The Chiropractic Board of Australia (CBA) has advised chiropractors not to use spinal manipulation to treat children under two years of age pending an independent expert review of the evidence and development of a final policy. Despite public outrage and calls for regulation brought on by recent viral videos of Australian chiropractors treating infants, the Board took action only after national health authorities forced their hand.
Prior to the CBA’s ban, Victorian Minister for Health Jenny Mikakos asked Safer Care Victoria, the state’s healthcare quality and safety improvement agency, to lead an independent review of the practice of spinal manipulation on children under 12 years (not just children two and under) and for the findings of that review to be reported to the Council of Australian Governments (COAG) Health Council, including any need for changes to the national law governing chiropractic practice. At its March, 2019, meeting, the COAG Health Council, comprised of federal, state, and territory Health Ministers,
noted community concerns about the unsafe spinal manipulation on children performed by chiropractors and agreed that public protection was paramount in resolving this issue.
The Health Council welcomed the Victorian Health Minister’s proposal for an independent review with the findings reported to the Council.
Health Minister Mikakos took action after seeing a video of Melbourne chiropractor Andrew Arnold manipulating an infant’s spine, hips and collarbone, which she called “deeply disturbing”. Arnold uses an “activator”, a spring-loaded chiropractic device, on the baby, which elicits cries from the child as it is applied to his neck, tailbone and spine.
It’s appalling that young children and infants are being exposed to potential harm . . . Newborn babies are extremely fragile and it’s important to be aware that the damage done to an infant may not be obvious immediately and may not manifest until years later.
While Mikakos focused on manipulation of the baby’s spine, SBM’s resident pediatrician, Dr. Clay Jones, also exposed the quack diagnostic method used by Arnold in justifying his treatment, chiropractic shtick he’s seen in hundreds of chiropractic marketing videos.
What has people bent out of shape is that Arnold briefly holds the baby upside down by his feet, the rationale of which isn’t made clear in the video. I’ll explain what he’s doing, not that it matters. It’s ridiculous no matter how you slice it.
When explaining this “test” to parents, the reason given typically involves the “fencing reflex“, a primitive reflex where the arm and leg flex when a young infant’s head is turned to that side. Holding a baby upside down by one leg to see if a baby turns their head a certain way is an incredibly stupid means of testing for the presence of this reflex, but here we are. The chiropractor will claim that if the baby doesn’t turn correctly then there must be some kind of nervous system “interference” that only they can fix.
Sometimes this reflex isn’t mentioned at all and they just make the claim that the baby should keep their head straight. If the head turns, it must be because of some kind of spinal misalignment that only they can fix. Whatever the explanation, the chiropractor can literally use any response from the baby as a reason for treatment because it is all just made up. It’s all just a performance. The individual chiropractor may believe what they are saying, but that doesn’t mean that they aren’t fooling themselves by reading into random baby behavior.
It was Mikakos herself who referred Arnold to the Chiropractic Board and the Australian Health Practitioner Regulation Agency (AHPRA). Arnold has agreed not to treat children up to 12 years of age pending the results of an investigation by health authorities.
Yet, despite public outrage over the Arnold video, the CBA’s initial reaction was the same as ever — simply reiterating policies that were obviously being widely ignored by chiropractors:
The board has made a strong statement about the care of children and has written to every chiropractor in Australia to warn them to comply with their professional and ethical obligations, which are clearly outlined in the board’s code of conduct,” a [CBA] spokeswoman said.
It was only after the independent expert review train had left the station that CBA issued the “Interim policy on spinal manipulation for infants and young children“, banning, for now, manipulation of children under two. This action follows a 2017 CBA position statement on chiropractic pediatric care, itself an apparent response to public outcry following publication of several reported incidents of dubious chiropractic treatment of children. In the 2017 statement, the Board announced
an expectation that chiropractors ensure their clinical practice is consistent with current evidence and/or best-practice approaches.
But – OOPS! – the Board has now belatedly realized that
there is no current clinical guideline, or peer-reviewed publication to guide chiropractors with respect to the care of infants and young children, and the use of spinal manipulation in particular.
Thus, the CBA claims to “look forward to the outcomes of the independent review” which effectively wrests the pediatric spinal manipulation issue out of the CBA’s grip and into the hands of Safer Care Victoria, whose no-nonsense approach is evident from its plan to tackle the matter.
Safer Care Victoria will convene a panel of experts in healthcare evidence, governance, pediatrics, and musculoskeletal care, as well as consumer representatives, all of whom will be required to declare any conflicts of interest. Starting in June of this year, the panel will conduct a systematic review of the literature and review written submissions from the public. A final report and recommendations is expected within six months.
Repeatedly ignoring the CBA’s rules
The video Victoria’s Health Minister found so appalling was just one of several recent incidents of chiropractic malfeasance in Australia and the CBA’s anemic response, all ably covered by SBM’s Drs. Jones and Novella.
In 2013, a Melbourne pediatrician cared for a four-month-old infant whose neck was allegedly broken by a chiropractor attempting to treat torticollis. The CBA closed that case by allowing the chiropractor to continue practicing as long as he obtained further education in pediatric chiropractic care. As Dr. Novella noted at the time, “training is irrelevant when you don’t have a science-based practice in the first place.” Dr. Jones later reported that the Chiropractic Association of Australia tried to obfuscate the chiropractor’s role in the infant’s injury.
Then, in 2015, the media reported that chiropractors who had not been credentialed to practice in hospitals were nevertheless sneaking in to “adjust” newborns, further evidence that chiropractors were simply ignoring the rules. The chiropractors were ordered to undertake ethics and professional development training.
Next, in “the crack heard round the world“, Melbourne chiropractor Ian Rossborough’s promotional YouTube video (since removed) of himself manipulating a four-day-old premature infant’s thoracic spine hard enough to cause a loud cracking sound, and a cry of pain from the baby, went viral after being featured in an April, 2016, Australian Broadcasting Corporation Radio National story. Rossborough claimed the treatment was for acid reflux and/or colic, conditions, which as Dr. Jones pointed out, aren’t diagnosed in infants of that age.
The CBA did impose sanctions on Rossborough but, according to NewsGP,
despite these conditions, as well as restrictions related to testimonials and advertising, dozens of videos of Mr Rossborough appeared online in 2017 that show the controversial chiropractor performing a range of treatments on children – some as young as three weeks’ old.
Sanctions were lifted in July, 2018, and he is now free to treat patients of any age. His registration shows no disciplinary action.
Just a month prior to Rossborough’s video going viral, as Dr. Jones noted, the CBA had, once again, admonished chiropractors:
Claims suggesting that manual therapy for spinal problems can assist with general wellness and/or benefit a variety of pediatric syndromes and organic conditions are not supported by satisfactory evidence. This includes claims relating to developmental and behavioral disorders, ADHD, autistic spectrum disorders, asthma, infantile colic, bedwetting, ear infections and digestive problems.
But CBA’s repeated warnings did absolutely nothing to stop either Rossborough or Arnold.
“Plenty of science” say American chiropractors
The Royal Australian College of General Practitioners welcomed the evidence review, although the RACGP believes the inquiry should be more wide-ranging, broader than just the use of spinal manipulation in children.
Not surprisingly, the response from fellow chiropractors in America has been less enthusiastic. According to The Chronicle of Chiropractic, the CBA’s admission that there are no current clinical guidelines or peer-reviewed publications to guide to using spinal manipulation in the care of young children is false:
nothing could be farther [sic] from the truth. There is a robust base of evidence for the chiropractic management of children including practice guidelines by the Council on Chiropractic Practice and the International Chiropractors Association. Further, studies on safety and efficacy have been carried out by the International Chiropractic Pediatric Association among others.
The Foundation for Vertebral Subluxation chimed in, saying there is “plenty of science” supporting vertebral subluxation management.
Sherman College of Chiropractic also issued a statement supporting chiropractic care of children:
Misalignments in the spine may result from the birth process, falls, tumbles, and stresses of childhood, resulting in interference with proper function of the nerve system. These are called vertebral subluxations. Doctors of Chiropractic recognize the importance of locating and gently correcting vertebral subluxations so that the body may function at its best.
The International Chiropractors Association is “offering any and all assistance, information and available resources” to the Australian Chiropractors Association, while advocating “the earliest possible evaluation, detection and correction of chiropractic subluxations in children, especially infants, to maximize the potential for normal growth and development”.
To borrow Dr. Jones’s term, this is typical “straight” chiropractic shtick, and it’s nonsense. Yet it is the foundation upon which subluxation-based chiropractors, including the Australian video stars, base treatment of all manner of childhood conditions via “adjustments” to restore “proper nerve function” thereby allowing “the body to heal itself”. This is scaremongering to convince parents that the normal birth process (hence the chiropractors sneaking into hospitals) and everyday childhood activities are a dire threat to their children’s health and require immediate chiropractic treatment.
One of the supporters did make an interesting point, though. The CBA’s Interim Policy defines “spinal manipulation” as “moving the joints of the spine beyond the child’s usual physiological range of motion using a high velocity, low amplitude thrust”. But, as the author notes, “much of chiropractic care of infants does not involve cavitating joints.” This is, in fact, a chiropractic selling point: that their “adjustments” of a child’s “vertebral subluxations” is gentle or, as they like to say, comparable to the pressure used to check the ripeness of a tomato. Whether the ban will fall on this semantic nicety remains to be seen.
In any event, it is perfectly legal here in the U.S. to make these claims and no one seems to be doing a thing about it. Notably, Sweden has legislated that no child under eight can be treated by chiropractors.
Based on a recent systematic review of the evidence evaluating the use of manual therapy for clinical conditions in the pediatric population, assessing the methodological quality of the studies, and synthesizing findings based on health condition, it looks like Safer Care Victoria’s independent expert review cannot possibly support chiropractic manipulation for children. Put another way, actually there is not “plenty of science”.
Fifty studies investigated the clinical effects of manual therapies for a wide variety of pediatric conditions. Moderate-positive overall assessment was found for 3 conditions: low back pain, pulled elbow, and premature infants. Inconclusive unfavorable outcomes were found for 2 conditions: scoliosis (OMT) and torticollis (MT). All other condition’s overall assessments were either inconclusive favorable or unclear. Adverse events were uncommonly reported. More robust clinical trials in this area of healthcare are needed.
And that was the conclusion of researchers from three chiropractic colleges and a private chiropractic practice. Edzard Ernst, MD, was even less impressed with the evidence. His review of their review concluded
there is no good evidence for chiropractic, osteopathic or other manual treatments for children suffering from any condition.
And, as he pointed out, even if you accept the authors’ take,
Only three conditions are, according to the authors, based on evidence. This is hardly enough to sustain an entire speciality of paediatric chiropractors.
I hope Australia’s Health Ministers will come to the same conclusion and, more importantly, do something about it.