Original Articles
Chronic pediatric asthma and chiropractic spinal manipulation: A prospective clinical series and randomized clinical pilot study**,,★★,

https://doi.org/10.1067/mmt.2001.116417Get rights and content

Abstract

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 β2 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. (J Manipulative Physiol Ther 2001;24:369-77)

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.

. Flow of participants.

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)

    **

    This study was funded by the Foundation for Chiropractic Education and Research.

    Gert Bronfort, DC, PhD, holds the Greenawalt Research Chair, funded through an unrestricted grant from Foot Levelers, Inc.

    ★★

    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.

    J Manipulative Physiol Ther 2001;24:369-77

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