
chiropractic care in a nonresearch setting.
As there are strengths to this study, the authors also wish
to acknowledge a number of limitations. As with all surveys,
there is the element of subjectivity. As such, responders’
emotional states may influence the data at a specific point in
time and may not objectively measure their overall healthcare
experience. Interpretation of the results from surveys
presents challenges since patients have different expectations
to their healthcare experience, resulting in responses
that may vary widely despite similar care approaches or as
in this PBRN setting, different healthcare (i.e., chiropractic
technique) approaches. Likewise, as a result of baseline
assessment, parents may have been more aware of QoL
domains and reported differently at follow-up. The extent to
responder biases playing a role will surface through replication.
Furthermore, despite improvements/changes in QoL
as measured by mean T scores beyond statistical significance,
the authors do not have the minimally important
difference  for the PROMIS-25 instrument for pediatric
Future research should examine this
aspect in the chiropractic pediatric population. Despite the
large sample size in this study, generalizability of these
study findings to the general pediatric chiropractic population
remains uncertain. DC participants of this study were
previously or currently trained in pediatric chiropractic
through the International Chiropractic Pediatric Association  and volunteered to be part of a research study. There
may be fundamental differences in the way that these
pediatric-trained chiropractors practice than the general
chiropractic physician. Similarly, parents and children
consented to be part of the study and were not a random
sample of all children under chiropractic care. Thus, the
generalizability limitations of a convenience sample are
applicable here, despite the added strength of the sample
coming from a diverse network of doctors in practice. Despite
these limitations, surveys provide an important ‘‘voice
to patients and provide information to improving patient
care and establishing healthcare service standards.’’  Last,
an important limitation of this repeated measures study is
that there was not a control group to mitigate against internal
threats to validity, such as maturation or time, or
variation between baseline and follow-up measurement. The
latter was handled statistically through regression-based
controls; however, additional studies employing randomization
are warranted to better mitigate against threats related
to maturation and time effects and understand the causal
role of chiropractic in the reduction of problems related to
QoL indicators. This study was the first study of a program
of research that shows an association between chiropractic
and improved QoL. Results are promising for future studies
designed to establish a more rigorous causal link.
The PROMIS pediatric short forms instrument (PROMIS-
25) had demonstrable utility for chiropractic practice and
research within a chiropractic PBRN. With a course of
chiropractic care, the QoL measures of children improved
beyond statistical significance.
Author Disclosure Statement
The authors of this article received funding from the International
Chiropractic Pediatric Association. Dr. Joel Alcantara
received additional funding from Life West College
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