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

(J Manipulative Physiol Ther 2016;39:401-10.)

To the Editor,

Todd et al (1) are to be commended for attempting to describe commonly used forces used in chiropractic pediatric care. This is an important subject and given the relatively scarce data landscape, it's a difficult task. With limited published sources in this field there were only a small number of references with experimental data available and the authors therefore had to rely heavily on a few sources (2-4) to formulate their conclusions. This small amount of data leads to potential sampling and inferential bias, which can have an effect on the conclusions drawn.

There are, however, other peer-reviewed articles and books that could add information. Case reports (a source of qualitative data), and the search terms 'diversified' or 'Gonstead' could be included. The search term 'Gonstead' yields 20 case reports on Gonstead high velocity, low amplitude (HVLA) technique in infants and children. The authors reviewed one text on the Thompson technique, but there are other texts and chapters that feature modified manual HVLA/Spinal manipulative therapy (SMT) technique, (5-10) which could also be added to the list.

A concern arises, that while the authors indicated that "guidelines" had been excluded, the article by Marchand (2) was included as a "guideline", although that article is based on opinion. Not including the limitations of his study, as reported by Marchand, allows the possibility for repetition of the potential errors in that selective review.

Unfortunately, we are aware of no studies of HVLA applied or transmitted spinal-directed forces on infant patients or infant manikins. But there are data available from a study on simulated upper cervical infant HVLA/SMT (into a force plate) using an average force of 70 N (11). There also could have been a discussion of the distinction between measurements of applied contact point force and transmitted force using table-based force sensing technology relative to the data in Table 3. Listing forces without such context can lead to confusion.

An HVLA thoracic adjustment on an adult can produce a transmitted force of 400-500 N or more, so 70 N HVLA force in an infant may be similar to the 10-20% of force applied on an adult, an amount also suggested by Wiberg (7) and supported by randomized controlled trial evidence (13), compared to less than 20 N (type not specified) and low velocity suggested by Todd et al (1).

Given the rarity of cases of adverse reactions noted by Todd et al (13), and the presence of a guideline on chiropractic care (14) including modified HVLA techniques, it would appear that the use of HVLA/SMT in infants and small children carries minimal risks when used by chiropractors. Additionally, Koch et al (15) noted no serious adverse events in over 20,000 cases.

Todd et al, however, seem to discourage the use of HVLA/SMT with joint cavitation in young children and infants. We feel, however, that the suggested additions of available references that might reasonably be considered in this area, along with a history of safe application of such techniques by chiropractors for over 100 years, supports the use of HVLA/SMT in this population. In the absence of stronger evidence that might suggest otherwise, we feel it is premature to abandon such approaches.

Authors: Mark Lopes, D.C. and Greg Plaugher, D.C.

(Pre-Print Version)

Article In Press

1. Todd AJ, Carroll MT, Mitchell EK. Forces of commonly used chiropractic techniques for children: a review of the literature. J Manipulative Physiol Ther 2016;39:401-410.

2. Marchand AM. A Proposed Model With Possible Implications for Safety and Technique Adaptations for Chiropractic Spinal Manipulative Therapy for Infants and Children. J Manipulative Physiol Ther. 2015 Nov-Dec;38(9):713-726.

3. Marchand AM. 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.

4. Pohlman KA, Carroll L, Hartling L, Tsuyuki R, Vohra S. Attitudes and Opinions of Doctors of Chiropractic Specializing in Pediatric Care Toward Patient Safety: A Cross-sectional Survey. J Manipulative Physiol Ther. 2016 Sep;39(7):487-493.

5. Fysh P. Chiropractic Care for the Pediatric Patient, 2nd ed. Arlington, VA: International Chiropractors' Association Council on Chiropractic Pediatrics, 2010.

6. Stierwalt DD. Adjusting the child. Davenport, IA: D.D. Stierwalt, 1976.

7. Wiberg J. Paediatric manipulative skills. In: Byfield D, ed. Chiropractic manipulative skills, 2nd. ed. Elsevier Health Sciences, UK, 2005:403-420.

8. Williams S. Basic Paediatric Manual Skills. In: Byfield D, ed. Technique Skills in Chiropractic, Elsevier Health Sciences UK, 2011.

9. Anrig, CA. Spinal examination and specific spinal and pelvic adjustments. In: Anrig, CA, Plaugher G. Pediatric Chiropractic. Wolters Kluwer/Lippincott Williams & Wilkins, 2013;175-179.

10. Plaugher G, Alcantara J. Adjusting the pediatric spine. Top Clin Chiropr 1997;4(4):59-69

11. Koch LE, Girnus U. Kraftmessung bei Anwendung der impulstechnik in der chirotherapie. Physikalische Darstellung der einwirkenden kraft in der manuellen Medizin. Manuelle Medizin 1998;36:21-26.

12. Wiberg JM, Nordsteen J, Nilsson N. The short-term effect of spinal manipulation in the treatment of infantile colic: a randomized controlled clinical trial with a blinded observer. J Manipulative Physiol Ther. 1999;22:517-522.

13. Todd AJ, Carroll MT, Robinson A, Mitchell EK. Adverse Events Due to Chiropractic and Other Manual Therapies for Infants and Children: A Review of the Literature. J Manipulative Physiol Ther. 2015 Nov-Dec;38(9):699-712.

14. Hawk C, Schneider MJ, Vallone S, Hewitt EG. Best Practices for Chiropractic Care of Children: A Consensus Update. J Manipulative Physiol Ther. 2016 Mar-Apr;39(3):158-168.

15. Koch LE, Koch H, Graumann-Brunt S, et al: "Heart rate changes in response to mild mechanical irritation of the high cervical spinal cord region in infants." Forensic Science International 2002;128:168.

Chiropractic Care of a Pediatric Patient with Myasthenia Gravis

Alcantara J, Plaugher G, Araghi J. J Manipulative Physiol Ther 2003;26(6):390-4.
OBJECTIVE: To describe the chiropractic care of a pediatric patient with complaints associated with myasthenia gravis.
CLINCIAL FEATURES: A 2-year-old girl was provided chiropractic care at the request and consent of her parents for complaints of ptosis and generalized muscle weakness (ie, lethargy), particularly in the lower extremities. Prior to entry into chiropractic management, magnetic resonance imaging of the brain and acetylcholine receptor antibody tests were performed with negative results. However, the Tensilon test was positive and the diagnosis of myasthenia gravis was made by a pediatrician and seconded by a medical neurologist. Intervention and outcome. The patient was cared for with contact-specific, high-velocity, low-amplitude adjustments to sites of vertebral subluxation complexes in the upper cervical and sacral spine. The patient's response to care was positive and after 5 months of regular chiropractic treatment her symptoms abated completely.
CONCLUSION: There are indications that patients suffering from disorders "beyond low back pain" as presented in this case report may derive benefits from chiropractic intervention/management.