Chiropractic Pediatrics: “delayed referral, misdiagnosis, adverse events and ineffective treatments”

“Adjusting” an infant.

The premise of this study was simple: Review medical records to see how chiropractors actually diagnose and treat pediatric patients with orthopedic pathology. After all, chiropractors claim they are experts in musculoskeletal conditions.

Medical records of patients under age 19 presenting at the Pediatric Bone and Joint Institute at Penn State over a 4.5-year period were reviewed for use of chiropractic services for orthopedic pathology, resulting in 23 cases with an average patient age of 12 years, with the youngest being 21 months old. Twelve of the 23 patients went to a chiropractor first, but only five were referred to a pediatric orthopedic surgeon by the chiropractor. The remaining 18 were referred by a pediatrician or another orthopedic physician. Why so few patients who had seen a chiropractor were discovered in this search is unclear, although we do know that patients, or their parents, often do not reveal CAM use to physicians.

The results were reported recently in the Journal of Surgical Orthopedic Advances as well as published in Pediatrics as a Meeting Abstract. (Because the authors understandably use medical terms, I’ve added explanations and links from the American Academy of Orthopedic Surgeons, the Pediatric Orthopedic Society of North America, and a medical dictionary.)

Adverse outcomes were documented when one or more of the following issues were encountered: misdiagnosis, delay to diagnosis or treatment, and contraindication to manipulative therapy. Contraindications were determined on the basis of the current orthopaedic literature and consisted of hip manipulation in children with DDH [developmental dysplasia of the hip, in which the hip socket is shallow, meaning the ball of the thighbone cannot firmly fit into the socket], Perthes disease [blood supply to the rounded head of the thighbone is disrupted, causing bone cell death], and SCFE [slipped capital femoral epiphysis; for reasons that are not well understood, the ball at the head of the thighbone, slips off the neck of the bone in a backwards direction], as well as displacement of a proximal phalanx [finger bone] fracture. Misdiagnosis was recorded in four cases, with delay to diagnosis or delay to treatment observed in an additional seven cases. Of the 23 patients studied, 11 cases (48%) were found to have a to least one adverse outcome.

In addition to adverse outcomes, the authors discovered that, despite the lack of evidence of safety and efficacy of manipulative therapy for pediatric patients, 19 received just that, some seeing the chiropractor for as many as one to two visits per month. This included manipulation of the spine, hip, wrist, and shoulder for a chiropractic diagnosis (some of which, again, were misdiagnoses) of developmental dysplasia of the hip, leg length discrepancy (whether real or the imaginary discrepancies found by chiropractors, we don’t know in all cases), scoliosis, hip pain, hip dislocation, knee pain, muscular dystrophy, cerebral palsy (for three years in one case!), and wrist deformity. Other treatments included kinesiotaping, electrical stimulation, and acupuncture.

The many ways chiropractic pediatrics can go wrong

With that overview in mind, let’s look more closely at some specific cases.

Five patients with scoliosis received spinal manipulation and none reported improvement. As noted by the authors, although evidence is lacking, there is “continued intention among chiropractors to treat idiopathic scoliosis with manipulation.”

In one of these cases, an 18-year-old’s long-standing back deformity had been managed by a chiropractor since age two. The chiropractor recommended that he avoid surgery until he reached skeletal maturity, but he was finally referred to an orthopedic surgeon when his back pain worsened and he had difficulty in breathing on exertion. Orthopedic exam revealed significant congenital scoliosis, which is almost universally treated with surgery at an early age. He ended up having a two-stage T2 to L3 spinal fusion.

As the authors note, from a medical standpoint, manual therapy is often contraindicated in pediatric hip conditions. Yet, in reviewing the chiropractic literature, including chiropractic pediatric textbooks and American Chiropractic Association and International Chiropractic Association publications, the authors found that manipulation has not even been investigated as a therapy for hip conditions, nor were hip conditions uniformly identified as contraindications to manipulation. But to chiropractors, hip manipulation of children with symptoms of pediatric hip conditions is just what the doctor ordered.

In all, there were five cases where a direct contraindication to manipulation was present and, of these, subsequent orthopedic treatment in four cases required stabilization techniques such as casting and pinning. All five were also subject to misdiagnosis, delay to diagnosis, or delay to treatment.

One 4-year-old girl had a limp favoring her left leg, worsening over two years, which raised the possibility of a hip condition. Yet, she was treated by her chiropractor with manipulation of the hip, pelvis, spine, and gluteal muscles in seven visits over three months, but no x-rays were taken. The chiropractor then incorrectly diagnosed her with developmental dysplasia of the hip (DDH) and leg length discrepancy and referred her to an orthopedic surgeon. Her orthopedic diagnosis was avascular necrosis of the left hip (the blood supply to the femoral head is disrupted, bone cells die and the area becomes intensely inflamed and irritated) and a large femoral head consistent with Perthes disease.

In another case, a chiropractor diagnosed a two-year-old girl with leg length discrepancy and treated her with hip manipulation. When she didn’t improve, he referred her to an orthopedic surgeon. An x-ray revealed complete dislocation of the left hip, almost certainly congenital. (That this was not discovered earlier raises the possibility that she had never been seen by a pediatrician or family doctor.) She was diagnosed with DDH and underwent surgery. Despite the delayed diagnosis caused by her chiropractor and inappropriate treatment with manipulation, her parents continued to take her to a chiropractor for what she described as her left hip “popping,” which her chiropractor “popped” back into place, although further x-rays showed no evidence of dislocation.

In other cases:

• A 14-year-old boy with dwarfism and bowed legs received hip and spinal manipulation for hip and knee pain, one to two times a month, from his chiropractor. On referral to an orthopedic surgeon, he was diagnosed with a defect of the growth plate in the legs which required surgery to straighten them.
• A 16-year-old ballet dancer with back pain was treated with spinal manipulation, massage and laser therapy; on referral to an orthopedic surgeon she was diagnosed with scoliosis.
• An 11-year-old runner with hip pain was treated with hip manipulation by his chiropractor; he was actually suffering from chondrolysis of the hip (rapid progressive damage to the articular cartilage of the hip) and early Perthes disease.
• After a fall, an 8-year-old’s putative finger dislocation was supposedly put back into place by his chiropractor; it was actually a fracture, worsened by the chiropractor’s inappropriate treatment, and treated with six weeks of taping by an orthopedic surgeon.
• An 11-year-old cheerleader’s “right hip dislocation” was treated with hip manipulation (3 visits in one week); she was subsequently diagnosed by the orthopedic surgeon with leg length discrepancy.
• A 16-year-old ballet dancer’s low back pain was treated by her chiropractor with spinal manipulation; the orthopedic surgeon’s diagnosis was spondylolysis, a crack or stress fracture of the vertebrae.
• A 15-year-old with cerebral palsy was treated with spine and hip manipulation; an orthopedic surgeon diagnosed left hip dysplasia and chronic left hip subluxation (the real kind, a partial dislocation, not the mythical chiropractic subluxation). Surgery is normally necessary and was offered.
• A 14-year-old was treated with hip manipulation for hip pain; his orthopedic surgeon diagnosed SCFE, which required surgical pinning of the left hip. According to the American Academy of Orthopedic Surgeons it is important to diagnose SCFE as quickly as possible because, without early detection and treatment, SCFE can lead to serious complications like painful arthritis of the hip joint.

In only one of the 23 cases did the chiropractor directly refer the patient to her primary care physician with a correct diagnosis (a dislocated right hip) without first instituting a course of inappropriate joint manipulation, as happened in most cases, or some other unproven treatment, like acupuncture.

Yet, despite the fact that:

chiropractic intervention for the conditions encountered in this case series . . . was either insufficiently studied, contraindicated, or found to be of no measurable benefit,

and the authors discovered

missed or delayed diagnosis [and] more invasive surgery needed because of a delay to treatment,

nine patients (or, more likely, their parents) opted to continue chiropractic management after a diagnosis was made by their orthopedic surgeon and their perception toward chiropractic was positive in every case.

In other words, some patients will continue choosing chiropractic care even in the face of its ineffectiveness and adverse outcomes.

States should act to protect children

We’ve discussed chiropractors’ incompetent management of pediatric cases (not to mention anti-vaccination ideology) many times here on SBM. We’ve also covered their lack of education and training in pediatrics, to the point that some of them have never even encountered a pediatric patient before they go into practice. In fact, although the response rate was small, in surveys chiropractors themselves have owned up to the fact that, although they see pediatric patients for a variety of conditions, their pediatric training is lacking. Their post-graduate courses in pediatrics, another topic we’ve covered on SBM, are wholly inadequate to remedy these deficiencies. This is on top of the fact that many chiropractors who self-identify as practicing “pediatric chiropractic” are of the straight variety, believing that the mythical chiropractic subluxation must be “adjusted” in everyone from neonates on, at the risk of poor health.

Given that chiropractors will continue putting young patients in harm’s way, the only reasonable solution is that they be prohibited from seeing infants and children until they can satisfactorily demonstrate they can competently diagnose and treat them, a fact that has been, to date, simply presumed, without proof, by the state legislatures who grant them that authority.