A horrifyingly unethical study of chiropractic treatment of infants with torticollis

I don’t often write about chiropractic, although perhaps I should do so more often, at least about chiropractic itself. Usually, when I write about chiropractic, it’s in the context of quackery other than chiropractic that many chiropractors have added to their armamentarium of woo, such as when I recentlywrote about a “functional neurologist,” basically a chiropractor who embraced the additional quackery of functional medicine as applied to neurology or the other time when I wrote about functional medicine as done by a chiropractor. Alternatively, I sometimes write about the antivaccine activities of chiropractors, such as Heather Wolfson, a chiropractor who happens to be the wife of Dr. Jack Wolfson, the rabidly antivaccine cardiologist in Arizona. What I don’t often write about is chiropractors doing chiropractic, other than perhaps the occasional post about the risk of stroke from chiropractic neck manipulation. Oh, sure, I posted a video of a chiropractor manipulating the back of a duck as an example of the most ridiculous thing I’ve ever seen from a chiropractor. However, there is funny as in “Haha!” and there is funny and horrifying. This next example is funny and horrifying. No, strike that. It’s just horrifying. I’m referring to a study that reader made aware of, Manipulation Under Anesthesia in Infants With Arthrogenic Newborn Torticollis: A Retrospective Case Series. Yes, it’s exactly what you think it is. It’s a case series reported by a chiropractor named Inga Paravicini, DC, MME from Universitätsklinik Balgrist in Zurich.

First, I wanted to know who Inga Paravicini is. Unfortunately (for me), her website is—surprise, surprise, given that she practices in Switzerland—in German. Looking at her list of services, I see that it’s a fairly unremarkable list of conditions chiropractors treat, such as osteoarthritis pain, intervertebral disc complaints, sciatica, and the like. There were others, such as “psseudoangina pectoris” (chest pain in blocked vertebral or rib joints) and, yes, torticollis. But what is infant torticollis? In the US, it’s more commonly called congenital torticollis, and it’s a condition in which one of the sternocleidomastoid muscles, the two muscles that extend down either side of the neck, is tight and shortened. The condition is usually diagnosed between 6-8 weeks of age, when the baby starts to gain more control of his head and neck. The usual treatment consists of stretching exercises and changes in how the infant is held or positioned, which gradually lengthen the muscle and correct the problem. Well under 10% of children with torticollis will require surgery to correct the problem by lengthening the sternocleidomastoid muscle, which is usually carried out when the child reaches preschool age. Causes are thought to include abnormal position in the uterus, such as breech, or the use of forceps or a vacuum device during delivery.

You can see where this case series is going. Here, we have a condition that usually responds to physiotherapy, exercise, and teaching the parents to position the infant differently that usually doesn’t need surgery. Also, interestingly, if you do a Google Search for “arthrogenic torticollis,” what you will find high on this search list is this very case series, plus articles in German, Finnish, and Czech, among others. Be that as it may, let’s look at this case series. The first thing I noticed is that I couldn’t find much, if anything, about “athrogenic torticollis.” This is what Paravicini writes about it:

Another category of newborn torticollis is the arthrogenic type. In Germany, this condition sometimes is called kopfgelenk induzierte symmetrie störung.1 According to Kraenzlin and Kind, this type of torticollis indicates a joint dysfunction caused by capsular adhesions at the atlantoaxial joint.3 The arthrogenic and muscular types sometimes coexist. The arthrogenic atlantoaxial dysfunctions are most likely secondary and due to the fibrotic changes in the sternocleidomastoid muscle.4 In the German literature, they both fall under the term muskuloskelettaler Neugeborenen-Torticollis (musculoskeletal newborn torticollis), which means that the cause of the torticollis lies within the musculoskeletal system. In the English literature, the term congenital torticollis is more common and it is subdivided into 2 groups: postural and muscular.

Most of the references were in German, and the Kraenzlin and Kind didn’t show up when I clicked on it, and various attempts to use Google Scholar to search for it failed. Also, I couldn’t find anything implicating the atlantoaxial joint in congenital torticollis, only in acquired torticollis, and even then it’s a rare condition. Now here’s the passage that horrified me:

Because the fixation of the atlantoaxial joint is not due to a neuromuscular reflex mechanism but rather due to capsular adhesions, the specific mobilization is without impulse and the sound that is heard during the mobilization is not a cavitation but rather the breaking up of adhesions.6 Approximately 2.5% of the children will not respond to in-office chiropractic therapy and therefore may be candidates for manipulation under anesthesia (MUA). This may be due to a lack of compliance or having a mixed form of an arthrogenic and muscular torticollis that needs a partial tenotomy of the M. sternocleidomastoideus or because the conventional radiography shows a severe form of torticollis with a subluxated C1/C2 articulation. These numbers are anecdotal data originating from 1 specialized chiropractor in Switzerland who treats approximately 400 infants per year with arthrogenic newborn torticollis. From these 400 infants, 10 will end up needing MUA due to the reasons mentioned above.

You read that right. This chiropractor is talking about manipulating babies’ necks and how the cracking sound heard is the “breaking up of adhesions.” It gets worse. Paravicini openly admits the risks of anesthesia and radiation in infants:

Currently, as far as the author is aware, all of the published studies on MUA have been done on adult patients. It is unknown from the scientific literature how infants with torticollis respond to MUA. Certainly the risks of administration of general anesthesia and computed tomography (CT) scans in children need to be discussed. Looking at the literature, the main concern for applying anesthesia in children seems to be the effects it has on neurodevelopment and later cognitive function. The most current prospective clinical studies show that shorter general anesthetic exposures in early life (under age 2) and of short duration (<1 to 2 hours) are safe.7, 8 A retrospective matched cohort study with 18 056 children below the age of 4 years done in 2016 was able to show that general anesthesia exposures in children between 2 and 4 years of age did show a decrease in the Early Development Instrument score but not so between birth and 2 years.9 A similar population-based cohort study with children aged 5 to 6 years, done in 2016, showed the same results.10

Yes, the risk is small, but this is why we don’t subject infants to general anesthesia unless there is a clear benefit to the procedure that requires general anesthesia. Ditto the radiation from CT scans. So, basically, Paravicini knows that there’s a small risk from anesthesia and radiation due to CT scans, but used them anyway to do chiropractic manipulation of infants’ necks, even though there is no possible benefit and quite a bit of potential harm, up to and including a fractured vertebrae, but none of that stops chiropractors from doing neck manipulation in infants for torticollis.

Before the manipulation under anesthesia (MUA):

The MUA procedures were performed on an outpatient basis and in the operating room of a children’s hospital. The author was the assistant chiropractor. Along with the doctor of chiropractic and his assistant, a children’s anesthesiologist, 1 to 2 operating nurses, a children’s radiologist, and in 1 case a pediatric surgeon were present.

Written informed consent for publication of the material was obtained from the parents of the 6 infants.

Before the procedure, the patient was connected to a cardiac monitor, blood pressure cuff, and oximeter. The patient then was sedated with intravenous, short-acting anesthetics such as Diprivan (propofol, a lipophile, fast-acting derivate of alkylphenol) and finally intubated.

Just reading this passage enraged me. Treating infants this way with no evidence was unethical, given that, as was admitted by Paravicini herself, there was no evidence for MUA as a treatment for congenital torticollis. As for the study itself, of course Paravicini found a benefit in all six infants. Not surprisingly, there are lots of issues. It’s retrospective, and thus prone to selection bias. It’s very small. It’s uncontrolled. It had no scientific basis to justify it. The followup times were highly variable. Even Paravicini herself admits that the range of motion measurements are “only moderately reliable” because of “variations in the level of activity and cooperation of the infant that cannot be avoided on clinical examination.”

I’ve discussed dubious chiropractic “research” before, although not recently, including using chiropractic to treat autistic children as part of a meaningless study. As I discussed then, what the chiropractors did to autistic children was to take a plunger, stick it between the mastoid process right near the ear and the back part of the mandible, and hit it to “impart energy,” all accompanied by unnecessary radiation exposure and trauma of being held down in order to obtain completely unnecessary X-rays of the cervical spine. It is a procedure that my good bud Mark Crislip described as “frightening autistic children for no good purpose.” I guess that I should be grateful that this study actually placed the children under general anesthesia. Oh, wait. No I shouldn’t Again, the risk of general anesthesia in infants, although small, is not zero, as is the risk of radiation from CT scans. without a demonstrable benefit, there is no ethical justification for submitting children to these procedures.

Of the various forms of unscientific and pseudoscientific medicine, chiropractic is probably the most “respectable,” with state licensure in all states and their presence seemingly as ubiquitous as dentists. Indeed, there are at least five chiropractors within walking distance of my house, albeit a long walk for a couple of them. Unfortunately, when it comes to treatment they are physical therapist wannabes with delusions of grandeur who think they can treat all manner of illnesses that have nothing to do with the spine and will subject infants to the risk of general anesthesia in order to manipulate their necks.