Research Review Corner: Chiropractic Care

Study title: Chiropractic care for non-musculoskeletal conditions: A systematic
review with implications for whole systems research

Author: Hawk C et al.

Publication information:  The Journal of Alternative and Complementary Medicine 2007; 13(5): 491-512.

Summary:  Below

In response to the growing demand for evidence-based information, and in order to better inform clinical decision making, the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) established expert teams to evaluate and critique the evidence for the treatment of various conditions. This paper summarizes the evidence regarding chiropractic care for non-musculoskeletal (NMSK) conditions.  For this review, NMSK conditions were defined as those in which the primary symptoms are not related to the spine or musculature. (For operational purposes, the review specifically excluded “headaches”, as they are included in the CCGPP cervical spine project.) 

THE SPECIFIC AIMS OF THIS REVIEW WERE TO:

1) evaluate the efficacy of chiropractic “care,” not meaning only spinal manipulation, on NMSK conditions and,
2) identify specific deficiencies in the literature in order to develop a whole systems approach to researching this topic.

A comprehensive literature search (PubMed, Ovid, Mantis, ICL, CINAHL) identified studies evaluating spinal manipulation/mobilization – both chiropractic and osteopathic – or general chiropractic management of NMSK conditions.  Papers were excluded if they: 1) did not present or analyze original data, 2) did not evaluate treatment outcomes, 3) did not involve a specific condition, or 4) did not utilize at least one manual intervention.

Fourteen randomized controlled trials, investigating 10 different conditions, met these criteria and were formally reviewed and evaluated for quality using the following:

1) Scottish Intercollegiate Guidelines Network (SIGN) checklist
2) Jadad scale
3) modified CONSORT checklist
4) whole systems research considerations
An additional 165 papers were included in the review – case series, single group studies, case reports etc. – for a total of 179 citations.

Each condition will be summarized individually:

ASTHMA (15 CITATIONS TOTAL):
• three RCTs reported no adverse effects from spinal manipulative therapy (SMT)
• although physiological measures did not improve in any study, medication use generally declined, and symptoms were generally reported to improve

HYPERTENSION (12 CITATIONS TOTAL):
• two RCTs reported no adverse effects with SMT (directed at the thoracic and
cervical spines)
• however, in one study, six subjects had to withdraw due to unacceptable increases in blood pressure (note: medication had been withdrawn prior to treatment)
• some results suggest decreased medication use and blood pressure, but the overall conclusion at this point is that: “…chiropractic care is not of great clinical utility to a broad population of
hypertensive patients.” (Goertz CH et al., 2002)

VERTIGO (12 CITATIONS TOTAL):
• one RCT reported no adverse effects with SMT
• most studies reported dizziness accompanied by neck pain
• in general, patients with dizziness and neck pain/cervical spine dysfunction appeared to benefit from SMT and manual therapy (note: the controlled studies were underpowered to reach statistical significance)

DYSMENORRHEA AND PREMENSTRUAL SYNDROME (10 CITATIONS TOTAL):
• one RCT reported minor low back soreness in both treatment and sham treatment groups
• across studies, any group receiving an intervention involving any amount of biomechanical force, even when minor, showed some improvement
• a Cochrane review has concluded that active treatment is no more efficacious than sham treatment, but is more effective than no treatment
• for premenstrual syndrome, results were inconsistent across four papers, each intervening over at least three menstrual cycles

INFANTILE COLIC (NINE CITATIONS TOTAL):
• one RCT reported no adverse effects from SMT
• a variety of manipulative techniques were utilized in the other eight citations (including localized and full-spine approaches)
• generally, results indicated improve-ment with SMT
• one systematic review reported insufficient evidence, while another indicated that although not superior to sham/no treatment, SMT seemed to improve parent-reported outcomes

OTITIS MEDIA (EIGHT CITATIONS TOTAL):
• two RCTs reported no adverse effects, and even some patient-reported positive effects (relaxation and improved sleep)
• again, a variety of manual techniques were utilized
• in one RCT, significantly fewer surgical procedures were needed in the osteopathic mobilization group compared to usual medical care (Mills MV et al., 2003)
• in the other citations, natural history of the condition could not be differentiated from the treatment
effects

NOCTURNAL ENURESIS (FIVE CITATIONS TOTAL):
• one RCT reported only transient pain (headache and low back) that
resolved with further treatment in the treatment group
• generally, the trend is in the direction of no treatment effect

PNEUMONIA (TWO CITATIONS TOTAL):
• both studies included patients over 60 years of age who were hospitalized
• one RCT reported withdrawal of two patients due to transient muscle/joint soreness after osteopathic manipulative therapy (OMT)
• generally, hospital stays and courses of intravenous antibiotics were shorter in those receiving OMT, mobilization, myofascial release, and other soft tissue treatment versus those receiving only light touch

JET LAG AND PHOBIA (TWO CITATIONS TOTAL):
• two RCTs (one for each condition)
• the study on jet lag showed no significant treatment effects (but, this study had only 15 subjects divided
into three groups, and, so was underpowered)
• the study on phobia did report significant improvement in emotional response, but not pulse rate reduction, with SMT (however, no statistical data was provided to support this “significant” change – a vital flaw in the study)

CONCLUSIONS AND PRACTICAL APPLICATION:
Several limitations of this project should be kept in mind when interpreting the results:
• there is limited literature on this topic on which conclusions can be based
• the literature selection was limited only to English
• potential bias when evaluating studies (authors attempted to reduce this by using accepted checklists).

PRACTICE IMPLICATIONS
1) adverse effects noted with SMT are rare, non-severe, and transient
2) evidence is adequate to indicate that chiropractic (including SMT and “other” factors) can provide benefit for those with asthma, cervicogenic vertigo, or infantile colic
3) promising evidence exists for the potential benefit of manual therapy for children with otitis media and hospitalized elderly patients with pneumonia – more research is required, however.
4) the evidence does not support chiropractic care for hypertension; however, a subset of hypertensive patients may exist that could benefit – more research is required.
5) evidence is equivocal for chiropractic care for dysmenorrhea and premenstrual syndrome
6) there is insufficient evidence to conclude whether chiropractic care can benefit other NMSK conditions.
 
Additional References:

Goertz CH et al. Treatment of Hypertension with Alternative Therapies (THAT) Study: A randomized clinical trial. J Hyper-tension 2002; 20: 2063-2068.
Mills MV et al. The use of osteopathic manipulative treatment as adjuvant therapy in children with recurrent acute otitis media. Arch Pediatr Adolesc Med 2003; 157: 861-866.

Dr. Shawn Thistle is the founder and president of Research Review Service Inc., an online, subscription-based service designed to help busy practitioners to integrate current, relevant scientific evidence into  their practice. Shawn graduated from CMCC and holds an Honours Degree in Kinesiology from McMaster University. He also holds a certificate in Contemporary Medical Acupuncture from McMaster University, and is a Certified Active Release Techniques (ART®) Provider.  For more information about the Research Review Service, visit http://www.researchreviewservice.com .