Scientific Papers

Chiropractic care and research priorities for the pediatric population: a cross-sectional survey of Quebec chiropractors | Chiropractic & Manual Therapies


As illustrated in a previous publication on this descriptive cross-sectional study, Quebec chiropractors commonly provide pediatric care but do not exclusively treat pediatric populations [2]. Our results reveal that chiropractors adapt their treatment techniques based on the patient’s age, using softer techniques on younger patients and slowly gravitating toward more commonly used techniques on adults when patients reach the age of six years. This appears to be consistent with a recent publication that showed differences in spine tensile strength between adult and pediatric patients and that proposed a preliminary model of care in which it is recommended that spinal manipulation therapy (SMT) techniques be adapted based on the patient’s age [11].

As this study has shown, a small to moderate percentage of practitioners use high-velocity low-amplitude techniques and techniques assisted by instruments, such as activators, to treat pediatric age groups. Based on a survey of chiropractors, infants aged 0 to 2 months old should receive only 10% of the equivalent adult SMT force (roughly 2 N), and toddlers aged 3–23 months should receive approximately 30% of the adult SMT force (5.8 N) [11, 12]. Research on adverse events and SMT in children has not demonstrated a difference between instrument-assisted techniques and manipulation [13]. More research on the thresholds of SMT force for children and adverse events are needed to draw any conclusions about this finding.

Common therapeutic objectives of the respondents in this study were to improve function (47.3%) and improve quality of life (16.7%). A minority of the respondents were focused on removing subluxations (10.2%), which might reflect a vitalistic or more conservative philosophy based on the traditional chiropractic paradigm [14]. This faction in the profession is likely to retain opinions and perspectives that are in contrast with current scientific paradigms, as illustrated in a previous publication [15]. Adhering to the vitalistic paradigm has previously been identified as a barrier to interprofessional collaboration [16].

The chiropractors in this study mainly promoted physical activity and strategies for at-home care when giving health advice to patients, while they scarcely included nutritional recommendations or advice on the prevention or screening of disease. Nutritional recommendations are currently given by practitioners but are not included within the scope of MSK recommendations and might not be aligned with current best practice and recommendations [17]. If chiropractors were to provide wider public and preventative health advice to patients, future research on the matter would be recommended.

Continuing education

Although Quebec chiropractors see pediatric patients for a variety of health conditions, the respondents in this study considered their undergraduate training on the subject to be suboptimal; they believed that educational content included in the core curriculum should be augmented and developed in collaboration with institutions/organizations with expertise in the matter and then included in the core curriculum [18]. This study showed that most chiropractors had approximately 8 h of continuing education in the field of chiropractic pediatrics per year that mostly came from either the OCQ, written articles or seminars and conferences. Most Quebec chiropractors were not part of any pediatric organizations, but those who were members of such organizations were linked to either the Association québécoise de chiropratique pédiatrique et en périnatalité (AQCPP), International Chiropractors Association (ICA) or International Chiropractic Pediatric Association (IPCA). The main source cited for continuing education was the OCQ. An examination of the past yearly continuous education programs offered by the OCQ indicated that the last educational conferences on the subject were in 2017. Hence, the respondents in this study might have been influenced by the OCQ’s conference agenda that year. Since then, no further pediatric content has been included in their program. Written articles could be an excellent source of information, but it is unclear which articles chiropractors are reading and how the data extracted from them translate into day-to-day practice. Furthermore, the current scientific evidence on the topic of pediatric chiropractics remains limited, and it has been stated that more high-quality research and clinical trials are necessary [3]. Finally, seminars and conferences on the subject of pediatric chiropractic tend to be very rare and are not necessarily given by a licensed organization with clear, evidence-based competencies [19], which prevents them from being a valid source of training. More broadly, although some continuing education in the field is obtained by the doctors, the source and accuracy of their information is unclear due to the lack of current high-quality scientific data available in the field [20].

Research priorities

This is the first Canadian study identifying research priorities for chiropractic pediatric care from the clinician perspective. When asked to rank future research focuses in the field of pediatric chiropractics, the respondents mainly focused on the subjects of effectiveness of chiropractics for MSK and viscerosomatic conditions. In comparison, it was previously shown that Canadian chiropractic organizations had identified priorities in the area of health services, such as the integration of chiropractic care into multidisciplinary settings, the cost-effectiveness of chiropractic care and the effect of chiropractic care on reducing medical services [21].

In studies across Europe and Canada, research priorities such as the cost-effectiveness of chiropractic care, as well as multidisciplinary and interprofessional collaboration, were recurrent topics among academic members or organizations of the profession [21, 22]. These results show a gap between practitioners’ and the priorities in future research agendas, thus going against previous research that showed an overall agreement between practitioners and academics across most research priorities [23]. It seems that organizations tend to prioritize subjects in the area of health services, while practitioners tend to gravitate toward the effectiveness of chiropractic treatment on different health issues with the hopes of obtaining data on chiropractic treatment outcomes for conditions for which there is sometimes a lack of scientific evidence.

Furthermore, the respondents in this study rated viscerosomatic conditions as one of their two main future research focuses in the field of pediatric chiropractic, even though the conclusions of recent systematic reviews on the effectiveness of manual therapy on some non-MSK conditions showed no evidence of an effect [24, 25]. The interest behind the treatment of non-MSK conditions might be related to the fact that recent systematic reviews have not been based on topics or conditions of interest for clinicians. In light of our findings, although chiropractors are trained and considered MSK experts, some practitioners may have higher expectations in terms of their ability to treat non-MSK conditions with the pediatric population than what recent literature on the subject suggests.

Limitations

Our findings might have limited generalizability given our response rate of 21% and the higher proportion of women in the sample than in the Quebec chiropractor population; however, a higher proportion of women than men may be attending to the pediatric population, as shown in the medical profession [26]. It is likely that the respondents in this study might have had a specific interest in pediatric care since 22% of them reported being a part of the AQCPP, an association that includes only 11% of Quebec chiropractors. Although our questionnaire demonstrated satisfactory reliability, its validity was not assessed. Therefore, it is possible that the responses provided by the respondents might not have perfectly reflected reality. For the specific question on research priorities, the scope of the assessed priorities might have been limited because the question started with preestablished research categories; however, we attempted to resolve this issue with the use of an open-ended question, which was completed by 59% of the respondents. Furthermore, it is unclear how the COVID-19 pandemic might have influenced our data collection.



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