Correspondence
Chiropractic Manipulation for Childhood Asthma
N Engl J Med 1999; 340:391-392February 4, 1999
- Article
To the Editor:
The report by Balon et al. (Oct. 8 issue)1 on a comparison of active and simulated chiropractic manipulation for childhood asthma revealed interesting findings, but the conclusions were confusing and not totally accurate, because of the terminology used. In both groups of children, symptoms of asthma and use of β-agonists decreased and the quality of life increased, but the authors concluded, “In children with mild or moderate asthma, the addition of chiropractic spinal manipulation to usual medical care provided no benefit.”
The simulated chiropractic treatment (or adjustment) consisted of low-velocity, low-amplitude impulses that did not produce joint cavitation, whereas active treatment consisted of high-velocity, low-amplitude thrusts that produced joint cavitation. Chiropractic treatment, however, and specifically chiropractic manipulation, is not limited to the cavitation produced by high-velocity, low-amplitude thrusts. Chiropractic manipulative therapy is defined as a form of manual treatment used to influence joint and neurophysiologic function, and it may be accomplished with a variety of techniques.2 The chiropractic “adjustment” can involve a low or high level of force, and it can be directed at joints or soft tissues. Although manipulation to produce joint cavitation is an important part of chiropractic treatment, other manipulative procedures are important and commonly used as well, along with appropriate education of the patient and lifestyle modification.
The view that asthma is a nonmusculoskeletal condition is not totally correct. Asthma can cause symptoms that are manifested in the musculoskeletal system, such as labored respiration and the use of secondary muscles for respiration. Although chiropractic treatment may not be a cure for asthma, the use of chiropractic manipulation to control musculoskeletal symptoms is a major benefit if it leads to an increase in the quality of life.
2 ReferencesBrian V. Jongeward, D.C.
701 DeMers Ave., Grand Forks, ND 582011
Balon J ,Aker PD ,Crowther ER , et al. A comparison of active and simulated chiropractic manipulation as adjunctive treatment for childhood asthma. N Engl J Med 1998;339:1013-1020
Full Text | Web of Science | Medline2
Physicians' current procedural terminology. 4th ed. Chicago: American Medical Association, 1997.
To the Editor:
The conclusion reached by Balon et al. is based on the finding that there was no significant difference between low-velocity, high-amplitude chiropractic manipulation and a “simulated” chiropractic treatment involving low-velocity, low-amplitude manipulation. Regarding the rationale for this simulated treatment, the authors state, “We are unaware of published evidence that suggests that positioning, palpation, gentle soft-tissue therapy, or impulses to the musculature adjacent to the spine influence the course of asthma.” Although this may be true of the chiropractic literature, the manipulations used for the simulated treatment are those typical of osteopathic manipulative therapy, and there is substantial research on the effect of these types of manipulations on physiologic functioning, including respiration. Examples include the report by Howell et al.1 on osteopathic systemic therapy for chronic obstructive lung disease and the report by Purdy et al.2 on the systemic effects of manipulation of the neck. Kuchera and Kuchera3 and Stanton and Mein4 provide detailed discussions of techniques and mechanisms.
Balon et al. found that both forms of treatment resulted in improvement in symptoms, decreased use of medication, and improvement in the quality of life. Although the relevant statistical data are not provided, an examination of the reported data suggests that these improvements were likely to have been significantly different from the base-line findings in both groups.
Thus, the most that can be concluded from the study is that chiropractic spinal treatment is not significantly better than a rather crude form of osteopathic soft-tissue treatment. Concluding, as the authors do, that the improvement in both groups was simply due to a placebo effect is not justified, since the physiologic effects of manipulations similar to the simulated treatment are well documented.
4 ReferencesDouglas G. Richards, Ph.D.
Eric A. Mein, M.D.
Carl D. Nelson, D.C.
Meridian Institute, Virginia Beach, VA 234541
Howell RK ,Allen TW ,Kappler RE . The influence of osteopathic manipulative therapy in the management of patients with chronic obstructive lung disease. J Am Osteopath Assoc 1975;74:757-760
Medline2
Purdy WR ,Frank JJ ,Oliver B . Suboccipital dermatomyotomic stimulation and digital blood flow. J Am Osteopath Assoc 1996;96:285-289
Medline3
Kuchera M, Kuchera WA. Osteopathic considerations in systemic dysfunction. Kirksville, Mo.: KCOM Press, 1991.
4
Stanton DF, Mein EA, eds. Manual medicine. Phys Med Rehabil Clin North Am 1996;7.
Author/Editor Response
The authors reply:
To the Editor: Richards et al. and Jongeward raise similar points, stating that our placebo treatment was not truly inert but had beneficial effects on childhood asthma. Surprisingly, this concern was not expressed earlier by the chiropractic-research agencies that reviewed the protocol and funded the study. The theory of chiropractic is that spinal adjustment is essential for efficacy. Hence, our active-treatment group received typical chiropractic adjustments, whereas the placebo group received low-velocity, low-amplitude treatment at nontherapeutic contact sites. Our placebo maneuvers were not standard techniques in either chiropractic or osteopathic treatment. We failed to find any significant difference in any outcome between the chiropractic and placebo groups, and we reported that chiropractic manipulation with adjustment, as usually practiced, did not confer a benefit over and above that seen in the placebo group.
The placebo effect may reflect spontaneous improvement, a positive patient–doctor relationship, the expectation of a benefit, and other factors.1 The question is whether the symptomatic improvement we reported in both groups was a placebo or study effect or whether it was a real response to the sham measures. We have reviewed three of the articles cited by Richards et al. and find them unconvincing. Howell et al. described 11 patients with chronic obstructive pulmonary disease who received medical therapy and underwent osteopathic manipulation. In the absence of a control group, the slight trend toward an improvement over a period of nine months is uninterpretable. Purdy et al. described the effects of kneading the suboccipital triangle on the digital pulse and suggested that their placebo treatment of touch without kneading was not inert, since there were changes in the amplitude of the pulse in both groups. The relevance of these findings to our study is unclear. Stanton and Mein's work provides no data that we think can be interpreted in a way that supports their statements.
In our study, subjective outcomes (symptom scores, quality of life, and β-agonist use) improved in both groups, whereas objective outcomes (peak flow rates, spirometric results, and airway responsiveness) did not change. This combination strongly suggests a placebo or study effect in both groups. There was no effect of active or placebo treatment on the fundamental characteristics of asthma — namely, variable airway obstruction and increased airway responsiveness. Frequent contact with a health care provider who is interested in asthma, whether a medical practitioner or a chiropractor, is likely to improve subjective outcomes, whereas modulation of the underlying disease necessitates an effective intervention at the level of the airway.
1 ReferencesJeffrey Balon, M.D.
Edward R. Crowther, D.C.
Canadian Memorial Chiropractic College, Toronto, ON M4G 3E6, CanadaMalcolm R. Sears, M.B.
St. Joseph's Hospital, Hamilton, ON L8N 4A6, Canada1
Kaptchuk TJ . Powerful placebo: the dark side of the randomised controlled trial. Lancet 1998;351:1722-1725
CrossRef | Web of Science | Medline
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