Journal of Manipulative and Physiological Therapeutics
Original ArticlesChronic pediatric asthma and chiropractic spinal manipulation: A prospective clinical series and randomized clinical pilot study**,★,★★,♢
Introduction
Asthma is a multifactorial condition and the most common chronic disease of childhood.1 Since 1980, the prevalence of pediatric asthma has increased more than 50% and mortality more than 70%.2 The management of asthma has changed substantially since the early 1990s, and national and international guidelines now recommend a stepwise approach to treatment.3 Fundamental to current management is the early introduction of antiinflammatory medication rather than reliance on bronchodilators. Inhaled steroids suppress the inflammation of asthma and effectively control symptoms in most patients. By contrast, inhaled β2-agonists relieve symptoms for a short-term period but do not control the underlying inflammation. Indeed, it has been questioned whether excessive use of inhaled β2-agonists may contribute to the increased morbidity and mortality of the condition.4
Alternative and complementary treatments are commonly used by the general population.5 The dependence on medication and the uncertainty about outgrowing the disease lead many parents of children with asthma to seek these types of treatments.6, 7, 8, 9 There is some evidence from randomized clinical trials (RCT) that acupuncture, yoga, suggestion, hypnosis, massage, and relaxation can be beneficial as adjunctive measures in the management of chronic asthma.6, 7
Studies indicate that it is not uncommon for patients with breathing difficulties such as asthma to receive chiropractic care. According to a Danish survey,10 a substantial number of children with chronic asthma receive chiropractic care, and 92% of parents consider this treatment beneficial. A 1998 report of an Australian survey estimated that 1% to 10% of children with asthma receive chiropractic treatment for this condition.9
Several descriptive studies and anecdotal reports in the literature claim positive clinical effect of manual spinal therapy for lung dysfunction and asthma.11, 12, 13, 14 A few clinical studies have also addressed the role of spinal manipulative therapy (SMT) in obstructive bronchial disorders.15, 16 Increases in vital capacity, total lung capacity, and forced expiratory volume in chronic obstructive pulmonary disease were reported in a controlled trial on the effectiveness of spinal manipulation.15 These improvements were greater than in a control group, although statistical significance was not reached. A preliminary study by Hviid16 showed that chiropractic SMT seemed to improve vital capacity, peak expiratory flow rate, and subjective symptoms in a group of patients with various types of obstructive lung disease. Unfortunately, the small sample size did not allow for definitive conclusions. A pilot study17 of asthmatic patients in a chiropractic clinic found that although chiropractic SMT did not reduce airway obstruction, patients reported subjective reduction in their asthma symptoms.
At the time the current study was initiated, only one RCT had assessed the effectiveness of SMT for patients with asthma.18 The crossover trial by Nielsen et al18 was performed on adult patients and found no clinically important change in pulmonary function. A reduction in patient-rated asthma severity and hyperresponsiveness was observed; however, there were no differences between the active and sham SMT phases.
In 1993, the authors proposed a prospective case series and pilot study with two objectives. The first was to determine if chiropractic SMT in addition to optimal medical management resulted in clinically important changes in asthma-related outcomes. The second objective was to assess the feasibility of conducting a full-scale RCT in terms of recruitment, evaluation, treatment, and ability to deliver a sham SMT procedure.
Section snippets
Study sites
This study was conducted at the Wolfe-Harris Center for Clinical Studies at Northwestern College of Chiropractic, Bloomington, Minn, and Children's Health Care, St Paul, Minn (formerly Children's Hospital). The study was approved by the institutional review boards of both institutions, and informed consent was sought from all study participants and their parents or guardians.
Recruitment
Patients were recruited through a pediatric pulmonary practice at Children's Health Care and through newspaper
Results
The pilot study took place from May 1996 to August 1998. Flow of study participants is outlined in Fig 1.A total of 96 patients were screened by telephone, with 46 patients undergoing baseline evaluations. Of the 46 patients evaluated, 10 did not qualify for inclusion. Of these, 6 patients decided they could not commit the time and effort, 3 had intermittent asthma, and 1 had severe asthma. Thirty-six qualified patients were randomly assigned to treatment, 24 to the active
Discussion
The Medical Expenditure Panel Survey estimated that almost 7% of the United States population sought unconventional health care in addition to conventional medical care in 1996.5 The most common of the unconventional therapies was chiropractic care. Parents frequently seek care for their asthmatic children from chiropractors; however, there has been little scientific evidence to support such practices. Our study was an initial step in evaluating the scientific evidence of chiropractic spinal
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 to be the result of the specific effects of chiropractic SMT, but other aspects of the clinical
Acknowledgements
We thank Jennifer Hart for assistance with manuscript preparation and the staff of the Wolfe-Harris Center for Clinical Studies and Children's Health Care for their assistance with evaluation and treatment appointments. Finally, we thank the children and their guardians for devoting their time to this project and teaching us more about pediatric asthma.
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Cited by (0)
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This study was funded by the Foundation for Chiropractic Education and Research.
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Gert Bronfort, DC, PhD, holds the Greenawalt Research Chair, funded through an unrestricted grant from Foot Levelers, Inc.
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Submit reprint requests to: Gert Bronfort, DC, PhD, Wolfe-Harris Center for Clinical Studies, Northwestern Health Sciences University, 2501 West 84th Street, Bloomington, MN 55431.
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J Manipulative Physiol Ther 2001;24:369-77