HOW DOES CHIROPRACTIC CARE AFFECT PATIENT OUTCOMES 1 HOW DOES CHIROPRACTIC CARE AFFECT PATIENT OUTCOMES IN CHILDREN EXPERIENCING PAIN?

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1 HOW DOES CHIROPRACTIC CARE AFFECT PATIENT OUTCOMES 1 HOW DOES CHIROPRACTIC CARE AFFECT PATIENT OUTCOMES IN CHILDREN EXPERIENCING PAIN? Jessica L. Kendall Saint Mary s University of Minnesota

2 HOW DOES CHIROPRACTIC CARE AFFECT PATIENT OUTCOMES 2 Table of Contents Introduction Reported Outcomes in Infants and Toddlers Reported Outcomes for Children with Chronic Pain Conditions Outcomes for Pediatric Patients Experiencing Neck and Back Pain Outcomes for Pediatric Patients Seeking Overall Wellness Care Limitations Discussion...12 Conclusion...13 References...15

3 HOW DOES CHIROPRACTIC CARE AFFECT PATIENT OUTCOMES 3 Abstract CAM therapies are used in combination with, and/or as an alternative to conventional medical practices. Among these CAM therapies, chiropractic care is the most commonly utilized and highly desired therapies to help children with vast amount of diagnoses associated with chronic pain (Hawk et al., 2016). This literature review aims to examine the existing literature on how chiropractic care affects patient outcomes in children experiencing pain. The literature presented significant patient outcomes, yet acknowledges the literature s significant limitations. Keywords: Complementary and Alternative Medicine (CAM), Chiropractic, Spinal Manipulation, Pediatrics, Patient Outcomes, Pain

4 HOW DOES CHIROPRACTIC CARE AFFECT PATIENT OUTCOMES 4 How does chiropractic care affect patient outcomes in children experiencing pain? In comparison to the adult population, chronic pain in children is poorly under researched and often underestimated by the general public. Alcantera and Davis (2011) predicted approximately 15-25% of all children suffer from recurrent or chronic pain. This pain often originates from musculoskeletal issues that cause headaches, abdominal pain, in addition to other ailments shown to negatively impact a child s quality of life. According to Alcantera and Davis (2011), children who experienced recurring and chronic pain were at a greater risk of missing days of school and presented high risks for physical, mental, and psychosocial dysfunctions that may follow them well into their adult years. Human development is measured through chronological age, which correlates with specific developmental milestones such as crawling, talking, and problem-solving abilities. These milestones represent-what is referred to as neurological age. Doscher (2009) stated, when chronological age and neurological age do not match up, this is a sign that a problem exists, and chiropractic care is needed. According to Miller et al. (2010), chiropractic is a health care profession concerned with the diagnosis, treatment, and prevention of disorders of the neuromusculoskeletal system and the effects of these disorders on general health (p.1). When problems, also known as subluxations, are present in pediatric patients, doctors of chiropractic (DC) perform manual techniques. These manual techniques are referred to as adjustments and manipulations (interchangeable terms) and focus on restoring the patient s normal nervous system functions (Miller et al). In the chiropractic world, a subluxation, is a problem or dysfunction because it is an abnormal nervous system interference. This can cause pain and a lack of movement in the body (Yeomans, 2009). According to Doscher (2009), when subluxation exists in children,

5 HOW DOES CHIROPRACTIC CARE AFFECT PATIENT OUTCOMES 5 chiropractors begin to see developmental delays, as well as the presence of disease, disorders, and dysfunctions. Gleberzon et al. (2012) stated the most common treatments chiropractors use are spinal manipulative therapy (SMT), soft tissue therapy, and stretching/exercise techniques. Gleberzon et al. (2012) also reported that the presence of different conditions in pediatric patients depended heavily on age. For example, the majority of infants and patients up to the age of 11 years old, sought chiropractic care for colic (episode of excessive crying), preventative care, and inner ear infections. As patients increased in age, the most common complaints were musculoskeletal issues such as growing pains, neck pains, and headaches. Parents often seek CAM therapies such as chiropractic care after conventional medical practices failed to alleviate their child s symptoms (Miller et al., 2010). According to Shaw (2014), parents are looking for more options besides putting their kids on more drugs, and chiropractic care can provide great alternative treatments. This may help to explain the significant rise in pediatric visits to chiropractors, as the number has more than doubled from 30 million in 2000 to 68 million in 2009 (Shaw, 2014). This review will highlight the outcomes and limitations of the existing literature available on pediatric chiropractic patients who have experienced pain. Reported Outcomes in Infants and Toddlers In the literature exploring the reported chiropractic pediatric outcomes in infants and toddlers specifically, a significant decrease in pain symptoms were presented after receiving chiropractic care. Alcantera and Davis (2011) study examined toddlers complaining of growing pains. The participants reported pains persisting for several months causing them to wake up throughout the night.

6 HOW DOES CHIROPRACTIC CARE AFFECT PATIENT OUTCOMES 6 The participants in Alcantera and Davis (2011) study followed conventional medical advice to take over the counter Tylenol, but the pain symptoms were not relieved. The participants received chiropractic care three times a week for three weeks. The participants were released from care after two follow up visits within a three month period due to the relief of symptoms. Therefore, Alcantera and Davis (2011) study found significant improvements in patient outcomes due to the toddler participant s relief of pain symptoms after receiving chiropractic care. In addition, The Foundation of Chiropractic Progress (2017) reported data from several studies investigating patient outcomes in infants with colic. Upon receiving chiropractic care, crying time in infant patients decreased by 50%. Moreover, Sherry McAllister, a DC and vice president of this foundation, reported results from a two-month chiropractic study evaluating care among 81 asthmatic pediatric participants. Patients receiving chiropractic care saw a 45% decrease in the number of asthma attacks, with 31% of them deciding to decrease their use of medications (The Foundation of Chiropractic Progress, 2017). Reported Outcomes for Children with Chronic Pain Conditions Additionally, there is literature examining patient outcomes for children experiencing pain that were diagnosed with specific conditions. Similar to the infant and toddler participants, study participants who presented chronic pain conditions displayed significant decreases in pain symptoms after receiving chiropractic care. Crawford s study (2009) reported on pediatric patients with Cerebral Palsy who often experienced constant muscle tension, spasms, joint irritation, and inflammation leading to symptoms of chronic pain. According to Crawford (2009), regular chiropractic adjustments helped normalize the motion of the joints, and helped patients become more comfortable and relaxed. Crawford

7 HOW DOES CHIROPRACTIC CARE AFFECT PATIENT OUTCOMES 7 described patients living with Cerebral Palsy who started receiving chiropractic care at a very early age. After receiving consistent and continued chiropractic care every 6-8 weeks, patients with Cerebral Palsy reported a significant reduction in pain symptoms, as well as an increased quality of life. Crawford (2009), much like Alcantera and Davis (2011) resorted reported patients with Cerebral Palsy resorted to painkillers to help relieve symptoms of pain. Given the side effects of the tried conventional medical practices, Crawford stated patients decided to give chiropractic care a chance. After receiving two chiropractic adjustments, a patient reported, I had more control over my body than a lifetime of surgeries and painkillers had ever given me (p.9). Moreover, Alcantera and Mayer s (2008) study reported chiropractic outcomes for constipation, a chronic condition facing children starting at very young age. According to Alcantera and Mayer, the pain and symptoms of chronic constipation account for 25% of all medical visits in the pediatric population. Alcantera and Mayer s study examined patients under the age of two, who received full spinal chiropractic care for a period spanning from three weeks to three months. Similar to Alcantera and Davis (2011) and Crawford s (2009) studies, Alcantera and Mayer (2008) reported all patients had unsuccessful relief of their pain symptoms following conventional medical advice. Upon receiving chiropractic care, Alcantera and Mayer concluded all patients experienced a significant increase in the number of bowel movements without the accompanying symptoms of pain. On the other hand, Gleberzon, Arts, Mei, and McManus (2012) performed a systematic review of eligible clinical trials investigating the use of chiropractic care for pediatric with painful health conditions. Gleberzon et al. s initial search yielded 79 clinical trials. Out of the

8 HOW DOES CHIROPRACTIC CARE AFFECT PATIENT OUTCOMES 8 79 trials, only 16 met criteria for further review. Within the 16 clinical trials, chiropractic effectiveness was investigated in a total of 1,980 children receiving chiropractic treatments. Overall, none of the trials could confirm or deny the effectiveness of chiropractic care among children experiencing symptoms of pain. Outcomes for Pediatric Patients Experiencing Neck and Back Pain In accordance to chiropractic patient outcomes in children experiencing neck and back pain, studies have shown significant improvements in pain symptoms. A recent study conducted by Young and Young (2017), described how chiropractic management helped pediatric patients under the age of three with torticollis. Torticollis, characterized by an abnormal twisting of the neck, caused severe neck aches for patient participants. The DC completed a physical examination and determined all patients presented a limited range of motion in her neck. For treatment, the DC performed chiropractic care and soft tissue therapy massage. At the time of this case study, three years had passed with no recurrence of torticollis with accompanying pain symptoms in all patients. Likewise, Cox, Davidian, and Mior (2016) reported data displaying outcomes of chiropractic care among pediatric patients presenting neck pain. Cox, Davidian, and Mior collected records from a chiropractic clinic in the Greater Toronto Area. Utilizing a standardized intake form, the three DC s reported the demographics, medical histories, examination notes, treatment plans, and outcomes for 50 pediatric patients. With an average age of 13.1, the 50 pediatric patients represented an equal distribution of males and females, with 98% reporting consistent neck pain. Treatment was considered complete when the patient reported no neck pain (complaints) for two consecutive visits. The data concluded 96% of the pediatric patients in the study experienced a significant reduction in

9 HOW DOES CHIROPRACTIC CARE AFFECT PATIENT OUTCOMES 9 pain symptoms. As a result, Cox, Davidian, and Mior concluded pediatric neck pain appears to be successfully managed by chiropractic care (p.213). By the same token, Hayden et al. s (2003) study described the chiropractic management and outcomes of school-aged children reporting low back pain. Hayden et al. randomly selected chiropractors in selected cities in Canada to provide data on 54 pediatric patients experiencing lower back pain. Using the pediatric visual analogue scale (VAS), a scale labeled with a huge smiley face next to the number 0=no hurt, all the way to the number 10 displaying a frowning face, where 10=the biggest hurt the patient could ever have. The pediatric patients were asked to mark the severity of their pain on a VAS scale from The majority of patients involved in the study were school-aged children who experienced pain due to sports injuries and other traumatic events and/or accidents. With an average age of 13.1 years, the majority of patients presented mild lower back pain and were treated with 6 weeks of chiropractic manipulation. Overall, 55-62% of the pediatric patients experienced significant improvements in their pain symptoms according to the VAS scale. Outcomes for Pediatric Patients Seeking Overall Wellness Care The patient outcomes for children seeking chiropractic care for overall wellness reported differing conclusions. Alcantera, Ohm, and Kuntz (2008) performed a research survey examining the overall safety and effectiveness of pediatric chiropractic care. Alcantera, Ohm, and Kunz requested for parents to report their children s age, gender, reason for seeking chiropractic care, and any observed treatment outcomes following treatment such as further aggravations and improvements. A total of 239 parents completed the survey, displaying data of children with an average age of 6.15 years.

10 HOW DOES CHIROPRACTIC CARE AFFECT PATIENT OUTCOMES 10 While a majority of the children reported seeking chiropractic care for overall wellness, (N=131), the rest reported seeking care due to pain complaints associated with musculoskeletal disorders, birth trauma, and ear infections. Following chiropractic care, Alcantera, Ohm, and Kuntz (2008) report 115 of the 125 pediatric patients experienced significant improvements in their overall pain symptoms. In addition, a total of 48 parents indicated the appearance of unexpected improvements including improved sleep, relief of cold and flu symptoms, and better attitudes/behavior. Alternatively, Hawk et al. (2016) completed a systematic review of the relevant literature between the years of 2009 and 2015, with the purpose of examining the overall effectiveness of chiropractic care for conditions present in children. Hawk et al. used a total of five databases to search specific terms, including but not limited to: manipulation, pediatrics, and chiropractic. The results yielded 21 full-text articles on effectiveness, with a total of three randomized controlled trials. Overall, limited evidence was found to support conclusive outcomes for children with asthma, infant colic, bedwetting, and respiratory disease. Similarly, Shaw (2014) stated there was currently no evidence to support or refute utilizing chiropractic care to treat chronic ear infections, as well as no evidence suggesting chiropractic care produced any adverse effects. As a result, Shaw summarized there is insufficient evidence to make conclusions on the overall effectiveness of chiropractic care for children experiencing colic, musculoskeletal conditions, bedwetting, and respiratory disease. Consequently, Homola (2016) conveyed the special expertise required to care specifically for the pediatric population, and disclosed the potential risks and complications in treating children s overall wellness with chiropractic care. Homola questioned the field s overall safety, challenged the DC s limited amount of training, and repeatedly addressed chiropractic s

11 HOW DOES CHIROPRACTIC CARE AFFECT PATIENT OUTCOMES 11 ineffectiveness in treating any pediatric ailments due to the lack of available evidence. Homola concluded pediatric chiropractic care has more potential risks and complications that outweigh the unknown benefits. Limitations In addition to Homola s (2016) abovementioned limitations, it is important to examine the additional limitations declared in the studies throughout this review. Firstly, all five direct studies with children participants had small sample sizes and represented small geographical areas. Therefore the studies are deemed ungeneralizable to the larger pediatric population. Correspondingly, Alcantera and Davis (2011), Hayden et al. s (2003) and Young and Young s (2017) studies discussed the major limitations associated with the inability to establish a cause and effect relationship due to the lack of control groups, potential effects of subjectivity and placebos, and unaccounted effects of patient s natural history. Cox, Davidian, and Mior (2016) also noted their inability to access unreported data and lack of randomization throughout their study. Consequently, Shaw (2014), Homola (2016), Gleberzon et al. (2012), emphasized the limited evidence on the effectiveness of chiropractic care on pediatric conditions. And, although Hawk et al. (2016) did not address the issue of pain specifically, it was included in this review to highlight the lack of available evidence on chiropractic care regarding the pediatric population experiencing pain explicitly. All in all, the majority of authors in this review, besides Homola, concluded the outcomes experienced by the children should be acknowledged, and will hopefully encourage more robust chiropractic explanatory studies to be conducted in the near future. Discussion Throughout the literature presented, the specific participatory studies provided evidence

12 HOW DOES CHIROPRACTIC CARE AFFECT PATIENT OUTCOMES 12 supporting the safety and effectiveness of chiropractic care in treating pain symptoms among the select pediatric populations. The data recorded from the chiropractic participatory studies concluded that the children who received care experienced reduced pain symptoms, displayed a reduction or elimination in their medication(s), and increased patient s quality of life. In addition to the positive patient outcomes found in the participatory studies, improved outcomes were also found in the literature s select data collection and surveys. However, it is important to note the significant limitations including small sample sizes, scarce data, and the inability to determine cause and effect relationships throughout the participatory and nonparticipatory studies. As numerous positive results are presented throughout the studies, I agree with the majority of the literature encouraging further research to be conducted to examine the relationship between pediatric chiropractic care and patient outcomes. In addition, after thoroughly reviewing the literature, there were several discoveries that I found to be noteworthy. Shaw (2014) stated chiropractic care has had a minimal amount of adverse events, with only nine reported over the past 110 years. This, along with the improvements in patient outcomes throughout the literature s participatory studies may contribute to the growing popularity and overall positive outlook ahead for the future of chiropractic care. On another note, given the growth of this topic and other CAM intervention treatments and therapies in general, Shaw (2014) and Homola (2016) have cautioned making pre-mature statements on the effectiveness of chiropractic care without sufficient evidence to support it. The risks throughout the literature note the limited amount of generalizable data, emphasized the fact that chiropractic care must be developmentally appropriate for pediatric patients, and encouraged the general population to see a chiropractors who specialized in treating children specifically.

13 HOW DOES CHIROPRACTIC CARE AFFECT PATIENT OUTCOMES 13 Overall, it has been found that pediatric chiropractic care may have many physical, emotional, and biological benefits in reducing pain symptoms given a child is seen by a DC. The literature presented gives insight into successful chiropractic outcomes among children experiencing chronic pain, and has the opportunity to improve the lives of many as the field continues to grow in popularity in both clinical practice and research. Conclusion Miller et al. (2010) and Shaw (2014) confirm the rapidly growing popularity of chiropractic care among the pediatric population. Despite the increase in visits, research examining pediatric patient outcomes is deemed insufficient and limited. Although the literature in this review highlighted significant limitations, it is crucial to acknowledge the evidence that does exists. Following chiropractic care, all five participatory studies reported positive patient outcomes in children with significant pain symptoms. Therefore, it is strongly recommended that researchers address the abovementioned limitations and gaps in the literature by conducting future research. This research must include more robust, randomized, controlled, and less subjective studies to better explain the relationship between chiropractic care and pediatric patient outcomes. As more studies help to explain the cause and effect relationship between pediatric chiropractic care and patient outcomes, the field can then better address how chiropractic care effects specific pain symptoms in children. This is crucial in world displaying an increased interest and utilization of complementary and alternative therapies to address children s pain symptoms, wellness and overall quality of life.

14 HOW DOES CHIROPRACTIC CARE AFFECT PATIENT OUTCOMES 14 References Alcantara, J., & Davis, J. (2011). The chiropractic care of children with growing pains : A case series and systematic review of the literature. Complementary Therapies In Clinical Practice, doi: /j.ctcp Alcantara, J., & Mayer, D. M. (2008). The successful chiropractic care of pediatric patients with chronic constipation: A case series and selective review of the literature. Clinical Chiropractic, 11(3), doi: /j.clch Alcantara, J., Ohm, J., & Kuntz, D. (2008). Chronic Pain Symptoms: The safety and effectiveness of the chiropractic care of children: Results from a practice-based research survey of parents. European Journal Of Integrative Medicine, 1(Supplement 1), 14. doi: /j.eujim Cox, J., Davidian, C., & Mior, S. (2016). Neck pain in children: a retrospective case series. Journal Of The Canadian Chiropractic Association, 60(3), Crawford, M. (2010). Chiropractic Care Brings a Higher Quality of Life to Cerebral Palsy Patients. Journal Of The American Chiropractic Association, 47(9), 7-9. Doscher, B. (2009). Seeing the Power of Chiropractic through the Children. American Chiropractor, 31(7), Gleberzon, B. J., Arts, J., Mei, A., & McManus, E. L. (2012). The use of spinal manipulative therapy for pediatric health conditions: a systematic review of the literature. Journal of The Canadian Chiropractic Association, 56(2), Groenewald, C. B., Beals-Erickson, S. E., Ralston-Wilson, J., Rabbitts, J. A., & Palermo, T. M. (2017). Complementary and Alternative Medicine: Complementary and Alternative

15 HOW DOES CHIROPRACTIC CARE AFFECT PATIENT OUTCOMES 15 Medicine Use by Children With Pain in the United States. Academic Pediatrics, doi: /j.acap Hayden, J. A., Mior, S. A., & Verhoef, M. J. (2003). Evaluation of chiropractic management of pediatric patients with low back pain: A prospective cohort study. Journal of Manipulative And Physiological Therapeutics, doi: /mmt Hawk, C., Schneider, M. J., Vallone, S., & Hewitt, E. G. (2016). Best Practices for Chiropractic Care of Children: A Consensus Update. Journal Of Manipulative & Physiological Therapeutics, 39(3), 158. doi: /j.jmpt Homola, S. (2016). Pediatric Chiropractic Care: The Subluxation Question And Referral Risk. Bioethics, 30(2), doi: /bioe Miller, J., Vallone Sharon, A., Larsdotter, A., & Barham-Floreani, J. (2010). Chiropractic approach to the management of children. Chiropractic And Osteopathy, Vol 18, Iss 1, P 16 (2010), (1), 16. doi: / Shaw, G. (2014). Safety and Effectiveness of Pediatric Chiropractic. ACA News (American Chiropractic Association), 10(8), The Foundation of Chiropractic Progress (2017). UCLA Pediatric Pain and Palliative Care Program Director, Lonnie Zeltzer, MD, Joins F4CP in Recommending Drug-Free Chiropractic Care for Pediatric Pain Management. Business Wire (English). Yeomans, S. (2009). Subluxation and Chiropractic. Veritas Health. Retrieved from Young, M. D., & Young, J. L. (2017). Topics in pediatrics: Conservative care of Pediatric acquired Torticollis: A report of 2 cases. Journal Of Chiropractic Medicine, doi: /j.jcm