Chronic asthma and chiropractic spinal manipulation: a randomized clinical trial

The global summit on the efficacy and effectiveness of spinal manipulative therapy for the prevention and treatment of non-musculoskeletal disorders: a systematic review of the literature

Background

A small proportion of chiropractors, osteopaths, and other manual medicine providers use spinal manipulative therapy (SMT) to manage non-musculoskeletal disorders. However, the efficacy and effectiveness of these interventions to prevent or treat non-musculoskeletal disorders remain controversial.

Objectives

We convened a Global Summit of international scientists to conduct a systematic review of the literature to determine the efficacy and effectiveness of SMT for the primary, secondary and tertiary prevention of non-musculoskeletal disorders.

Global summit

The Global Summit took place on September 14–15, 2019 in Toronto, Canada. It was attended by 50 researchers from 8 countries and 28 observers from 18 chiropractic organizations. At the summit, participants critically appraised the literature and synthesized the evidence.

Systematic review of the literature

We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, the Cumulative Index to Nursing and Allied Health, and the Index to Chiropractic Literature from inception to May 15, 2019 using subject headings specific to each database and free text words relevant to manipulation/manual therapy, effectiveness, prevention, treatment, and non-musculoskeletal disorders. Eligible for review were randomized controlled trials published in English. The methodological quality of eligible studies was assessed independently by reviewers using the Scottish Intercollegiate Guidelines Network (SIGN) criteria for randomized controlled trials. We synthesized the evidence from articles with high or acceptable methodological quality according to the Synthesis without Meta-Analysis (SWiM) Guideline. The final risk of bias and evidence tables were reviewed by researchers who attended the Global Summit and 75% (38/50) had to approve the content to reach consensus.

Results

We retrieved 4997 citations, removed 1123 duplicates and screened 3874 citations. Of those, the eligibility of 32 articles was evaluated at the Global Summit and 16 articles were included in our systematic review. Our synthesis included six randomized controlled trials with acceptable or high methodological quality (reported in seven articles). These trials investigated the efficacy or effectiveness of SMT for the management of infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine. None of the trials evaluated the effectiveness of SMT in preventing the occurrence of non-musculoskeletal disorders. Consensus was reached on the content of all risk of bias and evidence tables. All randomized controlled trials with high or acceptable quality found that SMT was not superior to sham interventions for the treatment of these non-musculoskeletal disorders. Six of 50 participants (12%) in the Global Summit did not approve the final report.

Conclusion

Our systematic review included six randomized clinical trials (534 participants) of acceptable or high quality investigating the efficacy or effectiveness of SMT for the treatment of non-musculoskeletal disorders. We found no evidence of an effect of SMT for the management of non-musculoskeletal disorders including infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine. This finding challenges the validity of the theory that treating spinal dysfunctions with SMT has a physiological effect on organs and their function. Governments, payers, regulators, educators, and clinicians should consider this evidence when developing policies about the use and reimbursement of SMT for non-musculoskeletal disorders.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12998-021-00362-9.

An Osteopathic Modular Approach to Asthma: A Narrative Review

Asthma is among of the first ailments documented in the existing academic literature as being successfully managed with osteopathic manipulative treatment (OMT) techniques. Time-efficient and well-tolerated OMT techniques have been gradually added to the literature to manage this increasingly prevalent disease. In this narrative review, the authors discuss previously-published literature describing the history, diagnosis, and management of asthma related to osteopathic principles and practices and OMT application. They also present current and newly-approved medical managements, including biologics and inhaled corticosteroids. This article also includes supplemental videos showcasing OMT techniques for asthma management, which were developed by the authors based on recommendations indicated in the literature.

Predictive factors for reporting adverse events following spinal manipulation in randomized clinical trials - secondary analysis of a systematic review

While spinal manipulative therapy (SMT) is recommended for the treatment of spinal disorders, concerns exist about adverse events associated with the intervention. Adequate reporting of adverse events in clinical trials would allow for more accurate estimations of incidence statistics through meta-analysis. However, it is not currently known if there are factors influencing adverse events reporting following SMT in randomized clinical trials (RCTs). Thus our objective was to investigate predictive factors for the reporting of adverse events in published RCTs involving SMT. The Physiotherapy Evidence Database (PEDro) and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for RCTs involving SMT. Domains of interest included: sample size; publication date relative to the 2010 CONSORT statement; risk of bias; the region treated; and number of intervention sessions. 7398 records were identified, of which 368 articles were eligible for inclusion. A total of 140 (38.0%) articles reported on adverse events. Articles were more likely to report on adverse events if they possessed larger sample sizes, were published after the 2010 CONSORT statement, had a low risk of bias and involved multiple intervention sessions. The region treated was not a significant predictor for reporting on adverse events. Predictors for reporting on adverse events included larger sample size, publication after the 2010 CONSORT statement, low risk of bias and trials involving multiple intervention sessions. We recommend that researchers focus on developing robust methodologies and participant follow-up regimens for RCTs involving SMT.

Changes in biochemical markers following spinal manipulation-a systematic review and meta-analysis

The aim of this meta-analysis was to determine the effectiveness of spinal manipulation in influencing various biochemical markers in healthy and or symptomatic population. Electronic databases (n = 10) were searched (from inception till September 2016) and eight trials (325 participants) that met the inclusion criteria were included in the meta-analysis. Two authors independently extracted and assessed the risk of bias in included studies. Standardised mean differences for outcome measures were used to calculate effect sizes. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) tool was used for assessing the quality of the body of evidence for each outcome of interest. There was moderate quality evidence that spinal manipulation influenced biochemical markers. There was moderate quality evidence of significant difference that spinal manipulation is better (SMD -0.46, 95% CI - 0.93 to 0) than control in eliciting changes in cortisol levels immediately after intervention. There was also a low quality evidence that spinal manipulation is better than control at post-intervention in increasing substance-P (SMD -0.48,95%CI-0.87 to -0.1), neurotensin (SMD -1.8,95%CI-2.56 to -1.04) and oxytocin levels (SMD -2.61,95%CI-3.5to-1.72). However, low quality evidence indicated that spinal manipulation did not influence epinephrine (SMD 0.1,95%CI- 0.56to0.75) or nor-epinephrine levels (SMD -0.06,95%CI-0.71to0.6). The current review found that spinal manipulation can increase substance-p, neurotensin, oxytocin and interleukin levels and may influence cortisol levels post-intervention. However, future trials targeting symptomatic populations are required to understand the clinical importance of such changes.

The quality of placebos used in randomized, controlled trials of lumbar and pelvic joint thrust manipulation-a systematic review

BACKGROUND CONTEXT

Spinal manipulative therapy (SMT) has been attributed with substantial non-specific effects. Accurate assessment of the non-specific effects of SMT relies on high-quality studies with low risk of bias that compare with appropriate placebos.

PURPOSE

This review aims to characterize the types and qualities of placebo control procedures used in controlled trials of manually applied, lumbar and pelvic (LP)-SMT, and to evaluate the assessment of subject blinding and expectations.

STUDY DESIGN

This is a systematic review of randomized, placebo-controlled trials.

METHODS

We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Index to Chiropractic Literature, and relevant bibliographies. We included randomized, placebo or sham-controlled trials where the index treatment was manually applied LP-SMT. There were no restrictions on the type of condition being investigated. Two independent reviewers selected the studies, assessed study quality, and extracted the data. Relevant data were the type and quality of placebo control(s) used, the assessment of blinding and expectations, and the results of those assessments.

RESULTS

Twenty-five randomized, placebo-controlled trials were included in this review. There were 18 trials that used a sham manual SMT procedure for their placebo control intervention; the most common approach was with an SMT setup but without the application of any thrust. One small pilot study used an unequivocally indistinguishable placebo, two trials used placebos that had been validated as inert a priori, and eight trials reported on the success of subject blinding. Risk of bias was high or unclear, for all included studies.

CONCLUSIONS

Imperfect placebos are ubiquitous in clinical trials of LP-SMT, and few trials have assessed for successful subject blinding or balanced expectations of treatment success between active and control group subjects. There is thus a strong potential for unmasking of control subjects, unequal non-specific effects between active and control groups, and non-inert placebos in existing trials. Future trials should consider assessing the success of subject blinding and ensuring inertness of their placebo a priori, as a minimum standard for quality.

Choosing wisely: practical considerations on treatment efficacy and safety of asthma in the elderly

The prevalence of asthma in the most advanced ages is similar to that of younger ages. However, the concept that older individuals may suffer from allergic asthma has been largely denied in the past, and a common belief attributes to asthma the definition of "rare" disease. Indeed, asthma in the elderly is often underdiagnosed or diagnosed as COPD, thus leading to undertreatment of improper treatment. This is also due to the heterogeneity of clinical and functional presentations of geriatric asthma, including the partial loss of reversibility and the lower occurrence of the allergic component in this age range. The older asthmatic patients are also characterized the coexistence of comorbid conditions that, in conjunction with age-associated structural and functional changes of the lung, may contribute to complicate the management of asthma. The current review addresses the main issues related to the management of allergic asthma in the geriatric age. In particular, the paper aims at revising current pharmacological and non pharmacological treatments for allergic asthmatics of advanced ages, primarily focusing on their safety and efficacy, although most behaviors are an arbitrary extrapolation of what has been tested in young ages. In fact, age has always represented an exclusion criterion for eligibility to clinical trials. Experimental studies and real life observations specifically testing the efficacy and safety of therapeutic approaches in allergic asthma in the elderly are urgently needed.

Is manipulative therapy more effective than sham manipulation in adults : a systematic review and meta-analysis

BACKGROUND

Manipulative therapy is widely used in the treatment of spinal disorders. Manipulative techniques are under debate because of the possibility of adverse events. To date, the efficacy of manipulations compared to sham manipulations is unclear. The purpose of the study is: to assess the efficacy of manipulative therapy compared to sham in adults with a variety of complaints.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

Bibliographic databases (PubMed, EMBASE, CINAHL, PEDro, Central) along with a hand search of selected bibliographies were searched from inception up to April 2012.

RESULTS

In total 965 references were screened for eligibility and 19 RCTs (n = 1080) met the selection criteria. Eight studies were considered of low risk of bias. There is moderate level of evidence that manipulative therapy has a significant effect in adults on pain relief immediately after treatment (standardized mean difference [SMD] - 0.68, 95% confidence interval (-1.06 to -0.31). There is low level of evidence that manipulative therapy has a significant effect in adults on pain relief (SMD - 0.37, -0.69 to -0.04) at short- term follow-up. In patients with musculoskeletal disorders, we found moderate level of evidence for pain relief (SMD - 0.73, -1.21 to -0.25) immediate after treatment and low level of evidence for pain relief (SMD - 0.52, -0.87 to -0.17) at short term-follow-up. We found very low level of evidence that manipulative therapy has no statistically significant effect on disability and perceived (asthma) recovery. Sensitivity analyses did not change the main findings. No serious adverse events were reported in the manipulative therapy or sham group.

CONCLUSIONS

Manipulative therapy has a clinical relevant effect on pain, but not on disability or perceived (asthma) recovery. Clinicians can refer patients for manipulative therapy to reduce pain.

Role of chiropractic and sacro-occipital technique in asthma treatment

Asthma is a multifactorial dysfunction of the respiratory system. Nutritional, environmental, genetic, and emotional factors all play animportant part in the etiology of this condition. One form of chiropractic, Sacro Occipital Technique (SOT), offers some conservative alternatives to the treatment of asthma. SOT expands the chiropractic armamentarium of techniques available, allowing methods putatively affecting the viscera, vertebra, post and preganglionic reflexes, as well as cranial and sacral influences on the primary respiratory mechanism. Though more research is needed to evaluate the efficacy of chiropractic care of asthma, the conservative nature of chiropractic care with its minimal side effects, warrants patient and a health practitioner's consideration prior to embarking on any course of treatment that might have serious side effects.

Chiropractic diagnosis and management of non-musculoskeletal conditions in children and adolescents

Background

A great deal has been published in the chiropractic literature regarding the response, or lack thereof, of various common pediatric conditions to chiropractic care. The majority of that literature is of low scientific value (that is, case reports or case series). The purpose of this review is to summarize the literature from the point of view of clinicians, rather than researchers, and to discuss some additional detail of the conditions themselves.

Methods

Databases searched were PubMed, Mantis, Index to Chiropractic Literature, and CINAHL. Keywords were chiropractic paired with colic, crying infant, nocturnal enuresis, asthma, otitis media and attention deficit hyperactivity disorder.

Results

Most of the published literature centers around case reports or series. The more scientifically rigorous studies show conflicting results for colic and the crying infant, and there is little data to suggest improvement of otitis media, asthma, nocturnal enuresis or attention deficit hyperactivity disorder.

Discussion

The efficacy of chiropractic care in the treatment of non-musculoskeletal disorders has yet to be definitely proven or disproven, with the burden of proof still resting upon the chiropractic profession.

Complementary/alternative medicines in allergic disease

Complementary/alternative medicines is a generic term that encompasses a variety of approaches, including homeopathy, acupuncture, phytotherapy and numerous holistic or behavioral techniques. Complementary/alternative medicines are widely used in a number of conditions, including asthma and rhinitis. The medical literature on complementary/alternative medicines is impressive, but there are few clinical studies conducted with an appropriate methodology, and their results are negative or conflicting. In general, the results are insufficient to provide recommendations for the use of complementary/alternative medicines in clinical practice. Regarding diagnostic techniques, none have demonstrated the capability of distinguishing between healthy and allergic subjects and none are able to identify sensitizations.

Effectiveness of manual therapies: the UK evidence report

BACKGROUND

The purpose of this report is to provide a succinct but comprehensive summary of the scientific evidence regarding the effectiveness of manual treatment for the management of a variety of musculoskeletal and non-musculoskeletal conditions.

METHODS

The conclusions are based on the results of systematic reviews of randomized clinical trials (RCTs), widely accepted and primarily UK and United States evidence-based clinical guidelines, plus the results of all RCTs not yet included in the first three categories. The strength/quality of the evidence regarding effectiveness was based on an adapted version of the grading system developed by the US Preventive Services Task Force and a study risk of bias assessment tool for the recent RCTs.

RESULTS

By September 2009, 26 categories of conditions were located containing RCT evidence for the use of manual therapy: 13 musculoskeletal conditions, four types of chronic headache and nine non-musculoskeletal conditions. We identified 49 recent relevant systematic reviews and 16 evidence-based clinical guidelines plus an additional 46 RCTs not yet included in systematic reviews and guidelines.Additionally, brief references are made to other effective non-pharmacological, non-invasive physical treatments.

CONCLUSIONS

Spinal manipulation/mobilization is effective in adults for: acute, subacute, and chronic low back pain; migraine and cervicogenic headache; cervicogenic dizziness; manipulation/mobilization is effective for several extremity joint conditions; and thoracic manipulation/mobilization is effective for acute/subacute neck pain. The evidence is inconclusive for cervical manipulation/mobilization alone for neck pain of any duration, and for manipulation/mobilization for mid back pain, sciatica, tension-type headache, coccydynia, temporomandibular joint disorders, fibromyalgia, premenstrual syndrome, and pneumonia in older adults. Spinal manipulation is not effective for asthma and dysmenorrhea when compared to sham manipulation, or for Stage 1 hypertension when added to an antihypertensive diet. In children, the evidence is inconclusive regarding the effectiveness for otitis media and enuresis, and it is not effective for infantile colic and asthma when compared to sham manipulation.Massage is effective in adults for chronic low back pain and chronic neck pain. The evidence is inconclusive for knee osteoarthritis, fibromyalgia, myofascial pain syndrome, migraine headache, and premenstrual syndrome. In children, the evidence is inconclusive for asthma and infantile colic.

The immediate effect of individual manipulation techniques on pulmonary function measures in persons with chronic obstructive pulmonary disease

BACKGROUND

The use of manipulation has long been advocated in the treatment of chronic obstructive pulmonary disease (COPD), but few randomized controlled clinical trials have measured the effect of manipulation on pulmonary function. In addition, the effects of individual manipulative techniques on the pulmonary system are poorly understood. Therefore, the purpose of this study was to determine the immediate effects of four osteopathic techniques on pulmonary function measures in persons with COPD relative to a minimal-touch control protocol.

METHODS

Persons with COPD aged 50 and over were recruited for the study. Subjects received five, single-technique treatment sessions: minimal-touch control, thoracic lymphatic pump (TLP) with activation, TLP without activation, rib raising, and myofascial release. There was a 4-week washout period between sessions. Protocols were given in random order until all five techniques had been administered. Pulmonary function measures were obtained at baseline and 30-minutes posttreatment. For the actual pulmonary function measures and percent predicted values, Wilcoxon signed rank tests were used to test within-technique changes from baseline. For the percent change from baseline, Friedman tests were used to test for between-technique differences.

RESULTS

Twenty-five subjects were enrolled in the study. All four tested osteopathic techniques were associated with adverse posttreatment changes in pulmonary function measures; however, different techniques changed different measures. TLP with activation increased posttreatment residual volume compared to baseline, while TLP without activation did not. Side effects were mild, mostly posttreatment chest wall soreness. Surprisingly, the majority of subjects believed they could breathe better after receiving osteopathic manipulation.

CONCLUSION

In persons with COPD, TLP with activation, TLP without activation, rib raising, and myofascial release mildly worsened pulmonary function measures immediately posttreatment relative to baseline measurements. The activation component of the TLP technique appears to increase posttreatment residual volume. Despite adverse changes in pulmonary function measures, persons with COPD subjectively reported they benefited from osteopathic manipulation.

Spinal manipulation for asthma: a systematic review of randomised clinical trials

Some clinicians believe that spinal manipulation is an effective treatment for asthma. The aim of this systematic review was to critically evaluate the evidence for or against this claim. Four electronic databases were searched without language restrictions from their inceptions to September 2008. Bibliographies and departmental files were hand-searched. The methodological quality of all included studies was assessed with the Jadad score. Only randomised clinical trials of spinal manipulation as a treatment of asthma were included. Three studies met these criteria. All of them were of excellent methodological quality (Jadad score 5) and all used sham-manipulation as the control intervention. None of the studies showed that real manipulation was more effective than sham-manipulation in improving lung function or subjective symptoms. It is concluded that, according to the evidence of the most rigorous studies available to date, spinal manipulation is not an effective treatment for asthma.

Chiropractic care for nonmusculoskeletal conditions: a systematic review with implications for whole systems research

OBJECTIVES

(1) To evaluate the evidence on the effect of chiropractic care, rather than spinal manipulation only, on patients with nonmusculoskeletal conditions; and (2) to identify shortcomings in the evidence base on this topic, from a Whole Systems Research perspective.

DESIGN

Systematic review.

METHODS

Databases included were PubMed, Ovid, Mantis, Index to Chiropractic Literature, and CINAHL. Search restrictions were human subjects, peer-reviewed journal, English language, and publication before May 2005. All randomized controlled trials (RCTs) were evaluated using the Scottish Intercollegiate Guidelines Network (SIGN) and Jadad checklists; a checklist developed from the CONSORT (Consolidated Standards of Reporting Trials) guidelines; and one developed by the authors to evaluate studies in terms of Whole Systems Research (WSR) considerations.

RESULTS

The search yielded 179 papers addressing 50 different nonmusculoskeletal conditions. There were 122 case reports or case series, 47 experimental designs, including 14 RCTs, 9 systematic reviews, and 1 a large cohort study. The 14 RCTs addressed 10 conditions. Six RCTs were rated "high" on the 3 conventional checklists; one of these 6 was rated "high" in terms of WSR considerations.

CONCLUSIONS

(1) Adverse effects should be routinely reported. For the few studies that did report, adverse effects of spinal manipulation for all ages and conditions were rare, transient, and not severe. (2) Evidence from controlled studies and usual practice supports chiropractic care (the entire clinical encounter) as providing benefit to patients with asthma, cervicogenic vertigo, and infantile colic. Evidence was promising for potential benefit of manual procedures for children with otitis media and elderly patients with pneumonia. (3) The RCT design is not necessarily incompatible with WSR. RCTs could improve generalizability by basing protocols on usual practice. (4) Case reports could contribute more to WSR by increasing their emphasis on patient characteristics and patient-based outcomes. (5) Chiropractic investigators, practitioners, and funding agencies should increase their attention to observational designs.

Chiropractic Clinical Research: Progress and Recommendations

OBJECTIVE

The purpose of this white paper is to help inform the chiropractic clinical research agenda with a focus on the United States.

METHODS AND DISCUSSION

The recommendations and action items from 2 previous articles published in 1997 are discussed within the context of 3 broad topics: research culture, research infrastructure, and clinical research studies. Progress made toward the action items in these areas is summarized. A summary of findings is presented of the most influential clinical research studies during the past decade performed by or with major contributions by chiropractic investigators. In light of the current evidence and previous recommendations, new clinical research recommendations are proposed.

CONCLUSIONS

Based on the assessment of the scientific literature and research currently underway, it is evident that members of the chiropractic research community have made important progress in becoming active players in the clinical research arena. During the past decade, the work of chiropractic researchers has contributed substantially to the amount and quality of the evidence for or against spinal manipulation in the management of low back pain, neck pain, headache, and other conditions.

Comparison of Bioenergetic Synchronization Technique and Customary Chiropractic Care for Older Adults With Chronic Musculoskeletal Pain

OBJECTIVE

The aim of the study was to compare the clinical outcomes of 2 approaches to chiropractic care for patients with chronic musculoskeletal pain. Included were the approach most commonly used by doctors of chiropractic (diversified technique spinal manipulation) and a nonmanipulative mind-body approach (Bioenergetic Synchronization Technique). This clinical experiment tested the null hypothesis that there is no clinically or statistically significant difference in effect between the 2 approaches.

METHODS

The study was conducted in the research clinic of the Parker College of Chiropractic. Patients were initially recruited by contacting a previously developed pool used for studies related to fall prevention in the elderly. Eighty-one patients (74 females; median age, 66 years) were enrolled and 78 (96%) completed the study. The primary end point was the end of a 3-week nontreatment interval after a 4-week treatment period. An intention-to-treat analysis was used; all patients who completed assessments were included whether or not they were compliant with the treatment protocol. A sample size of 55 per group was estimated to be necessary to detect a clinically significant (6-point) between-group difference in the Pain Disability Index (PDI). The primary outcome, the mean between-group difference between PDI scores at visit 1 and the exit visit, was tested with a 2-tailed t test for independent samples.

RESULTS

Mean improvements in the PDI from visit 1 to the exit visit were 6.9 points in the Bioenergetic Synchronization Technique group (n = 40) and 6.4 in the diversified technique group (n = 38); the between-groups difference was not statistically or clinically significant (95% confidence interval, -4.7 to 5.8).

CONCLUSIONS

For this particular group of patients, both groups demonstrated similar improvement scores on the PDI; the study's null hypothesis was not rejected.

ARIA update: I--Systematic review of complementary and alternative medicine for rhinitis and asthma

Complementary-alternative medicines are extensively used in the treatment of allergic rhinitis and asthma, but evidence-based recommendations are lacking. To provide evidence-based recommendations, the literature was searched by using MedLine and the Cochrane Library to March 2005 (Key words: Asthma [OR] Rhinitis, [AND] Complementary [OR] Alternative Medicine, [OR] Herbal, [OR] Acupuncture, [OR] Homeopathy, [OR] Alternative Treatment). Randomized trials, preferably double-blind and published in English, were selected. The articles were evaluated by a panel of experts. Quality of reporting was assessed by using the scale validated by Jadad. The methodology of clinical trials with complementary-alternative medicine was frequently inadequate. Meta-analyses provided no clear evidence for the efficacy of acupuncture in rhinitis and asthma. Some positive results were described with homeopathy in good-quality trials in rhinitis, but a number of negative studies were also found. Therefore it is not possible to provide evidence-based recommendations for homeopathy in the treatment of allergic rhinitis, and further trials are needed. A limited number of studies of herbal remedies showed some efficacy in rhinitis and asthma, but the studies were too few to make recommendations. There are also unresolved safety concerns. Therapeutic efficacy of complementary-alternative treatments for rhinitis and asthma is not supported by currently available evidence.

Validation of a sham manipulative procedure for the cervical spine for use in clinical trials

OBJECTIVE

To develop a sham manipulation procedure for the cervical spine for use in randomized clinical trials of cervical disorders.

METHODS

A single-group, single-intervention study design was used. Adult neck pain subjects underwent a screening examination that included palpation for a site of cervical spine joint dysfunction. Eligible subjects underwent measurements of regional cervical ranges of motion as well as pressure algometry (tenderness) at the site of cervical joint dysfunction. Subjects were instructed that they would receive one of several types of manipulative procedures. A newly developed sham manipulation was delivered once. Subjects were then remeasured for ranges of motion and tenderness. They were asked if they had experienced any pain during the procedure, if they had experienced a "cavitation" sound, and if they thought that the procedure they received was a "real" manipulation. Finally, they were debriefed as to the deception involved in this study. A prior level of 65% was set for endorsement that the procedure was a real manipulation. Changes in pre-post measures of ranges of motion and tenderness were analyzed descriptively for clinically important differences.

RESULTS

Twenty eligible subjects were included (12 males, 8 females) with an average age of 30.4 (2.8) years. Twelve of the subjects were not students, with 3 of these having no prior experience with chiropractic treatment; 8 were students. Of the total sample (N = 19), 8 (42.1%) indicated that the procedure was a "real adjustment"; of the 12 nonstudents, 8 (58.3%) indicated similarly. None of the procedures in the final sample resulted in a cavitation, and none of the subjects registered the procedure as painful. None of the measures for ranges of motion or tenderness showed clinically important changes.

CONCLUSIONS

The sham cervical manipulation studied here appears to approximate the necessary features of a placebo maneuver in that it is perceived by a majority of nonstudent neck pain subjects to be a real manipulation, although it does not produce any important change in cervical status. The small sample size of nonstudent participants precludes a strong recommendation for this procedure at this time.

Manual therapy for asthma

BACKGROUND

A variety of manual therapies with similar postulated biologic mechanisms of action are commonly used to treat patients with asthma. Manual therapy practitioners are also varied, including physiotherapists, respiratory therapists, chiropractic and osteopathic physicians. A systematic review across disciplines is warranted.

OBJECTIVES

To evaluate the evidence for the effects of manual therapies for treatment of patients with bronchial asthma.

SEARCH STRATEGY

We searched for trials in computerized general (EMBASE, CINAHL and MEDLINE) and specialized databases (Cochrane Complementary Medicine Field, Cochrane Rehabilitation Field, Index to Chiropractic Literature (ICL), and Manual, Alternative and Natural Therapy (MANTIS)). In addition, we assessed bibliographies from included studies, and contacted authors of known studies for additional information about published and unpublished trials. Date of most recent search: August 2004.

SELECTION CRITERIA

Trials were included if they: (1) were randomised; (2) included asthmatic children or adults; (3) examined one or more types of manual therapy; and (4) included clinical outcomes with observation periods of at least two weeks.

DATA COLLECTION AND ANALYSIS

All three reviewers independently extracted data and assessed trial quality using a standard form.

MAIN RESULTS

From 473 unique citations, 68 full text articles were retrieved and evaluated, which resulted in nine citations to three RCTs (156 patients) suitable for inclusion. Trials could not be pooled statistically because studies that addressed similar interventions used disparate patient groups or outcomes. The methodological quality of one of two trials examining chiropractic manipulation was good and neither trial found significant differences between chiropractic spinal manipulation and a sham manoeuvre on any of the outcomes measured. One small trial compared massage therapy with a relaxation control group and found significant differences in many of the lung function measures obtained. However, this trial had poor reporting characteristics and the data have yet to be confirmed.

AUTHORS' CONCLUSIONS

There is insufficient evidence to support the use of manual therapies for patients with asthma. There is a need to conduct adequately-sized RCTs that examine the effects of manual therapies on clinically relevant outcomes. Future trials should maintain observer blinding for outcome assessments, and report on the costs of care and adverse events. Currently, there is insufficient evidence to support or refute the use of manual therapy for patients with asthma.

Chiropractic care in asthma and allergy

OBJECTIVE

To provide a brief overview of the current state of evidence for chiropractic care, specifically in the management of asthma and to a lesser extent allergy.

DATA SOURCES

A search of MEDLINE for English-language articles published between January 1966 and July 2002 was conducted using the keywords asthma, allergy, manual therapy, physical therapy techniques, chiropractic, physical therapy (specialty), physiotherapy, massage, and massage therapy. A hand search of the primary chiropractic and osteopathic literature on the treatment of asthma was performed, and proceedings from a recent research symposium on spinal manipulation were included.

STUDY SELECTION

Clinical controlled studies and systematic reviews on spinal manipulative therapy (SMT) and asthma were selected. There were no primary clinical trials on SMT and allergy found.

RESULTS

Many of the claims of chiropractic success in asthma have been primarily based on anecdotal evidence or uncontrolled case studies. Three recently reported randomized controlled studies showed benefit in subjective measures, such as quality of life, symptoms, and bronchodilator use; however, the differences were not statistically significant between controls and treated groups. There were no significant changes in any objective lung function measures. The clinical issues emanating from these trials are discussed.

CONCLUSIONS

There is currently no evidence to support the use of chiropractic SMT as a primary treatment for asthma or allergy. Based on reported subjective improvement in patients receiving chiropractic care, certain clinical circumstances may warrant a therapeutic trial in patients with asthma. Further properly designed, collaborative research is needed to determine if there is a role for chiropractic SMT in the care of asthma or allergy.

Manual therapy for asthma

BACKGROUND

A variety of manual therapies with similar postulated biologic mechanisms of action are commonly used to treat patients with asthma. Manual therapy practitioners are also varied, including physiotherapists, respiratory therapists, chiropractic and osteopathic physicians. A systematic review across disciplines is warranted.

OBJECTIVES

To evaluate the evidence for the effects of manual therapies for treatment of patients with bronchial asthma.

SEARCH STRATEGY

Trials were searched in computerized general (EMBASE, CINAHL and MEDLINE) and specialized databases (Cochrane Complementary Medicine Field, Cochrane Rehabilitation Field, ICL, and MANTIS). In addition, bibliographies from included studies were assessed, and authors of known studies were contacted for additional information about published and unpublished trials. Date of most recent search: February 2002.

SELECTION CRITERIA

Trials were included if they: (1) were randomised; (2) included asthmatic children or adults; (3) examined one or more types of manual therapy; and (4) included clinical outcomes.

DATA COLLECTION AND ANALYSIS

All three reviewers independently extracted data and assessed trial quality using a standard form.

MAIN RESULTS

From 393 unique citations, 59 full text articles were retrieved and evaluated, which resulted in nine citations to five RCTs (290 patients) suitable for inclusion. Trials could not be pooled statistically because studies that addressed similar interventions used disparate patient groups or outcomes. The methodological quality of one of two trials examining chiropractic manipulation was good and neither trial found significant differences between chiropractic spinal manipulation and a sham manoeuvre on any of the outcomes measured. Quality of the remaining three trials was poor. One small trial compared massage therapy with a relaxation control group and found significant differences in many of the lung function measures obtained. However, this trial had poor reporting characteristics and the data have yet to be confirmed. One small trial compared chest physiotherapy to placebo and one small trial compared footzone therapy to a no treatment control. Neither trial found differences in lung function between groups.

REVIEWER'S CONCLUSIONS

There is insufficient evidence to support the use of manual therapies for patients with asthma. There is a need to conduct adequately-sized RCTs that examine the effects of manual therapies on clinically relevant outcomes. Future trials should maintain observer blinding for outcome assessments, and report on the costs of care and adverse events. Currently, there is insufficient evidence to support or refute the use of manual therapy for patients with asthma.

Spinal manipulation: a systematic review of sham-controlled, double-blind, randomized clinical trials

For many years, spinal manipulation has been a popular form of treatment. Yet the debate about its clinical efficacy continues. The research question remains: Does spinal manipulation convey more than a placebo effect? To summarize the evidence from sham-controlled clinical trials of spinal manipulation as a treatment of various conditions, and to assess the methodological quality of these studies, a comprehensive search strategy was designed to locate all sham-controlled, double-blind, randomized trials of spinal manipulation as a treatment of any medical condition. Data were extracted from these trials and validated by two independent reviewers in a standardized fashion. All trials were critically analyzed and their methodological quality evaluated. Eight studies fulfilled the pre-defined inclusion/exclusion criteria. Three trials (two on back pain and one on enuresis) were judged to be burdened with serious methodological flaws. The results of the three most rigorous studies (two on asthma and one on primary dysmenorrhea) do not suggest that spinal manipulation leads to therapeutic responses which differ from an inactive sham-treatment. This analysis demonstrates that sham-controlled trials of spinal manipulation are sparse but feasible. The most rigorous of these studies suggest that spinal manipulation is not associated with clinically-relevant specific therapeutic effects.

Chronic pediatric asthma and chiropractic spinal manipulation: a prospective clinical series and randomized clinical pilot study

OBJECTIVES

The first objective was to determine if chiropractic spinal manipulative therapy (SMT) in addition to optimal medical management resulted in clinically important changes in asthma-related outcomes in children. The second objective was to assess the feasibility of conducting a full-scale, randomized clinical trial in terms of recruitment, evaluation, treatment, and ability to deliver a sham SMT procedure.

STUDY DESIGN

Prospective clinical case series combined with an observer-blinded, pilot randomized clinical trial with a 1-year follow-up period.

SETTING

Primary contact, college outpatient clinic, and a pediatric hospital.

PATIENTS

A total of 36 patients aged 6 to 17 years with mild and moderate persistent asthma were admitted to the study.

OUTCOME MEASURES

Pulmonary function tests; patient- and parent- or guardian-rated asthma-specific quality of life, asthma severity, and improvement; am and pm peak expiratory flow rates; and diary-based day and nighttime symptoms.

INTERVENTIONS

Twenty chiropractic treatment sessions were scheduled during the 3-month intervention phase. Patients were randomly assigned to receive either active SMT or sham SMT in addition to their standardized ongoing medical management.

RESULTS

It is possible to blind the participants to the nature of the SMT intervention, and a full-scale trial with the described design is feasible to conduct. At the end of the 12-week intervention phase, objective lung function tests and patient-rated day and nighttime symptoms based on diary recordings showed little or no change. Of the patient-rated measures, a reduction of approximately 20% in beta(2) bronchodilator use was seen (P =.10). The quality of life scores improved by 10% to 28% (P <.01), with the activity scale showing the most change. Asthma severity ratings showed a reduction of 39% (P <.001), and there was an overall improvement rating corresponding to 50% to 75%. The pulmonologist-rated improvement was small. Similarly, the improvements in parent- or guardian-rated outcomes were mostly small and not statistically significant. The changes in patient-rated severity and the improvement rating remained unchanged at 12-month posttreatment follow-up as assessed by a brief postal questionnaire.

CONCLUSION

After 3 months of combining chiropractic SMT with optimal medical management for pediatric asthma, the children rated their quality of life substantially higher and their asthma severity substantially lower. These improvements were maintained at the 1-year follow-up assessment. There were no important changes in lung function or hyperresponsiveness at any time. The observed improvements are unlikely as a result of the specific effects of chiropractic SMT alone, but other aspects of the clinical encounter that should not be dismissed readily. Further research is needed to assess which components of the chiropractic encounter are responsible for important improvements in patient-oriented outcomes so that they may be incorporated into the care of all patients with asthma.

Reflexology and bronchial asthma

Many asthma patients seek alternative or adjunctive therapies. One such modality is reflexology, whereby finger pressure is applied to certain parts of the body. The aim of the study was to examine the popular claim that reflexology treatment benefits bronchial asthma. Ten weeks of active or simulated (placebo) reflexology given by an experienced reflexologist, were compared in an otherwise blind, controlled trial of 20+20 outpatients with asthma. Objective lung function tests (peak flow morning and evening, and weekly spirometry at the clinic) did not change. Subjective scores (describing symptoms, beta2-inhalations and quality of life) and also bronchial sensitivity to histamine improved on both regimens, but no differences were found between groups receiving active or placebo reflexology. However, a trend in favour of reflexology became significant when a supplementary analysis of symptom diaries was carried out. It was accompanied by a significant pattern compatible with subconscious unblinding, in that patients tended to guess which treatment they had been receiving. No evidence was found that reflexology has a specific effect on asthma beyond placebo influence.

A primer of complementary and alternative medicine commonly used by cancer patients

Complementary and alternative medicine (CAM) is frequently used by cancer patients, and many oncologists have limited knowledge of CAM. This article provides a brief, evidence-based introduction to several CAM treatments relevant in the context of cancer. "Alternative" diets, chiropractic, coffee enemas, ozone therapy, and shark cartilage seem to have little to offer cancer patients. The evidence for or against homoeopathy and spiritual healing is at present inconclusive. Acupuncture, aromatherapy, and meditation may be useful for nausea/vomiting, for mild relaxation, and for pain/anxiety, respectively. Herbal treatments offer no reasonable prospect of a cure (mistletoe), but could be useful as palliative treatments (eg, for depression [St John's wort] or anxiety [kava]). Our knowledge regarding the potential benefit and harm of CAM is insufficient.

Integrity and research: introducing the concept of dual blindness. how blind are double-blind clinical trials in alternative medicine?

Double-blind methodology is used in clinical studies to control for potential external or nonspecific influences such as belief and expectation, as well as to maintain as much objectivity as possible on the part of the researchers. Despite not being feasible in all medical disciplines, as in the case of some modalities of complementary and alternative medicine, there are numerous studies that spuriously claim its use. Distinctions and standards therefore need to be set to avoid misleading information. We propose a new term in research methodology, dual-blind, to describe a methodological alternative in which the caregiver is not blind but the patient and an external evaluator/investigator are. The term double-blind should be used strictly to describe a methodology in which both the patient and the caregiver are blind. Making the distinction between these two terms will result in more reliable reports of clinical trials and will support integrity in research.

Complementary/alternative medicine in the treatment of asthma

OBJECTIVE

This review will familiarize clinical allergists/immunologists with the common forms of complementary/alternative medicine (CAM) that are being used frequently by their patients. It reviews reasons that patients seek alternative health care therapies and the most common illnesses that are treated with this form of medicine. Cultural differences in CAM are also reviewed. The article focuses on specific therapies used to treat asthma and reviews the efficacy of these therapies based on the available scientific literature. The reader will also learn about views of other physicians on CAM and how this topic is being addressed in US medical schools.

DATA SOURCES

Computer-assisted MEDLINE searches for articles on "complementary/alternative medicine" or "herbal therapy" and "asthma" or "atopy."

STUDY SELECTION

Pertinent abstracts and articles in the above areas were selected. Articles selected for detailed review included review articles of the subjects along with randomized, double-blind placebo-controlled studies in animals and humans.

RESULTS

Complementary/alternative medicine is commonly used by patients with chronic conditions including asthma. One-third of the US population has tried CAM. The literature supporting the efficacy of these therapies is lacking. Some reports elucidate the mechanism of action of certain herbal therapies that could possibly be helpful in the treatment of allergic diseases. There are, however, few well-controlled studies that support the efficacy of CAM in the treatment and clinical improvement of human subjects with asthma or atopic disorders.

CONCLUSION

Available scientific evidence does not support a role for CAM in the treatment of asthma. The studies in the literature often have significant design flaws that weaken the conclusions such as insufficient numbers of patients, lack of proper controls, and inadequate blinding. Further studies are needed to prove or disprove the efficacy of CAM. Physicians often find CAM intimidating because they are unaware of the clinical evidence and feel uncomfortable advising their patients on its efficacy. There is definitely a need for more education among physicians in this area. It is also important that physicians inquire and discuss the use of CAM with their patients since the majority of patients are using some form of CAM.

Short-term effects of cervical manipulation on edge light pupil cycle time: a pilot study

BACKGROUND

Edge light pupil cycle time (ELPCT) is one of the eye's light reflexes. Studies have shown ELPCT to be a measurable constant, unaffected by visual acuity, refractive error, eye color, pupil size, or sex. Control of this reflex occurs through the autonomic nervous system. Various authors suggest that spinal manipulative techniques can produce distant effects mediated in part by alterations in autonomic tone after intervention.

OBJECTIVE

To investigate the effects of a C1-2 high-velocity, low-amplitude manipulation on ELPCT.

DESIGN

A single-group, randomized pilot study without a control group.

METHODS

Thirteen men (mean age 24.2 years) without a history of eye disease or central or autonomic nervous system pathologic conditions had their ELPCT measured before and after manipulation. The manipulation comprised a high-velocity, low-amplitude rotatory thrust, localized to the C1-2 joint on the left (n = 6) or right (n = 7) eye, determined randomly.

RESULTS

ELPCT measures demonstrated a significant difference for both eyes before and after manipulation (P = .002; the right eye, P = .027; the left eye, P = .046).

CONCLUSION

This suggests that ELPCT, which is mediated through the autonomic nervous system, can be directly influenced by high-velocity manipulation to the upper cervical spine.

Recent advances in alternative therapies

Complementary and alternative medicine (CAM) is becoming more popular, and CAM remedies are used instead of, or integrated with, orthodox allopathic therapies by many patients with asthma. Although most CAM remedies may have no discernible effects when analyzed by conventional medical techniques, some double-blind controlled studies do suggest that a meaningful benefit can be obtained with acupunture and homeopathic management in asthma. Herbal medicine is more popular, despite little evidence that the vast majority of herbs for asthma have any useful effects other than a nonspecific expectorant action. Dietary adjustment may benefit a small percentage of patients with asthma, but extreme measures are very rarely indicated. Formal pyschologic approaches can help some patients by reducing anxiety. Although most CAM approaches are harmless, the lack of benefit of many remedies and the potential harm from some of them must be recognized.

The types and frequencies of improved nonmusculoskeletal symptoms reported after chiropractic spinal manipulative therapy

OBJECTIVE

To investigate the frequency and types of improved nonmusculoskeletal symptoms reported after chiropractic spinal manipulative therapy.

DESIGN

Retrospective information obtained by chiropractors through standardized interview of patients on return visit within 2 weeks of previous treatment.

SETTING

The private practice of 87 Swedish chiropractors (response rate 81%).

SUBJECTS

Twenty consecutive (presumably naive) patients per chiropractor (1504 valid questionnaires returned, 86% of optimal number of replies).

INTERVENTION

Spinal manipulation with or without additional therapy provided by chiropractors.

MAIN OUTCOME MEASURES

Self-reported improved nonmusculoskeletal symptoms (reactions).

RESULTS

At least I reaction was reported after the previous treatment in 21% to 25% of cases. Of these responses, 26% were related to the airway passages (usually reported as "easier to breathe"), 25% were related to the digestive system (mostly reported as "improved function"), 14% were classified under eyes/vision (usually reported as "improved vision"), and 14% under heart/ circulation (about half of these reported as "improved circulation"). The number of spinal areas treated was positively associated with the number of reactions.

CONCLUSION

A minority of chiropractic patients report having positive nonmusculoskeletal reactions after spinal manipulative therapy but such reports cluster predominantly around specific symptoms. It would be interesting to find out if these can be verified objectively and, if so, to investigate if they are caused by the treatment or if they are signs of natural variations in human physiology.

A comparison of active and simulated chiropractic manipulation as adjunctive treatment for childhood asthma

BACKGROUND

Chiropractic spinal manipulation has been reported to be of benefit in nonmusculoskeletal conditions, including asthma.

METHODS

We conducted a randomized, controlled trial of chiropractic spinal manipulation for children with mild or moderate asthma. After a three-week base-line evaluation period, 91 children who had continuing symptoms of asthma despite usual medical therapy were randomly assigned to receive either active or simulated chiropractic manipulation for four months. None had previously received chiropractic care. Each subject was treated by 1 of 11 participating chiropractors, selected by the family according to location. The primary outcome measure was the change from base line in the peak expiratory flow, measured in the morning, before the use of a bronchodilator, at two and four months. Except for the treating chiropractor and one investigator (who was not involved in assessing outcomes), all participants remained fully blinded to treatment assignment throughout the study.

RESULTS

Eighty children (38 in the active-treatment group and 42 in the simulated-treatment group) had outcome data that could be evaluated. There were small increases (7 to 12 liters per minute) in peak expiratory flow in the morning and the evening in both treatment groups, with no significant differences between the groups in the degree of change from base line (morning peak expiratory flow, P=0.49 at two months and P=0.82 at four months). Symptoms of asthma and use of 3-agonists decreased and the quality of life increased in both groups, with no significant differences between the groups. There were no significant changes in spirometric measurements or airway responsiveness.

CONCLUSIONS

In children with mild or moderate asthma, the addition of chiropractic spinal manipulation to usual medical care provided no benefit.