in part 1 of this article, DCs do have spe-cialized postgraduate pediatric training pro-grams. This is not even acknowledged. If one was to read this paper critically and dig into the references cited, one would find more questionable elements. For ex-ample, Vohra et al. made an error in the application of their own adverse event clas-sification system. Dr. Joel Alcantara 9 published a pa-per that summarizes the deficiencies and oversights the authors. and brings up two things: it questions the paper’s claim to be-ing a thorough and academic review; and it emphasizes the importance of critical review. Alcantara took the time to review the papers referenced in Vohra’s review. He noted the following: i) Two cases cited from LeBoeuf et al., listed as moderate adverse events, involved headache/stiff neck and acute lumbar pain. These were, in fact, minor events since they were self-limiting, not requiring any further medical assistance or care. ii) Four other cases retrieved and clas-sified as adverse events by Vohra et al. included a 12-year-old girl who fell from an upper bunk bed and hit her head, re-sulting in one to two frontal headaches per week. While under chiropractic treat-ment after this incident, she was subse-quently accidentally crushed in a collision with playmates, falling backwards to the ground. Furthermore, between chiroprac-tic visits, she fell from her bicycle hitting her head. From the perspective of a prac-titioner, these incidents alone would have complicated the care and introduced new symptomatology. If these details are not disclosed, however, then yes, it certainly would have appeared as though she’d had a worsening of symptoms! But, given the knowledge of external sources of trauma, one would be challenged to ascribe the ex-acerbated symptoms to chiropractic care. iii) One out of the 10 cases mentioned as adverse was cited in Zimmerman’s paper. This was a seven-year-old male who had recurrent headaches. He had pre-existing headaches, often following his gymnastics sessions where he had once attempted mid-air somersaults and landed on his occiput and neck. Vohra et al. did not mention that prior to attending chiropractic care, the patient suffered from bilateral headaches without prodrome once or twice/week, often following his gymnastics. iv) One case cited was that of a 12-year-30 • CANADIAN CHIROPRACTOR | JUNE 2012 old female with osteogenesis imperfecta, a history of multiple fractures and sagging chin following a fall prior to chiropractic. This fall was not mentioned in Vohra et al.’s review. v) Citing another case published by Shafir and Kaufman, Vohra et al. leads us to believe a four-month-old patient’s demise held a close temporal association between chiropractic care and neurological dete-rioration. However, the source paper indi-cated the patient had an intraspinal mass prior to chiropractic care that may have compromised the blood supply to the tu-mour and spinal cord. The subsequent pa-thology demonstrated was mostly necrotic tissue suggestive of pre-existing pathology. Vohra et al. does not mention this but sim-ply states that while that patient was under chiropractic care neurological deterioration occurred. Finally, we want to encourage, and strive for, more evidence and funding for research. We are now seeing this materialize, but although our evidence base grows and improves, we need to remember a lack of evidence does not mean evidence of lack. As Sackett et al. note, “The practice of evidence-based medicine means integrating the indi-vidual clinical expertise with the best available external clinical evidence from systematic research. By individual clini-cal experience we mean the proficiency and judgment that individual clinicians acquire through clinical experience and practice.” 10 The key in this interaction continues to be you, the doctor, and your commit-ment to making the best decisions for your patient.• a GroWinG Safety reCord When we consider the critical analysis above, as well as all this additional infor-mation that can be gleaned from the pa-pers cited in Vohra et al., we see inconsis-tencies throughout the paper, including that some of the events classified as ad-verse had pre-existing morbidities or a history of trauma. In addition, four other cases where adverse events were noted were attributed to SMT that was not cared for by chiropractors. While we encourage any study into the efficacy and safety of chiropractic, we do need to truly observe what is being said by the data. If, in fact, we were to calculate the num-ber of pediatric visits to chiropractors over 117 years – where true adverse events re -quiring emergency care would have a high likelihood of being reported – we can see our safety record remains strong. All things remaining equal, there is perhaps insuffi-cient evidence to indicate that chiropractic care of children is, in any way, harmful. If, however, any adverse event did occur, it would be one too many – and so we need to continue to be diligent in our recommendations for children. A prudent rule of thumb is to co-manage always on the side of caution to the level of your ex-perience and within your comfort zone. As with any skill, knowledge and prac-tice experience require commitment and time. Reflecting on each day in practice with the attitude of “what can I continue to improve upon” generally keeps us on our toes. referenCeS 1. Gracovetsky S.A. The Spinal Engine. 1988 Springer Vienna 2. Biedermann H. Manual Therapy in Children. Churchill Livingstone-Elsevier Limited. 2004 3. Melillo R. Disconnected Kids. 2009. Perigee Book. Penguin Group 375 Hudson St. New York, NY. USA 4. Melillo R. Reconnected Kids. 2011. Perigee Book. Penguin Group 375 Hudson St. New York, NY. USA 5. Spigelblatt L. et al. The Use of Alterna-tive Medicine by Children on the Rise. Pediatrics 1994. 94:811-814. 6. Spigelblatt L. Alternative Medicine: A Pediatric Conundrum. Contemporary Pediatrics.1997. 14(8): 51-64. 7. College of Chiropractors of Ontario website http://www.cco.on.ca./english/ Members-of-the-Public/How-CCO-Protects-thePublic%20Interest/Policies-and-Guidelines 8. Vohra S, BC Johnston, K Cramer, K Humphreys. Spinal Manipulation: A Systematic Review. Pediatrics 119 (1) Jan 2007 e275-283 www.pediatrics. org/cgi/content/full/peds.2006-1392v1 9. Alcantara J. A critical appraisal of the systematic review on adverse events as-sociated with pediatric spinal manipu-lative therapy: A chiropractic perspec-tive. J Pediatr Matern & Fam Health -Chiropr 2010 Win;2010(1):22-29 10. Sackett DL, W Rosenberg, JA Gray, RB Haynes. Evidence Based Medicine: what it is and what it isn’t. BMJ 1996 312:71 www.canadianchiropractor.ca
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