Special Report
Chiropractic Spinal Manipulation Does Not Help Asthma
By Joseph J. Jacobs, MD
The use of alternative or complementary approaches, including chiropractic manipulation, to health care is increasing in the United States.1 Many physicians have, albeit somewhat grudgingly, accepted that chiropractic treatment may be of some value for musculoskeletal disorders such as low back pain. However, the efficacy and safety of chiropractic manipulation for nonmusculoskeletal disorders is far more controversial. Reports in the chiropractic literature suggest that spinal manipulation may be of benefit in pediatric disorders such as asthma.2,3
Balon and associates, several of whom work in the divisions of research in osteopathic colleges in Toronto and Los Angeles, compared the effects of chiropractic spinal manipulation with simulated chiropractic treatment without spinal manipulation on children with asthma.4 The study was approved by the ethics review board of the Canadian Memorial Chiropractic College in Toronto.
A randomized, controlled trial of chiropractic spinal manipulation was conducted on children with mild or moderate asthma. After a three-week baseline period, 91 children who had continuing symptoms despite usual medical therapy (beta-agonists, corticosteroids, etc.) were randomized to receive, in addition to usual therapy, either active or simulated chiropractic manipulation for four months. None of the children had received previous chiropractic treatment. Each patient was treated by one of 11 participating, practicing chiropractors who were selected by the family according to location. All 11 of these participating chiropractors had at least five years of experience, had successful private practices, and had apparent success, on the basis of anecdotal evidence, treating childhood asthma. Treatments were given three times a week for four weeks, twice a week for four weeks, then weekly for eight weeks. The primary outcome was the change from baseline in the peak expiratory flow, measured in the morning, before the use of a bronchodilator, at two and four months. In addition, secondary outcomes were measured that included changes in airway responsiveness, FEV-1, symptoms of asthma, the need for beta-agonists, the use of corticosteroids, quality of life, and satisfaction with treatment. Except for the treating chiropractors and a single investigator who was not involved in assessing outcomes, all participants remained fully blinded to treatment assignment throughout the study.
Active treatment consisted of spinal manipulation (adjustment). All the chiropractors used the diversified technique in common use in Canada and the United States, which involves manual contact with spinal or pelvic joints, followed by a low-amplitude, high-velocity directional push often associated with joint opening, creating a cavitation or "pop." The specifics of treatment of each subject (vertebral segments treated, direction and type of manipulation, and use of soft tissue therapy) were determined by the treating chiropractor.
Simulated treatment consisted of soft tissue massage and gentle palpation of the spine, paraspinal muscles, and shoulders. Low-amplitude, low-velocity impulses were applied in all nontherapeutic contacts with no joint opening, cavitation, or "pop." Thus, the comparison of treatment was between active spinal manipulation as routinely performed by chiropractors with hands-on procedures without adjustments or manipulations. Adults or parents were not permitted to observe the treatments.
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 (7-12 L/min) in the morning peak expiratory flow, but no significant differences between the groups in the degree of change from baseline at two and four months. Symptoms of asthma and use of beta-agonists decreased and the quality of life increased in both groups, but there were no significant differences between the two groups. There were no significant changes in FEV-1 or airway responsiveness in either group. Thus, in this group of children with mild or moderate asthma, the addition of chiropractic manipulation to usual medical care provided no benefit.
This may not be a major issue in the United States, because it has been estimated that 10-15 years ago, only about 1% of chiropractic visits were for conditions such as asthma or otitis media.5 There are really no current data concerning the use of chiropractors by parents of children with nonmusculoskeletal disorders. One of the difficult things in discussing nontraditional care with parents has been the reliance of these alternate forms of therapy on anecdotes about efficacy. There is a severe lack of data from randomized, controlled trials. It is hoped that further, well-designed studies of the possible role of spinal manipulation ideally will involve participation of chiropractors and can dispassionately and objectively prove or disprove efficacy and safety. The fact that asthmatic patients from both treatment groups in the Balon study reported subjective improvement in quality of life, even with no objective improvements, speaks for the well-known placebo effect of almost any treatment. (Dr. Jacobs is Medical Director, Office of Vermont Health Access. He also served as the first Director of the Office of Alternative Medicine of the National Institutes of Health.)
References
1. Eisenberg DM, et al. Unconventional medicine in the United States: Prevalence, costs and patterns of use. N Engl J Med 1993;328:246-252.
2. Garde DC. Asthma and chiropractic. Chiropractic Pediatr 1994;1:9-16.
3. Graham RI, Pistolese RA. An impairment rating analysis of asthmatic children under chiropractic care. J Vertebral Subluxation Res 1997;1:41-48.
4. Balon J, et al. A comparison of active and simulated chiropractic manipulation as adjunctive treatment for childhood asthma. N Engl J Med 1998;339:1013-1020.
5. Hurwitz et al. Use of chiropractic services from 1985-1991 in the United States and Canada. Am J Pub Health 1998;88:771-776.
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