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Table 5 Evidence Table: Case Reports

From: The safety of spinal manipulative therapy in children under 10 years: a rapid review

Author(s), YearSubjects & Setting; nIntervention(s)Method of Measurement of AEFollow-upKey Findingsa
Hubbard, 2010 [62]7-year-old; female; migraine HA, mid-back and abdominal pain for previous 2 mos, episodic vomiting for intermittently for 9 mos8-week course of low velocity, low-amplitude adjustments, following upper cervical pediatric protocol; 7 tx to C1 over 13 visits.Cannot sayDuring course of txNo report of adverse symptoms occurred after the intervention
Muir, 2012 [63]5-year-old; male; ADHD (no medication): acting out, inability to follow instructions, poor home and school performance11 tx over summer, 2-3x/week in November (re-evaluation at 4 wks, 2x/month between December–May); SMT, soft tissue therapy, and myofascial release therapyCannot say1 yearNo AE were reported
Bourque, 2018 [53]5-month-old; male; fussing, irritability, crying, grunting, rigidity, abnormal position of left arm, 2 wks of constipation, breastfeeding difficulties on right side, apparent discomfort lying on stomach; fracture of left clavicle during birth1x/week for 2 wks, 2 tx over 2 mos; sacro-occipital technic for occipital restriction, Thoracic spine (T2 and T5) was treated with the “touch and hold” technique by holding a specific, light pressure on the fixated vertebrae.Cannot sayPatient A: 5 weeks
Patient B: 4 weeks
No AE related with the intervention
Berube, 2004 [57]6-day-old; female; symptoms of digestive disorder that began at 4-days-old, difficulty with eructation, taking several minutes to elicit, trouble eliminating stool accompanied by crying; immediate crying when lying supineSMT performed with diversified technique modified for gestational age and size using low force; 1x/week, 4 weeks, re-evaluation with tx after 4 weeksCannot sayCannot sayNo AE due to chiropractic manipulation was reported by the parent
Dorough, 2018 [58]2.5-year-old; male; speech delay, difficulty lying prone, unable to lift head up well, crying when pushing up from groundCervical spine modified Gonstead Technique and instrument-assisted Sigma-Instrument; 7 visits 1x/wk., 8 weeksCannot sayOver the course of treatmentNo adverse reactions to tx were reported to occur with the intervention
Martin-Marcotte, 2018 [59]21-month-old; female; episodes of constipation for the past 15 mosModified Diversified Technique for the child’s age and development; 2x/week, 4 weeks, re-evaluation after 10 visits, 1x/month subsequentlyCannot sayOver the course of treatmentNo adverse reaction to adjustment reported
McCormick, 2018 [60]15-month-old; male; motor developmental delay, not able to crawl, pull up to stand, stand alone or walkFull spine SMT with Diversified Technique (Activator instrument-assisted); 1x/week for 4 weeks, 1x/every other week for 12 weeksCannot sayDuring the course of careNo adverse reactions were identified or reported to occur with the intervention
Lacroix, 2016 [64]4-month-old; female; recurrent regurgitation after feeding, averse to being carried, difficult eructation, interrupted sleep, choking and rumination, wheezing during sleep, fussiness, distended stomach, excessive intestinal gas17 chiropractic adjustments over 20 weeks; craniosacral technique and Diversified adjusting technique (high velocity low amplitude)Cannot sayDuring the course of careNo AE were reported to occur with the intervention
Makela, 2018 [65]3-year-old; female; autism spectrum disorder, no verbal or non-verbal communication, off balance when walking, toe-walking 50% of the timeSMT provided on 11 visits over 6 weeks; spring-loaded instrument assisted technique; after re-evaluation, 2x/week with re-evaluation every month (Dec – Mar)Cannot sayDuring the course of careNo adverse reactions to treatment were reported
Dobson, 1996 [46]5-year-old; male; asthmatic; seeks care to promote “normal” & vitality posture; ROM limited in extension; muscle tension cervical spine; neutral lateral radiograph revealed an os odontoideum3x/week for 4 weeks, 4x/week for 2 weeks, 1x/week for 3 years; toggle-recoil (short lever high velocity, very low amplitude) adjustment when indicatedCannot sayCannot sayNo negative effects were experienced with the intervention
Wilson, 2012 [48]21-day-old; female; reported to pediatrician w/ concern of abnormality/ crepitus on back; presented to chiropractor due to fussiness and colic at 16-days-oldDay 23, follow-up investigation by child abuse center with the chiropractor confirmed the parents report.
Parents described chiropractor initially held patient upside down by hips, with hands around hips and lower ribs. Applied pressure along spine with fingertips. Used a “spring-activated device” on back (in same location of fracture), while patient lay prone on the mother’s chest.
Chest radiograph and investigation by child abuse center to confirm reportsAt 35 days of life, evidence of rib fracture healing with no new fracturesAcute fractures of 7th and 8th posterior ribs
Shafrir, 1992 [51]4-month-old; male; head tilt noted in first week of life attributed to neck trauma during delivery, noted discomfort when placed on abdomen, could not raise head from prone; told would resolve but no improvement in head tilt after 4 monthsFirst tx: Neck manipulation including flexion, extension and axial loading and unloading
Second tx: parents returned after first response to manipulation, were reassured and infant was provided another neck manipulation
3 h post second tx, admitted to hospital; routine chest radiograph showed enlargement of the spinal canal from C3-T8. MRI of the head and spine showed a mass within the spinal cord, extending into the medulla superiorly and occupying the entire canal from mid-cervical to the lower thoracic region.
During surgery, thrombosed veins were noted on the dorsum of the enlarged spinal cord, when spinal cord was incised at C6 level, creamy white, viscoelastic tumour tissue exuded spontaneously. No normal cord tissue was identifiable at this level. Cervical and lower thoracic portions of the tumour were easily removed from normal-appearing spinal cord tissue.
Pathologic examination revealed mostly necrotic tissue, with the lack of inflammatory infiltrates (suggesting acute necrosis, rather than due to a high-grade malignancy), with several areas of low-grade astrocytoma.
Immediately after txAfter first tx: difficult to arouse him from a nap, he was described as limp, pale and moaning
After second tx: immediately post-manipulation was alert, later began to moan and grunt continuously, fed poorly, fever developed.
Three hours after second neck manipulation, he was admitted to the hospital, where he was described as listless and fussy, w/ a weak cry.
Early next morning, he had a brief, generalized seizure, followed by “gasping” respirations and cyanosis, requiring tracheal intubation, followed by another 3 h seizure.
Infant was admitted to the intensive care unit while comatose and rarely responsive to painful stimuli. Later, infant opened eyes and had conjugate movements. Infant had flaccid paralysis of both legs and right arm, with some active motion and withdrawal of the left arm.
Post-operatively, infant regained motor and sensory function to the T4 level. 18 months later, he had full use of the upper extremities, sensory function at approximately T9 level and some spontaneous but non-functional motion of the right leg.
Diagnosis: congenital spinal cord astrocytoma
Humphris, 2014 [52]6-month-old; female; left head rotation and ipsilateral flattening of her posterolateral cranium, frequent regurgitation of breast milk immediately after feeding with inability to feed from the right breast, unsettled sleep patterns3 visits over 4 months; Diversified technique with a light, modified, HVLA impulse; no other interventions providedCannot sayCannot sayNo AE were reported or observed to occur with the intervention
Fairest, 2013 [54]6-week-old; female; left-sided cranial flattening and favored left head rotation, occasional regurgitation of an entire breastfeed immediately after feeding, groaning when placed prone in an inclined position, unsettled sleep patterns; advised by GP & midwife to seek chiropractic care1x/week, 10 weeks; 7 visits included Diversified technique (modified HVLA thrust) to cervical (7 visits) and sacrum (1 visit) and Activator to thoracic (2 visits), 3 visits of no SMTCannot sayCannot sayNo AE were observed, nor reported to occur with the intervention
Gordon, 2011 [55]2-week-old; male; facial and upper limb postural asymmetry following a forceps-assisted vaginal birth after Caesarean, droopy lip on the right, right arm assumed waiter’s tip posture at restChiropractic craniosacral techniques: low-force static hold adjustments to cervical and sacral segments; soft tissue therapy to cervical muscles; 2x/week for 2 weeks, then 1x/every other week for 12 weeksCannot sayCannot sayNo adverse effects of management were reported
  1. AE Adverse events, D/t Due to, FU Follow-up, HA Headache, HVLA high velocity low amplitude, SMT spinal manipulative therapy, Months mos, RR relative risk, Tx Treatment, W/o Without, W/ With, Wks Weeks
  2. aResults reported in this column cannot be used to infer about the risk of adverse events or the effectiveness of SMT