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CHIROPRACTIC SPINAL MANIPULATION OF CHILDREN UNDER 12

Report of an independent review by Safer Care Victoria
October 2019

November 1, 2019

For immediate release

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Summary of outcomes and recommendations

SCVAs a consequence of concerns expressed by members of the public following the publication of a video showing the treatment by a chiropractor of a newborn infant in August 2018, the Minister of Health for the State of Victoria in Australia commissioned an independent review of the practice of spinal manipulation in children under the age of 12 years.

In March 2019 a panel was established to conduct this review. Panellists included medical experts in pediatrics, chiropractors, and regulators. It was chaired by the head of Safer Care Victoria, Professor Euan Wallace. The panel included Adjunct Professor Matthew Fisher, Chief Executive Officer of the Australian Chiropractors Association and Dr Wayne Minter, Chair of the Chiropractic Board of Australia.

The review included a public consultation, consultation with practitioners and regulators and a systematic review of the evidence by Cochrane Australia. For the purposes of the review, spinal manipulation was defined in terms of the application of a high velocity, low amplitude thrust beyond the physiological range of movement of a joint but within the limits of anatomical integrity. In Australia, the practice of spinal manipulation is limited to chiropractors, osteopaths, medical practitioners and physiotherapists.

Review of the evidence of harm

A search of the available literature was conducted by Cochrane Australia along with an analysis of patient complaints, practitioner notifications and an evaluation of insurance claims data from chiropractic insurers.

The review found very little evidence of patient harm for spinal manipulation in the treatment of children under 12 years. No patient complaints were identified and there were no practitioner notifications.

Three reports of serious harm were reported relative to spinal manipulation in children under 12 years. None of these events involved chiropractors, nor did they feature techniques used by chiropractors in Australia.

It was considered that there were 2 main reasons why evidence of harm was low:

- Spinal manipulation is rarely applied by chiropractors in the treatment of children under 2 years.

- Chiropractors utilise modified force techniques such that there is little likelihood of children receiving high velocity, low amplitude thrust spinal manipulation.

Despite these findings, the review states that spinal manipulation in children under the age of 12 years cannot be considered wholly without risk and that any risk of harm should be weighed against the evidence of benefit, especially in children under the age of 2 years.

Review of the evidence of effectiveness

Safer Care Victoria commissioned Cochrane Australia to undertake a systematic review of the effectiveness and safety of spinal manipulation in children under the age of 12 years.

The resulting systematic review concluded that the evidence base was very poor. It concluded that no strong evidence of effectiveness exists for the following conditions:

- Infantile colic
- Enuresis (bed wetting)
- Back and neck pain
- Headache
- Asthma
- Otitis media
- Cerebral palsy
- Hyperactivity
- Torticollis

Weak evidence was found for modestly reduced crying time in infantile colic and reduced wet nights in children with enuresis.

The review concluded that spinal manipulation cannot be recommended for headache, asthma, otitis media, cerebral palsy, hyperactivity or torticollis. It further concluded that the unlikely evidence of benefit versus the potential risks of harm should be considered in the use of spinal manipulation in the treatment of infantile colic and enuresis.

Public consultation

A public consultation resulted in 21,824 responses from people who had accessed chiropractic spinal care for children under the age of 12 years.

99.7% of respondents reported a positive experience of chiropractic care of children.

98% reported an improvement in symptoms following chiropractic care.

The panel noted a strong thread in the responses stressing the importance of the right of parents to choose the best care for their children.

The most common conditions for which chiropractic spinal care was sought for children under 12 years were as follows:

- Posture
- Colic
- Neck pain
- Breastfeeding issues
- Back pain
- Headache

0.3% of respondents reported a negative experience. Principal reasons cited included cost of care relative to perceived benefit, excessive use of x-rays, pressure to avoid medication or advice to avoid previously-consulted health professionals).

Health practitioner consultation

2735 responses were received from health care practitioners. Of the 85% of those confirming they provided spinal care for children, 99.5% were chiropractors.

Of the respondents, 80% stated they treated children aged 0-3 months, while 88% confirmed they treated children aged 0-24 months.

The most commonly reported benefits of care described by respondents were decreased pain, improved sleep patterns, more relaxed, improved breastfeeding and latching, and improved range of movement.

RECOMMENDATIONS

Improved safety

1. Spinal manipulation should not be provided to children under 12 for general wellness or for the management of the following conditions:

- Developmental or behavioural disorders
- Hyperactivity disorders
- Autism spectrum disorders
- Asthma
- Infantile colic
- Bedwetting
- Ear infections
- Digestive problems
- Headache
- Cerebral palsy
- Torticollis

2. National boards of those professions permitted to perform spinal manipulation should consider recommendation (1) when reviewing their policies in relation to the care of children.

3. Prior to treatment with spinal manipulation of children under 12, practitioner should provide written information setting out the proposed benefits and possible risks of care.

4. National boards should review notification data regularly to identify trends requiring modifications of policies, in line with the principle of risk-based regulation.

Improving quality

5. Practitioner groups permitted to perform spinal manipulation in Australia should urgently undertake research to develop an evidence base for spinal manipulation on children. The practice of spinal manipulation on children under 12 years should be ceased when there is the evidence shows no benefit. Ministers should consider whether funding should be allocated for the purpose of research.

6. Practitioner groups permitted to perform spinal manipulation in Australia must lead on developing evidence-based guidance on spinal manipulation of children for both practitioners and consumers, using National Health and Medical Research Council endorsed methods. This guidance material should form the basis of written information for parents in line with recommendation (3).

7. Consideration should be given by the Chiropractic Board of Australia to various models of advanced chiropractic training in pediatric care, particularly in spinal manipulation. Post-registration training on offer to chiropractors with a special interest in paediatrics should be assessed against the evidence-based guidelines.

Eliminating false advertising

8. Chiropractors should continue to be audited by regulatory authorities for their compliance with guidance relating to advertising.

9. National boards should consider whether prohibitive advertising statements are issued regarding spinal manipulation in children where there is evidence of no benefit.

10. Ministers should consider increasing penalties for advertising offences where a registered practitioner claim benefits of spinal manipulation in children that have no evidence base.


The full report is available at http://bit.ly/SCVpaediatric. It includes an Executive Summary, recommendations, a detailed description of the public consultation, and the systematic review undertaken by Cochrane Australia. 

                                                

 

 

WFC releases new guiding principles document

Statements reflect strong commitment to global advancement

September 24, 2019

For immediate release

Toronto, September 24, 2019. The World Federation of Chiropractic (WFC) has today published a suite of guiding principles that will support its strategy for supporting, empowering, promoting and advancing chiropractic globally.

The WFC’s new Principles document consists of 20 statements that set out clearly what the organization stands for and how it views chiropractic as a contemporary global health profession. The statements, which align with the WFC’s mission to advance awareness, utilization and integration of chiropractic internationally, were approved unanimously by the Board of Directors.

Launching the Principles, WFC Interim President Dr Vivian Kil said, “These Principles say who we are. It is important that our member national associations, corporate partners, supporters and the public clearly understand the role that the WFC plays internationally in representing chiropractors in over 90 countries worldwide. As our #BeEPIC campaign gathers momentum, these Principles underscore our values and our vision for the future.”

In drafting the statements the WFC has been mindful of the social determinants of health that influence access to care and the variety of environments in which chiropractic is practiced. Secretary-General Dr Richard Brown commented: “The WFC is an inclusive, global organization and we want these statements to resonate with chiropractors around the world. They reflect our commitment to support and develop the profession for the benefit of patients and the public and we’re excited to be launching the Principles document at this time.”

The WFC’s Principles are available for download and distribution in English, French and Spanish.

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The WFC Principles

For over 30 years the World Federation of Chiropractic has been at the forefront of the global development of chiropractic. Representing the interests of the profession in over 90 countries worldwide, the WFC has advocated, defended and promoted the profession across its 7 world regions. These WFC Principles set out who we are, what we stand for, and how chiropractic as a global health profession can impact on nations so that populations can thrive and reach their full potential.

Our 20 principles

1. We envision a world where people of all ages, in all countries, can access the benefits of chiropractic.

2. We are driven by our mission to advance awareness, utilization and integration of chiropractic internationally.

3. We believe that science and research should inform care and policy decisions and support calls for wider access to chiropractic.

4. We maintain that chiropractic extends beyond the care of patients to the promotion of better health and the wellbeing of our communities.

5. We champion the rights of chiropractors to practice according to their training and expertise.

6. We promote evidence-based practice: integrating individual clinical expertise, the best available evidence from clinical research, and the values and preferences of patients.

7. We are committed to supporting our member national associations through advocacy and sharing best practices for the benefit of patients and society.

8. We acknowledge the role of chiropractic care, including the chiropractic adjustment, to enhance function, improve mobility, relieve pain and optimize wellbeing.

9. We support research that investigates the methods, mechanisms, and outcomes of chiropractic care for the benefit of patients, and the translation of research outcomes into clinical practice.

10. We believe that chiropractors are important members of a patient's healthcare team and that interprofessional approaches best facilitate optimum outcomes.

11. We believe that chiropractors should be responsible public health advocates to improve the wellbeing of the communities they serve.

12. We celebrate individual and professional diversity and equality of opportunity and represent these values throughout our Board and committees.

13. We believe that patients have a fundamental right to ethical, professional care and the protection of enforceable regulation in upholding good conduct and practice.

14. We serve the global profession by promoting collaboration between and amongst organizations and individuals who support the vision, mission, values and objectives of the WFC.

15. We support high standards of chiropractic education that empower graduates to serve their patients and communities as high value, trusted health professionals.

16. We believe in nurturing, supporting, mentoring and empowering students and early career chiropractors.

17. We are committed to the delivery of congresses and events that inspire, challenge, educate, inform and grow the profession through respectful discourse and positive professional development.

18. We believe in continuously improving our understanding of the biomechanical, neurophysiological, psychosocial and general health effects of chiropractic care.

19. We advocate for public statements and claims of effectiveness for chiropractic care that are honest, legal, decent and truthful.

20. We commit to an EPIC future for chiropractic: evidence-based, people-centered, interprofessional and collaborative.

Be Epic sm

   

WFC Survey of Chiropractic Global Workforce Reveals Huge Imbalance in Service Provision.

July 26, 2019

For immediate release

ChiroMTToronto, July 24, 2019. The results of a global survey of the chiropractic profession have revealed a significant lack of provision in low- and middle-income countries, according to a new paper published today in Chiropractic and Manual Therapies.

The survey, undertaken by the World Federation of Chiropractic, gathered data from its constituent national associations, government websites, internet searches and personal correspondence. Information was sourced from all 193 United Nations member nations, including 90 countries where at least one chiropractor was practising.

The results showed that overwhelmingly chiropractors were mostly located in North America (United States and Canada).

The survey also revealed that of the 48 educational institutions offering chiropractic programs, the majority were in high-income countries with almost 60% located in North America or Europe.

The World Health Organization’s (WHO) Global Strategy on Human Resources for Health: Workforce 2030 has targeted universal availability, accessibility, acceptability, coverage and quality of health systems within strengthened health systems. The WFC’s mission statement (to advance awareness, utilization and integration of chiropractic internationally) aligns with this strategy.

WFC Secretary-General Richard Brown comments: “With low back pain being the biggest single cause of years lived with disability and an increasing ageing population, it is clear that there is a shortfall in the numbers of health workers globally who are trained to effectively manage spinal pain and disability. Chiropractors, as non-surgical experts in spine care, are well placed to make a positive impact, yet numbers need to rise. Expansion of educational provision in low- and middle- income countries and increased awareness by health policy makers are instrumental factors in meeting the needs of underserved populations.”

As with many global surveys, responses were mixed and the authors highlighted the need for further information gathering, monitoring and reporting of data. Despite this, the message is clear: health inequities seen throughout the world are reflected in the provision of chiropractic and more needs to be done to ensure adequate numbers of chiropractors in countries where the impact of spinal pain and disability is profound.

The full paper can be downloaded from Chiropractic and Manual Therapies at http://bit.ly/ChiroWorkforce

   

Australian Chiropractors Association Publishes Submission to Safer Care Victoria Independent Review into Chiropractic Spine Care For Children.

June 28, 2019

PRESS RELEASE

Following the publication in Australia earlier this year of a video showing a chiropractor treating a baby, the Health Minster for the state of Victoria called for the prohibition of chiropractic spinal manipulation for children under the age of 12 years. As a result, an independent panel has been appointed by Safer Care Victoria to examine the evidence and provide recommendations for the chiropractic care of children.

The role of the panel is to (a) examine and assess the available evidence, including information from consumers, providers, and other stakeholders, for the use of spinal manipulation by chiropractors on children less than 12 years of age and (b) provide recommendations regarding this practice to the Victorian Minister for Health.
Members of the public and key stakeholders, including the WFC’s member for Australia, the Australia Chiropractors Association (AusCA), were invited to submit observations. The AusCA’s submission can be read here.

The AusCA has drawn heavily in its response on the principles of evidence-based, people-centered, interprofessional and collaborative  (EPIC) care.

Points to note are as follows:

1.    The AusCA has taken a strongly evidence-based approach to its response, emphasising the safety and protection of the public, while setting out its position on the role of chiropractors in the Australian health care system.

2.    The document draws attention to the need for chiropractors to practice ethically, competently and professionally and in line with the code of conduct as drafted by the Chiropractic Board of Australia.

3.    The need for chiropractors to possess an approved qualification from an approved educational institution is emphasised.

4.    The AusCA has clearly defined spine care as the major or defining clinical purpose, with chiropractors being defined as community-based primary care health providers.

5.    The international, interdisciplinary evidence base for chiropractic is emphasised. The challenges of effective knowledge translation are described (noting that in general medicine, knowledge translation can sometimes take 15 years or more).

6.    Integration into the health care system is described, with chiropractic being described as a popular, highly utilised profession.

7.    In respect of infants, children and adolescents, evidence-based prevention and treatment strategies for musculoskeletal conditions are emphasised.

8.     The report describes 30,000 treatments per week (8-10% of all treatment provided) being provided to the paediatric population in Australia.

9.     The report emphasises the safety of chiropractic treatment by reference to 2 systematic reviews and insurance data from Scandinavia.

10.    The duty binding on chiropractors to obtain informed consent to care is supported.

11.    The report sets out the levels of effectiveness for manual therapies for paediatric conditions, noting its variable quality (in line with other professions) but stating that it is mostly ‘moderate-positive’ or ‘inconclusive-favourable’.

12.    The document states that there is no evidence that would support restriction of parental or patient choice when seeking chiropractic care for children under 12 years as there is no evidence of harm. There is, however, expressed outcome of benefit.

13.    The submission calls for a considered response by the Victoria government, noting that similar restrictions on the provision of care to those proposed have never been implemented. Instead, guidelines that minimise harm and define good practice have helped to ensure that consumers make informed choices about the care they receive have been introduced.

14.    The AusCA calls for:

a.    A trial of monitoring care, including outcomes, for children under 12 years;
b.    Refinement of industry-led standards and clinical guidelines informed by best practice, including CPD/CE and consensus approaches to care including interprofessional understanding;
c.     A commitment to knowledge translation;
d.    A call for greater support of research in investigating the role of chiropractors in the treatment of children.


AusCAAustralian Chiropractors Association

The Australian Chiropractors Association is the peak body for the chiropractic profession in Australia. Representing over 3000 members, it provides a strong, unified voice for chiropractors in Australia. Its work involves advocacy, membership services, research, public engagement and governance. Its current president is Dr Anthony Coxon.

The Australian Chiropractors Association is the WFC member for Australia and is located in the WFC’s Pacific Region.

 

 

   

UK to offer new university-based chiropractic program at University of Central Lancashire

June 24, 2019

PRESS RELEASE

 

UCLan webThe United Kingdom will soon have another new university-based chiropractic program, adding to four existing programs and the announcement of a fifth earlier this year. The University of Central Lancashire (UCLan) is located in the North West of England and last week announced that it was recruiting a senior lecturer to serve as a course leader within UCLan’s School of Health Sciences.

The launch of the new chiropractic program, which will be offered as an integrated Masters program, is the third to have been launched since the establishment of the Society for Promoting Chiropractic Education (SPCE), following the announcement of new programs at London South Bank University and Teeside University.

Chief Executive of SPCE, Satjit Singh, said: “We are delighted that UCLan are developing a new chiropractic programme. It will be of immense benefit to students, especially in the North-West, as well as help improve access to chiropractic care in the area. Students will enjoy a wonderful all-round experience, benefitting from UCLan’s excellent campus and teaching facilities. We look forward to supporting UCLan in developing the programme, which will meet the aspirations of the patients, profession and students.”

UCLan imageUCLan is a large provider of multi-professional healthcare education, traiing and development, offering a range of taught undergraduate and postgraduate modular based courses, research degrees and credit recognition. The School develops its portfolio collaboratively with partners in response to national policy and local requirements and needs, providing professional courses, short courses and continuing professional development. The focus is on students developing evidence-based knowledge, skills and person-centred values in preparation for employment. 

In addition to its newly-announced chiropractic provision, the School of Health Sciences at UCLan offers courses in: Physiotherapy, Sports Therapy, Paramedic Practice, Occupational Therapy, Operating Department Practice, Health Informatics, and Acute and Emergency Care.

Commenting on the announcement, WFC Interim President Dr Vivian Kil said: “The announcement of yet another chiropractic program at a mainstream UK university shows an exciting development in the provision of comprehensive, evidence-based chiropractic education. This will expand workforce capacity, increase access to and awareness of chiropractors and help in tackling the burden of spinal and joint pain and disability in the UK and Europe.”

The university is currently recruiting a Senior Lecturer to lead the chiropractic program. Applications are welcomed and further information can be found at http://bit.ly/UCLan_job.

   

WHO Focus on Low Back Pain Demonstrates Unprecedented Opportunities For Chiropractors

June 5, 2019

PRESS RELEASE

WHO Headquarters Geneva webToronto, June 5, 2019 The World Health Organization has published a paper in its Bulletin that warns of the risks of over-medicalizing the management of low back pain, instead advocating care that chiropractors are highly qualified to provide.
 
The paper (1), authored by leading experts from Australia and the UK, proposes non-drug, non-surgical approaches as the first line treatments for low back pain. They include advice, education and reassurance with manual therapies including spinal manipulation for patients at risk of developing chronicity.
 
The paper’s authors were particularly critical of the overuse of spinal surgery, hospitalization, injections, complex pharmaceuticals and diagnostic imaging. This mirrored the strong evidence cited in a series of articles on low back pain published last year in The Lancet.
 
The WHO Bulletin paper found that despite international recommendations, it was conservatively estimated that 32% of care provided for low back pain in the USA was inconsistent with clinical guidelines, including a rise of 62% in elective spinal fusion surgery (2004-2015) in the USA, despite no good evidence of benefit over non-surgical care.
 
“As spine care specialists, chiropractors are perfectly positioned to provide evidence-based, people-centered care for low back pain,” said WFC President Dr Vivian Kil. “All of the top guidelines published in the past few years are telling us that non-surgical, non-drug care is the preferred approach. Spinal manipulation is increasingly being seen as the treatment of choice. Chiropractors are highly skilled in this technique but can also deliver many of the other recommended interventions, such as patient education, soft tissue techniques and self-management advice.”
 
For chronic persistent low back pain, the guidelines recommend a multidisciplinary approach. As part of its #BeEPIC campaign, the WFC recommends interprofessional and collaborative care and increasingly chiropractors are engaging positively with spine care professionals from other disciplines.
 
WFC Secretary-General Richard Brown commented: “As well as meeting demand in high-income countries, more chiropractors are needed around the world to deliver evidence-based care to underserved communities. We know that in low- and middle-income countries many people have no access to health care, let alone spine care. Chiropractors have all the skills to make a real difference to the lives of those suffering from spinal pain and disability.”
 
The WHO Bulletin paper criticizes the persistent use of opiate painkillers for chronic back pain despite research showing limited benefit and the US Center for Disease Control being very clear that they should not be used for chronic, non-cancer pain. Yet many health systems remain non-compliant with guidelines at the expense of patient outcomes and huge costs.
 
As spine care experts, chiropractors are well-placed to re-educate patients around the many myths and misconceptions surrounding back pain management. Dr Kil continues, “Back pain is one of those conditions where everyone wants to give advice, but the reality is that it is not always grounded in evidence. Staying active and mobile may seem unnatural when you’re in pain, but it works and the guidelines support this approach.”

Reference
1.    Traeger AC, Buchbinder R, Eishaug AG, Croft PR, Maher CG. Bulletin of the World Health Organization 2019;97:423-433. doi: http://dx.doi.org/10.2471/BLT.18.226050
Notes
•    The WFC is the only chiropractic organization to be a non-state actor in official relations with WHO.
•    It represents the national chiropractic organisations of over 90 countries in 7 global regions.
•    Headquartered in Toronto, Canada, its current Interim President is Dr Vivian Kil of the Netherlands.

   

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