Spinal manual therapy in infants, children and adolescents: A systematic review and meta-analysis on treatment indication, technique and outcomes

BackgroundStudies on effectiveness and safety of specific spinal manual therapy (SMT) techniques in children, which distinguish between age groups, are lacking.ObjectiveTo conduct a systematic review of the evidence for effectiveness and harms of specific SMT techniques for infants, children and adolescents.MethodsPubMed, Index to Chiropractic Literature, Embase, CINAHL and Cochrane Library were searched up to December 2017. Controlled studies, describing primary SMT treatment in infants (ResultsOf the 1,236 identified studies, 26 studies were eligible. Infants and children/adolescents were treated for various (non-)musculoskeletal indications, hypothesized to be related to spinal joint dysfunction. Studies examining the same population, indication and treatment comparison were scarce. Due to very low quality evidence, it is uncertain whether gentle, low-velocity mobilizations reduce complaints in infants with colic or torticollis, and whether high-velocity, low-amplitude manipulations reduce complaints in children/adolescents with autism, asthma, nocturnal enuresis, headache or idiopathic scoliosis. Five case reports described severe harms after HVLA manipulations in four infants and one child. Mild, transient harms were reported after gentle spinal mobilizations in infants and children, and could be interpreted as side effect of treatment.ConclusionsBased on GRADE methodology, we found the evidence was of very low quality; this prevented us from drawing conclusions about the effectiveness of specific SMT techniques in infants, children and adolescents. Outcomes in the included studies were mostly parent or patient-reported; studies did not report on intermediate outcomes to assess the effectiveness of SMT techniques in relation to the hypothesized spinal dysfunction. Severe harms were relatively scarce, poorly described and likely to be associated with underlying missed pathology. Gentle, low-velocity spinal mobilizations seem to be a safe treatment technique in infants, children and adolescents. We encourage future research to describe effectiveness and safety of specific SMT techniques instead of SMT as a general treatment approach.

背景：目前针对儿童群体开展的、按年龄分层的特定脊柱手法治疗（spinal manual therapy, SMT）技术有效性与安全性的相关研究仍较为匮乏。目的：本研究旨在针对婴儿、儿童及青少年群体，对特定SMT技术的有效性与不良事件相关证据开展系统综述。方法：检索PubMed、《脊椎推拿文献索引》（Index to Chiropractic Literature）、Embase、CINAHL及Cochrane图书馆数据库，检索时限截至2017年12月。纳入描述针对婴儿的原发性SMT治疗的对照研究。结果：在检索到的1236项研究中，最终有26项符合纳入标准。婴儿及儿童/青少年因多种肌骨与非肌骨适应证接受治疗，上述适应证均被假设与脊柱关节功能障碍相关。针对相同人群、适应证及治疗对照的研究较为匮乏。由于证据质量极低，目前尚无法明确：轻柔低速度脊柱松动术是否可缓解婴儿肠绞痛或斜颈相关症状，以及高速低振幅（high-velocity, low-amplitude, HVLA）手法是否可改善自闭症、哮喘、夜间遗尿、头痛或特发性脊柱侧凸患儿及青少年的不适症状。另有5篇病例报告描述了4名婴儿与1名儿童接受HVLA手法治疗后出现严重不良事件。针对婴儿及儿童的轻柔脊柱松动术治疗后，有轻度一过性不良事件报告，可视为治疗相关不良反应。结论：基于GRADE分级方法学分析，本研究纳入的证据质量均为极低级别，因此无法针对婴儿、儿童及青少年的特定SMT技术有效性得出明确结论。纳入研究的结局指标多为家长或患者自评报告，未设置用于评估SMT技术与假设的脊柱功能障碍相关性的中间结局指标。严重不良事件相对少见，且描述不够详尽，其发生可能与潜在的未被发现的病理状态相关。轻柔低速度脊柱松动术在婴儿、儿童及青少年群体中似乎安全性良好。本研究呼吁未来开展针对特定SMT技术的有效性与安全性研究，而非将SMT作为通用治疗手段进行相关探讨。