Forces of Commonly Used Chiropractic Techniques for Children
Written by Editor   
Saturday, September 24, 2016 12:00 AM

More than 30 million child visits to doctors of chiropractic occur in the United States every year.  The published cases of serious adverse events in infants and children receiving chiropractic or other types of manual therapy are exceedingly rare.  This begs the question, is chiropractic pediatric care safe?

The purpose of this study is to review the available literature that describes forces of the most commonly used chiropractic techniques for children.  The initial search captured 1796 potential articles, of which 54 full-text articles were reviewed. There have been no cases of death associated with chiropractic care of children reported in the academic literature to date.  Nonetheless, studies of the amount of force used on children for safety purposes should still be considered.  

Chiropractic students undertake extensive theoretical and practical training at the university level, including study of and experience with the pediatric population. Doctors of Chiropractic (DCs) are trained to perform a thorough history and examination to determine whether chiropractic care is appropriate and identify a suitable technique, given the age and neurologic presentation of the child.  It should be noted that health professionals of all types face the same considerations when determining appropriate treatment approaches.

DCs have a range of techniques available to them and can modify these to suit the age and condition of the patient. The process of selecting one type of chiropractic technique over another is based on many factors, including the techniques the practitioner is clinically experienced in applying and the perceived effectiveness of each, as well as the practitioner’s understanding of the biological plausibility of using a particular therapy and the associated research evidence base.  Data from the National Board of Chiropractic Examiners identified that three-quarters of chiropractors use traditional styles of chiropractic spinal manipulation (diversified or Gonstead technique) and more than half use an Activator instrument or the sacro-occcipital technique (SOT).

Although these data are not age specific, a 2010 cross-sectional survey of 135 chiropractors with pediatric diplomate qualifications in the United States revealed that reduced-force diversified technique (spinal manipulative technique that has been modified to be lower force and amplitude) was used by 59% of pediatric chiropractors; 63% reported using an Activator instrument, 59% a drop-section table, and 77% cranial therapy.

In addition, this study found that cranial and Activator techniques were used mainly for children 5 years and younger, and that modified diversified, Activator, and drop-section table adjustments were used on older children. The Activator instrument, SOT, toggle, touch and hold, and modified spinal manipulative therapy (SMT) were typically used by chiropractors for restoring joint and neurologic function, and particularly in children to reduce neck pain, back pain, and joint stiffness.

The study continues to describe the diversity of styles of chiropractic manipulation and estimated amounts of force involved.  It also points to a survey of DCs in Europe and a proposed model with possible implications for safety and technique adaptations for chiropractic spinal manipulative therapy for infants and children. 

  • Grade 1: neonates and infants aged 0 to 2 months (low force, low speed) at 10% of estimated force for adults.

  • Grade 2: infants and toddlers aged 3 to 23 months (low force, low speed) at 30% of estimated force for adults.

  • Grade 3: young children aged 2 years to 8 years or younger (moderate force, moderate speed) at 50% of estimated adult force.

  • Grade 4: older children and young adults aged 8 to 18 years (moderate force, high speed) at 80% of estimated adult force.

Further the study reports that excluding mechanically assisted techniques and modified SMT, many of the methods used by chiropractors are similar to those of other manual therapists including osteopaths using craniosacral therapy with a very low force and physical therapists using spinal manipulation/mobilization with a moderate force.  One author notes that much of the concern about DCs using SMT on children is found in English-language medical practitioner journals, which seem to ignore the fact that their medical colleagues practicing manual medicine in Europe have been using SMT on children since the 1960s, and it is known that medical manual therapists apply pediatric manual therapy with moderate forces.

Practitioners should take into consideration the proposed “safe limits” to ensure that the forces associated with each technique are age appropriate. These safe limits suggest that low-force, low-speed therapies are more suitable for children younger than 2 years, increasing to moderate force with moderate speed in children aged 2 to 8 years, and then moderate force with high speed up to 18 years.  The results of this literature review demonstrate that these limits are achievable with the appropriate application of several of the modern mechanical instruments and with touch and hold, mobilization, modified SMT, modified Toggle, or sacro-occipital technique.  Further, this review found that technique selection and application by chiropractors treating infants and young children are typically modified in force and speed to suit the age and development of the child.