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The benefits of chiropractic care for children have become increasingly evident as the number of children receiving chiropractic care continues to rise.¹ Chiropractic research has overwhelmingly shown the benefit of chiropractic care for children.  However, there continue to be reports which question the safety of chiropractic care.³ In light of this trend of care for increased numbers of children, and those safety considerations, it has become important to evaluate the risk potential to the pediatric patient presenting for chiropractic care.

In response to these safety concerns, the research department of the ICPA has published a first paper concerning the safety of adjusting children. In the current issue of the Journal of Vertebral Subluxation Research, ICPA research assistant Rich Pistolese has published a report entitled, “Risk Assessment of Neurological and/or Vertebrobasilar Complications in the Pediatric Chiropractic Patient.”⁴ This timely paper specifically addresses the safety issues associated with chiropractic care for children.

Reports of serious complications (regardless of age) following chiropractic adjustments and/or manipulation are extremely rare.^5,6,7 Nevertheless, since disturbance of vertebral artery circulation is the most commonly reported adverse event associated with the adult population under chiropractic care, the study focused on evaluating the risk of occurrence of neurovascular complications in the pediatric patient.

The study acknowledges most complications following cervical manipulation are caused by disturbances of vertebral artery circulation, and the resultant damage to neurological components supplied by the vertebrobasilar system. While it has been reported that vertebral artery dissection is an uncommon cause for stroke in children,⁸ current statistics reveal that the pediatric population is not exempt from this phenomenon. Reports show the annual incidence of strokes for children under 15 years of age to be 2.7 per 100,000 children.⁹

There is a strong correlation between the severity of spinal cord injury and the immaturity of the spine.¹⁰ It behooves the chiropractic profession to pay special attention to avoiding procedures that could induce stroke or other related complications in the pediatric patient, since the majority of complications attributed to spinal manipulative procedures are related to rotational manipulation of the cervical spine.¹¹

The author advises that all spinal adjustments should be of very low force and short amplitude to minimize risk to the pediatric patient. Adjusting procedures should exclude any maneuver that includes rotation, extension and traction. The author also suggests a change from manipulative methods to low-force movements, which may help to minimize neurovascular complications and other types of potential harm.

In regards to risk assessment, in this report the research department of the ICPA has conducted an extensive search of Medline and Mantis and found only two questionable reports of adverse neurovascular events in pediatric patients following chiropractic care. While the author has heard claims from pediatricians and other health care professionals that chiropractic may cause epiphyseal plate fractures in children, no such cases were found reported in the scientific literature. Any health care professional who makes such claims should be quickly challenged to provide documentation of such claims.

Based on information gathered in this study, the ICPA’s research department has concluded the following:

• In the prevalent scientific/clinical literature spanning the last 32+ years, there are only two reported cases of neurovascular complications related to pediatric patients receiving chiropractic care.
• Based on an eclectic summation of data derived from three sources, a conservative estimate of the number of pediatric visits to chiropractors in the U.S. over the same time span amount to over 1/2 billion visits.
• The risk of a neurovascular complication occurring as the result of chiropractic care is approximately one out of every 250 million visits.

When considering the use of any health care procedure, the expected benefit must be weighed against the inherent risks. Based on this axiom, chiropractic care relative to neurovascular complications appears to present little risk to the pediatric patient when compared to cited reports related to benefits of chiropractic care. While some pre-existing conditions may predispose the pediatric patient to a higher probability of complication, the estimate provided is considered applicable to the general pediatric population.

By Claudia Anrig, DC

To obtain your copy of this report, contact the Journal of Vertebral Subluxation Research, 2950 N. Dobson Road, Suite 1, Chandler, AZ 85524, tel: 1-800-347-1011. You can also contact the ICPA at 5295 Highway 78, Suite D362, Stone Mountain, GA 30087, tel: 770-982-9037.

References

1. Goertz C. Summary of 1995 ACA annual statistical survey. JACA 1996;33(6):35-41.
2. Vange B. Contact between preschool children with chronic diseases and the authorized health services and forms of alternative therapy. Ugeskr Laeger 1989;151(28):1815-8.
3. Ernst E, Assendelft WJJ. Chiropractic for low back pain. BMJ 198;317(7152):160.
4. Pistolese RA. Risk assessment of neurological and/or vertebrobasilar complications in the pediatric chiropractic patient. J Vertebral Sublux Res 1998;2(2):73-81.
5. Crawford JP, Byoung YH, Asselbergs PJ, Hickson GS. Vascular ischemia of the cervical spine: a review of the relationship to therapeutic manipulation. J Manipulative Physiol Ther 1984;7(3):149-55.
6. Dvorak J, Baumgartner L, Burn JB, et al. Consensus and recommendations as to the side effects and complications of manual therapy of the cervical spine. J Manual Medicine 1991;6:117-8.
7. Fossgren J. Complications in manual medicine. J Manual Medicine 1991;6:83-4.
8. Khuruna DS, Bonnemann CG, Dooling EC, et al. Vertebral artery dissection: issues in diagnosis and management. Pediatr Neurol 1996;14(3):255-8.
9. Alvarez-Sabin J. Stroke in teenagers. Rev Neurol 1997;25(142):919-23.
10. Ruge JR, Sinson GP, McLone DG, et al. Pediatric spinal injury: the very young. J Neurosurg 1998;68:25-30.
11. Greenman PE. Principles of manipulation of the cervical spine. J Manual Medicine 1991;6:106-13.

Claudia Anrig, DC
Clovis, California

A majority of chiropractors had an opportunity to be exposed to the Gonstead technique while attending chiropractic college. This technique, although often difficult to master as a student, may provide an avenue for those doctors considering adding short-lever adjustments in their practice.

One might not realize that Clarence S. Gonstead, DC, taught infant and child adjustments as a part of his technique seminars. Later, a pediatric chapter on spinal examination and specific adjustments was included in Herbst’s 1968 description of the Gonstead technique.¹ In 1998, the textbook Pediatric Chiropractic contained several chapters dedicated to this system of analysis and specific adjusting protocol for the expectant mother, infant and child.²

What makes the Gonstead technique unique is its system that allows for a very thorough evaluation process: inspection (postural and gait), instrumentation (handheld), radiographs (when warranted), and static and motion palpation. Gonstead chiropractic evaluation allows for the doctor to determine a listing system for a systematic reference to the positional dyskinesia of the subluxated segment to be adjusted.³ This short-lever adjustment specifically directs a three-dimensional force away from the direction of misalignment while protecting the normal, functional spinal units.

The Gonstead technique does not advocate long-lever adjustments on the developing pediatric spine. The elastic properties of the spine and spinal cord dictate the minimizing of vectors that would introduce unnecessary forces and bending movements: longitudinal traction, extension, rotation, flexion and lateral flexion. This technique allows for the practitioner to evaluate from the condyle to the pelvic spine. One of the major contributions of Dr. Gonstead’s work was the development of a specific analysis for the AS (anterior-superior) condyle subluxation. Although not a common subluxation, the presence of this misalignment may present numerous neurological manifestations to the pediatric patient. Low APGAR score, depressed infant reflexes, failure to thrive, autism, ADD/ADHD and other disorders have been reported to be affiliated with this condyle presentation. This technique has further developed chiropractic analyses for the cervical, thoracic, lumbar and pelvic spine that accommodates the pediatric population.

One advantage to the Gonstead technique is that it allows for the doctor to adapt his or her hands to the segmental size of the pediatric patient. Often the second or fifth digit is used to contact the spinous process, lamina, transverse or mamillary process for the analysis and setup of the subluxated segment. By adapting the doctor’s hand to the patient size, this allows for a more specific correction and above all, avoids introducing unnecessary forces to the developing pediatric spine.

Another unique aspect of the Gonstead technique is its ability to look at the sacrum as segmental in the infant and young child. For example, a posterior S2 would require a specific contact to the sacral tubercle rather then a general sacral contact for correction.

Patient placement is another Gonstead opportunity for the doctor to reduce unnecessary stress to spinal joints and the neurological components. The Gonstead technique attempts to find a “neutral” position for the pediatric patient. For example, the newborn or infant may be placed across the lap of the parent. The toddler, young child or adolescent may be placed prone (for the majority of listings), seated for cervical adjustments and side posture for lumbar or pelvic adjustments.

Doctor positioning also is considered in the setup of the adjustment. Staying close to the patient, the doctor attempts not to place rotation or extension into the pediatric spine. The Gonstead technique advocates ambidextrous set-ups: the doctor positioning herself on the left or right side being able to deliver a specific adjustment from either hand.

This short-lever technique does not deliver a “forceful” thrust. During the setup stage, the doctor first considers the flexibility of the pediatric spine. Tissue pull and preload tension are essential prior to the adjustment. The purpose of preloading is to prevent the need for extra force to reach the end range of motion of the segment to be adjusted.

The Gonstead technique is ideal for the expectant mother.⁴ The pregnant patient may be placed prone using a hi-lo table or a side posture table for the lumbar or pelvic spine. Each adjusting table may be adapted for the comfort and safety of the patient. One particular adjustment table developed by Dr. Gonstead, the knee-chest table, is ideal for adjusting the spine of the pregnant patient, as it provides comfort to the breast region and there are no constraints to the abdominal regional. The knee-chest table also is helpful in adapting for the postnatal patient.

Additionally, the Gonstead technique gives the doctor the ability to adapt to different age groups and their needs. This technique allows for variety in hand contact, table selection, and setup choices, and the added benefits of safety and comfort for both the patient and doctor.

For more information, contact the not-for-profit Gonstead Clinical Studies Society at www.gonstead.com.

By Claudia Anrig, DC

References

1. Herbst RW. Gonstead Chiropractic Science and Art. Mt. Horeb, WI: Sci-Chi Publications 1968:261-268.
2. Anrig CA, Plaugher G. Pediatric Chiropractic. Baltimore, MD: Lippincott Williams & Wilkins 1998.
3. Kent C, Plaugher G, et al. “Diagnostic Imaging.” In: Anrig CA, Plaugher G. Pediatric Chiropractic. Baltimore, MD: Lippincott Williams & Wilkins, 1998:202-321.
4. Forrester JA, Anrig CA. “The Prenatal and Perinatal Period.” In: Pediatric Chiropractic. Baltimore, MD: Lippincott Williams & Wilkins, 1998:75161.

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