J Manipulative Physiol Ther. 2012 (Jun); 35 (5): 372–380 ~ FULL TEXT
Aurélie M. Marchand, DC, MScACPP
Via Piastreto 1,
51011 Buggiano (PT) Italy
OBJECTIVE: Few studies have addressed the practice of chiropractic care of children in Europe. No systematic classification of conditions currently exists in chiropractic pediatrics. The objective of this study was to investigate characteristics of clinical chiropractic practice, including the age of pediatric patients, the number of reports of negative side effects (NSEs), the opinions of doctors of chiropractic on treatment options by patient age groups, the conditions seen and the number of treatment sessions delivered by conditions and by patient age.
METHODS: An Internet cross-sectional survey was conducted in 20 European countries with 4109 doctors of chiropractic invited to reply. The 19 national associations belonging to the European Chiropractic Union and the Danish Chiropractic Association were asked to participate. Respondents were asked to self-report characteristics of their practices.
RESULTS: Of the 956 (23.3%) participating chiropractors, 921 reported 19821 pediatric patients per month. Children represented 8.1% of chiropractors' total patient load over the last year. A total of 557 (534 mild, 23 moderate, and 0 severe) negative (adverse) side effects were reported for an estimated incidence of 0.23%. On the given treatment statements, chiropractors reported varying agreement and disagreement rates based on patient age. The 8309 answers on conditions were grouped into skeletal (57.0%), neurologic (23.7%), gastrointestinal (12.4%), infection (3.5%), genitourinary (1.5%), immune (1.4%), and miscellaneous conditions (0.5%). The number of treatment sessions delivered varied according to the condition and the patient age.
CONCLUSION: This study showed that European chiropractors are active in the care of pediatric patients. Reported conditions were mainly skeletal and neurologic complaints. In this survey, no severe NSEs were reported, and mild NSEs were infrequent.
From the FULL TEXT Article
Pediatric patients represent between 5% and 17% of general chiropractic practice [1–5] and 39% of specialist pediatric chiropractic practice.6 In the absence of high levels of evidence,5 doctors of chiropractic have relied on clinical experience and education to provide care. The informative surveys available on chiropractic pediatric care mainly originate from North America and Australia, [6–12] and few studies have aimed at informing chiropractic pediatric practice in Europe. [1, 3, 5]
Pediatric health conditions seen by chiropractors have been reviewed systematically.13, 14 Several authors have traditionally reported conditions in 2 distinct categories of musculoskeletal and nonmusculoskeletal conditions. [3, 5, 7, 8, 10–12, 15, 16] The rationale behind such a separation has not been investigated (to the author's knowledge). The safety of spinal manipulative therapy in pediatric care has been addressed in the literature with few safety incidents reported. [10, 17–21]
The current state of the literature indicates a European gap in knowledge regarding pediatric patients' age, chiropractors' demographics, reports of safety incidents, opinions on given treatment options, conditions seen, and number of treatment sessions delivered. The purpose of this survey is to fill in these gaps and provide a classification system of conditions relevant to chiropractic practice.
This survey provides an overview on pediatric chiropractic care in Europe based on pediatric patient age, chiropractors' demographics, reports of safety, opinions on treatment statements, conditions seen, and number of treatment sessions delivered.
The mean age of chiropractors in this survey (39.9 years old) was similar to the mean of 37 years old (range, 25–72 years) of a previous study.  The 58% male predominance in this survey is in accordance with the 77.6% male (22.4% women) predominance observed in the United States.  This male predominance differs from previous pediatric chiropractic surveys reporting 60.6%  and 74%  female respondents. These last 2 studies were aimed at chiropractors specialized in pediatric care in the United States; their results may not be fully representative of the overall chiropractic profession. Indeed, age and sex of chiropractors were found to be confounding factors in this survey and were not taken into account in the limitations of those studies. In Europe, a previous 1994 survey showed a male predominance (75%) of chiropractors  supporting a tendency of European male predominance in chiropractic nowadays. However, the difference between 58% and 75% may be caused by more women entering the profession since 1994 as was reported in the United States  with a 10% increase in female chiropractors since 1991 or by a higher proportion of women participated in this survey because of their increased interest in pediatric care. [6, 12]
The age of chiropractic pediatric patients were not reported in several studies, [7, 9, 10, 12] whereas those addressing and classifying pediatric patients by age showed a lack of consensus on groupings: below 10 years old and between 1 and 3 years,  below 2 years old and from 2 to 17 years,  below 1 year old and from 1 to 18 years.  This caused the overall distribution of pediatric patients under chiropractic care to be unclear. This survey showed the distribution of pediatric patients by age with a higher frequency of patients older than 12 years and younger than 2 years. The number of pediatric age groups to be used when conducting research is open to debate and consensus within the chiropractic profession. Although this survey used 5 age groups, there was a tendency for earlier studies to create fewer groups. [8, 11, 16] It could be proposed to use 4 groups (0 to 23 months, 2 to 5 years, 6 to 12 years, and 13 to 18 years), which could be appropriate and more practical for chiropractic research because both the 0 to 2 months and 3 to 23 months groups showed similarities on conditions reported and treatment opinions.
The 8.1% mean pediatric patient load over the past year is consistent with previous studies, [1, 2, 3, 5] is lower than 17.1% in the United States,  but differs from results reporting 21.0% of weekly visits as pediatric and 28 visits per week for specialized chiropractors.  This difference may be caused by cultural differences, by the difference of information asked (number of separate patients seen per month versus number of visits per month), or by specialized chiropractors further developing their practice in pediatrics compared to nonspecialized ones.
Previous surveys investigating the overall pediatric population (0 to 18 years old) reported both mild and moderate NSEs, with 2 studies being conducted in teaching colleges (mild) [17, 19] and another study having a relatively small sample size (mild)  and a surveillance program (moderate).  A systematic review had previously reported 9 severe cases, 1 moderate case, and 2 mild cases of adverse events.  This survey reports the lowest rate (0.23%) to date compared with previous surveys: 0.51%,10 1%,  and 9%.  However, it is the first chiropractic study to report moderate NSEs (0.0001%) in a pediatric population possibly because of survey design: conducted outside of teaching colleges and/or on a larger sample size. Negative side effect reports were made by 86.2% of respondents indicating willingness to record and report this type of information. Therefore, this survey may suggest that NSEs in children after chiropractic care are less frequently occurring (rather than seldom reported) than in adults with 33% to 60.9% of adult patients reporting mild reactions posttreatment. 
This survey shows that chiropractors have different attitudes and opinions on several aspects of manual treatment according to patient age. This change in opinions on treatment statements seems to be in accordance with a consensus on chiropractic pediatric agreeing on adapting to patient size, structural development, flexibility, and patient preferences during treatment. 
The methodology used to classify reported conditions is inspired from the logic behind MedDRA: classifying conditions according to a pyramid organization. MedDRA was not used because of high and prohibitive costs of access. However, the chiropractic profession may decide to move toward the use of MedDRA in the future or may decide to validate a systematic classification system of conditions. This could improve reports of conditions and facilitate communication with the medical profession and pharmaceutical industry already using MedDRA in Europe, America, and Japan to report conditions systematically.
Because MedDRA was not used, conditions were classified according to logic, discussion, and agreement with a medical doctor having experience using MedDRA and based on the known etiology of reported conditions. For these reasons, the classification proposed in Table 1 may be debatable and may evolve in the future as knowledge on etiology continues to improve and consensuses are reached. For instance, colic was classified under gastrointestinal tract (GIT), whereas the diagnostic criteria for colic mainly rely on excessive crying and behavioral presentation with unclear pathologic link to the GIT.  In the future, several terms reported by chiropractors may need clarification and consensuses: the exact anatomical territory of back pain, low back pain, pelvic pain, and sacroiliac pain may be clarified in pediatric patients, and terms such as wellness and prevention not being recognized medical conditions could be referred to as check-up or well care as used in the medical literature or as functional optimization or else be clearly defined by the chiropractic profession.
Skeletal and neurologic reports of conditions were most prevalent in all pediatric patients in this survey. Previous chiropractic pediatric studies showed that, in children, nonmusculoskeletal conditions were most prevalent, [8, 11, 16] whereas other chiropractic pediatric studies showed that musculoskeletal conditions were most prevalent. [7, 9, 12] It was observed that the differences in results arose from the methodological designs of those studies: different pediatric age groups were investigated, [7, 8, 9, 11, 12, 16] and/or grouping of reports or verbatim reports were applied. [7, 8, 9, 10, 12] In this survey, it was observed that grouping of reports leads to different results. Indeed, on one hand, in patients from 0 to 23 months old, “gastrointestinal” reports of conditions (grouping as PGTs) were most frequent (37.1% and 25.2%), whereas “skeletal” conditions were most frequently reported in these same age groups (grouping by systems). On the other hand, in patients from 6 to 18 years old, the PT “lumbopelvic” was most frequent, but the SV “headache” was the most frequent.
This shows how patient age influenced the most common reports of conditions and how grouping of reports may show different results according to patient age in this survey. To increase consistency of reports and improve data homogeneity, it is proposed to clearly define pediatric age groups and to use a systematic classification of conditions. The change of prevalence in axial conditions from mostly cervical to lumbopelvic with increasing age is an original finding. Because this change occurs from 6 years old onward, the increased sitting time from schooling methods may be a plausible etiological hypothesis.
When analyzing recent results according to Table 1,  conditions by system would be 45.0% skeletal, 15.6% infections, 14.0% neurologic, 13.3% gastrointestinal, and 12.2% immune. By comparison, the skeletal and neurologic conditions would represent 59.0% compared with 80.7% in this survey. It was observed that chiropractic philosophy varied by geographical regions in Canada : by extrapolation cultural or philosophical differences between Europe and North America may be responsible for the differences in conditions reported between studies. These differences should be considered when extrapolating data to different geographical regions.
An original finding is the number of treatment sessions delivered by conditions as provided by the combined experience of 921 chiropractors with some experience in treating pediatric patients. The number of treatment sessions tended to increase with patient age; this is another original finding that may reflect the biomechanical changes of growing patients. Frequency of care has been recently addressed with no conditions requiring more than 2 treatments per week, some requiring 1 to 2 times per week or 1 to 3 visits per month.  In this survey, treatment numbers were provided by a fairly large number of chiropractors. These numbers are subject to several limitations arising from recall bias (reported by chiropractors), chiropractors' and parents' interpretations of significant improvement, and a noncontrolled manner of data collection. Despite these limitations, the reported numbers of treatment sessions delivered may provide a general guide until further prospective research is conducted on specific conditions.
Limitations and Future Studies
Limitations of this survey include inherent bias and bias from soliciting self-reported information. The questions were designed to minimize the risk of such bias, and the results and comments of the pilot indicated that questions were not biased. The questionnaire was not validated, which has implications on the reliability and the internal consistency of the information collected. Self-selection bias and low response rate should also be considered as limitations: the results of this survey are applicable to Europe and reflect the practice of participants only. Recall bias may also have occurred, and this survey did not attempt to verify self-reported information. In the future, validation procedures or prospective data collection could be considered to address this limitation. Although 86% of chiropractors were willing to report safety incidents in this survey, underreporting of adverse reactions has been previously mentioned.  Therefore, the rates of safety incidents may have been lowered by respondents unwilling to disclose such occurences.
Research in pediatric chiropractic care is in its early stages; gathering the data in a prospective and controlled manner on safety and reported conditions (along with developing a systematic classification for these) may be beneficial to the development of the profession and interprofessional relationships. Skeletal and neurologic conditions should be investigated in priority considering their high prevalence in this survey.
This study showed that pediatric patients represented 8.1% of European chiropractic practices; patients were seen mainly for skeletal and neurologic conditions, and few NSEs were reported after chiropractic care. The most common conditions reported by chiropractors were different by patient age, and the number of treatment sessions delivered varied by patient age for most reported conditions.
Pediatric patients represent 8.1% of European chiropractic practices.
Few negative side effects (NSEs) were reported after chiropractic care.
Conditions reported after grouping/classification were mainly
skeletal and neurologic conditions.
The number of treatment sessions varied for each reported condition
and by patient age.