Spinal Manipulation Effectiveness on Asthma
The study determines the effectiveness of spinal manipulation on asthma. Spinal manipulation is seldom associated with adverse effects and can prove to be a cheaper alternative. There are two schools of though regarding spinal manipulation in asthma, one is that the chiropractor is the primary healthcare provider and second he is responsible for the co-management along with others. Spinal manipulation can improve the symptoms of asthma or can improve the spinal symptoms of asthma and in this way provide relief. In this study more than 78 studies were identified from 5 databases and 8 appropriate studies were included as part of the study. Spinal manipulation may not be as effective in the treatment of asthma as compared to sham manipulation. However, the severity of the disease, quality of life and the dose of medications can be reduced. Chiropractic also needs to utilize more scientific basis to develop hypothesis. Chiropractic can be used in the co-management of asthma along with other medical therapies. Certain subjective and objective outcome measures need to be developed.
Today, chiropractic is one of the most widely used forms of healthcare intervention and is gaining huge acceptance throughout the world for its effectiveness in treating neck pain and back pain. Thousands and thousands of people from across the world have reported to gain benefits from chiropractic. Chiropractic spinal manipulation was first introduced by Daniel D Palmer in 1895, where he had first cured a patient of deafness through spinal manipulation. He initiated the Palmer Chiropractic School. Later, a lawyer from Oklahoma had opened a competing chiropractic school, and developed another school of thought. Willard Carver strongly believed that chiropractic needed to incorporate other modes of treatment such as nutrient therapy, herbal treatments, etc, which when combined with chiropractic would be more effective. This is still a competing school of thought in chiropractic. Most of the scientific branches of medicine work on the principle on scientific evidences. However, chiropractic gained popularity even before scientific evidences were drawn out. Many people started schools of chiropractic, but the practice of chiropractic did not be based on any kind of theory. It was only in the 1970s that scientific research in the field of chiropractic began and slowly a proper program to train and develop chiropractic research was being developed.
Spinal manipulation is a treatment technique in which the spine and its interrelationship with the nervous system are seen as a mean of restoring health. Chiropractic involves modifying subluxated vertebrae that have changed their position in the spine. It is said that due to the subluxation, the nerve that are present near the spine are impeded and are responsible for various disease and pain syndromes. Spinal manipulation is a technique in which these vertebrae are put back into position so that their function is restored. There is no evidence to show that pain is relieved by altering the position of the spine, although there is evidence that spinal manipulation resulting in loosening and easing the vertebrae. Another idea that has been proven by studies is that spinal manipulation results in better responses from the nerves, leading to a positive effect on the central nerves system, causing an improvement in pain relief.
Spinal manipulation is used to treat several muscular skeletal disorders, nervous disorders and the effect of these disorders over general health. Spinal manipulation is often used to treat neuro-musculoskeletal disorders that affect the arms, legs, neck, back and also headaches. Spinal manipulation can be used to treat acute as well as chronic disorders, and can also be used during pregnancy to manage pain during breech positioning of the baby. Besides, spinal manipulation can also be used to treat frequent common colds, infantile colic and respiratory disorders. In children who frequently fall and injure themselves, pain in the back, neck and legs is common, and often spinal manipulation can be utilized to manage back and neck problems such as pain, stiffness, soreness, discomfort, etc.
Chiropractic can be utilized both on an outpatient or an inpatient basis, and in certain instances, an inpatient can be advocated spinal manipulation as part of hisher rehabilitation. The chiropractor would be using their hands to manipulate the joints, especially the spine so as to improve function, restore integrity of the spine and lower pain. Patients during the process of spinal adjustments hear a popping sound that is heard due to release of gas bubbles from between the joints that may be present in the lubrication fluid of the joint. The release of these gas bubbles does not cause pain in anyway. A joint consists of the surface of the bone that fit into each other and is lined by a smooth cartilage that is enclosed in the joint capsule. A fluid fills and lubricates the movements of the joint. As gases are dissolved in this fluid, during the stretching of the joint capsule some amount of gases are released which helps to reduce the pressure within the joint.
The process of manipulation is considered to be safest and the most non-invasive of any that is available for the treatment of neuro-musculoskeletal disorders that are available, provided the same is performed by a qualified chiropractor. However, no intervention is free from potential adverse effects. Minor discomfort following chiropractic is common and occurs (but disappears) within 24 hours of treatment. Some people may experience a temporary rise in the symptoms along with fatigue, discomfort, headache, radiating pain at the site of manipulation, etc. Usually serious complications are rare and are associated with cervical spine manipulation. It is common in people affected with stroke, serious pinching or trauma of the nerve, fracture of the vertebrae, tracheal damage, disc herniation, etc. Often the vertebral artery at the base of the neck is damaged leading to stroke (NYU Longone MEdical Centre, 2010).
Figure 1. Serious Rare Complications of Spinal Manipulation
Studies performed to identify those at a high-risk for stroke during spinal manipulation have been inconclusive. However, the rate of serious complications following spinal manipulation is very rare, and occurs at the rate of 1 in every million cases. In patients receiving spinal manipulation for the neck, the rate of morbidity (complication) is about 1 in 100,000 and mortality of about 1 in 400,000. On the other hand, non-invasive allopathic treatment such as NSAIDS Administration, etc, has a 10 times higher complication rate.
For patients undergoing spinal manipulation, a proper history should be taken, with the mode of onset of the symptoms, aggravating and relieving factors, and any red flags (physical pathology in which spinal manipulation has been contraindicated such as severe trauma, thoracic pain, cancers, HIV, drug abuse, structural deformities, etc). The practitioner should also note any important medical history, drugs or past history that would include any condition in which spinal manipulation should not be performed (The Pain Clinic, 2009). These include-
Figure 2. Contraindications of Spinal Manipulation
It is also important to determine the yellow flags of the patient, which includes a mental assessment to identify the presence of anxiety, depression or any other mental disorder in which the patient would not cooperate towards the performance of the procedure. If the patient would not cooperate for spinal manipulation, the success of the treatment is unlikely.
Today more than 100 people around the world are affected with asthma. Chiropractic is one of the three most popular complementary and alternative medicine therapies (CAM). Since a long-time, chiropractors have been reporting successes at treating non-musculoskeletal disorders. Today with a greater expansion in the interventions of chiropractic, it has expanded from merely therapeutic spinal manipulation to greater prescription of nutrients and administering exercises. However, there are two schools of thought in the role of the chiropractors in managing asthma (Chiropractic care for patients with asthma A systematic review of the literature, 2010).
Figure 3. Two Schools of Thought of Spinal Chiropractors
This depends on the role chiropractic plays on asthma. There may several mechanisms by which chiropractic works on asthma-
Figure 4. Mechanisms by which Chiropractic works in Asthma
In the past several studies have been conducted to determine the role of spinal manipulation treatment over several issues in asthma including-
Figure 5. Effectiveness of Chiropractic in Asthma
In Australia, there is a several fold increase in the number of patients seeking management of asthma from non-allopathic professionals. More than 45 of the Australians seek alternative treatment of asthma, and most often it is the chiropractic that advice is sought from. Most of the Australians are equally satisfied with the treatment provided by the alternative practitioner. There has been a lot of controversy regarding the use of beta-agonists and corticosteroids in the treatment of asthma as more and more alternative techniques are showing better results. However, in many instances, alternative therapies also fail, causing a deterioration in the lung function and as such a scientific background is required to develop guidelines for managing asthma using alternative techniques. Australian chiropractors make assumptions regarding the use of spinal manipulation in the treatment of asthma ( A Comparison of Active and Simulated Chiropractic Manipulation as Adjunctive Treatment for Childhood Asthma, 1998).
Figure 6. How Asthma Occurs
In this study, a literature review would be conducted of the various studies that used spinal manipulation in the treatment of asthma (either alone or in combination with other forms of treatment), to determine the effectiveness and safety of spinal manipulation for asthma.
Description
The study was a literature review of spinal manipulation being used in the treatment of asthma (either alone or in combination with other forms of treatment), to determine the effectiveness and safety of spinal manipulation for asthma. The various databases searched were Pubmed, Cochrane, BMJ, TRIPS Database, SUM Search, Google Scholar.
A total of about 78 studies were identified from the 5 Internet databases, and from these, 8 of the most relevant studies were identified and included as a part of the review for this dissertation.
Graham 2000 (Complementaryalternative medicine in the treatment of asthma, 2000) tried to provide allergists and immunologists with knowledge of complementary and alternative forms of medicine that could be used in treating their patients. Such specialists could have an idea of what forms of alternative therapy are existing so that patients willing or demanding alternative therapy can effectively obtain the same. It is also important to take into consideration the various cultural issues whilst using alternative or complementary therapy. In this paper, the role of complementary and alternative therapy beyond chiropractic and spinal manipulation is taken into consideration, as chiropractors should also have an idea of the various other forms of therapy that can be applicable for treating conditions such as asthma. Not only should the chiropractor have such knowledge, but also the physician, nurse and specialists. Graham used Medline searches to obtain data on complementary and alternative forms of therapy on asthma and atopy. Several articles were obtained and further filtered out. The articles that were included were randomized and double-blind placebo-controlled studies.
Bronfort (2001) (Chronic pediatric asthma and chiropractic spinal manipulation a prospective clinical, 2001) conducted a study to determine the ability of chiropractic spinal manipulation therapy in managing medically the children suffering from asthma and improve the important clinical outcomes. The study also tried to determine if a comprehensive RCT could be conducted and determine the difference with a sham spinal manipulation procedure. In the US, many parents feel it safe and effective to use the services of the chiropractors for managing asthma in their children. This was a pilot study, with the possibility of using a prospective design in future. The observers were blinded and the clinical trial was conducted in a randomized basis. The follow-up period was about 1 year. The study was basically conducted in primary care settings, outpatient department of a college and a childcare hospital. The study included about 36 patients between the ages of 6 to 17 years. The patients were recruited to the active spinal manipulation therapy group or the sham spinal manipulation therapy group, and had to undergo 20 appointments during a 3 month period. The patient had to undergo chiropractic in addition to their regular medical treatment. The outcomes were determine through pulmonary function tests, quality of life factors that could be determined by the patient or the parent, the peak expiratory flow rates and also studying the recorded symptoms of the day and night of the patient recorded in a diary.
Nielsen (2010) (Chronic asthma and chiropractic spinal manipulation a randomized clinical trial, 2010) conducted a study to determine the effectiveness of chiropractic in treating chronic asthma along with other drugs used for maintenance therapy. The patients that were used in the trial were outpatients belonging to the national university Hospital of Copenhagen Denmark. About 31 patients between the ages of 18 to 44 years were included in the study and the patients who were using bronchodilators and corticosteroid inhalers were included in the study. The study excluded those patients who had received oral corticosteroids, immunotherapy or spinal manipulation during the last five years. The patients were put into either group active manipulation therapy or sham manipulation therapy for 1 month, twice weekly, and were then moved into the opposing group to receive the treatment for another 1 month. The phase between treatments was given a 2 week break. The outcome measures that were determined included-
Figure 7. Outcome Measures
Hondras, MA (2009) was a study that tried to determine the evidence available of the effect of manual therapies for patients affected with bronchial asthma. The author has felt that though medicines are effective in the treatment of asthma, having a non-medicine treatment would be a huge advancement in asthma management. Hondras felt that spinal manipulation is aimed at increasing the motion of the rib cage, improving the quality of life by improved lung function, increasing the oxygen content in arterial blood and improving the lymphatic return of the blood. Through chest percussion, vibration and mobilization of the patient, the bronchial secretions can be moved to the central airways thus helping the patient in expectoration and cough. Manual therapy was compared with other forms of treatment to determine the morbidity, mortality, physiological outcomes and side-effects in asthmatic patients. This review included only randomized and quasi-randomized studies where the patients were observed for at least 2 weeks. Child and adults patients suffering from asthma were included in the studies and patients affected with COPD were excluded.
Manual therapy such as manipulation, mobilization, massaging, physiotherapy, vibration and shaking were included and postural drainage alone was excluded from the study. The outcomes that were included in this study were pulmonary function, vital capacity, FEV1, FEV1FVC ratio, use of drugs, quality of life, subjective symptoms of asthma, hospitalization and length of stay, emergency visits, etc. A number of databases were searched for data including Cochrane, Chiropractic Research Archives Collection (CRAC), etc, from 2001 onwards. There were three reviewers for this study, who individually examined and extracted the data in the standardized template.
Kaminskyj 2010 conducted a systematic review of the literature to determine the rate of publishing and the quality of publishing studies on chiropractic especially spinal manipulation in patients suffering from bronchial asthma. The authors feel that chiropractic is one of the most often used form of CAM therapy and asthma is becoming a serious public hazard across the world. More and more chiropractors are using chiropractic for managing non-musculoskeletal conditions and are extending their treatment away from the traditional spinal manipulation therapy. The question being asked in this study was whether chiropractic is beneficial in the case of asthma and whether chiropractors have a role in the co-management or serve as primary healthcare providers for asthma. The outcome measures considered in this study was FEV, asthma severity self-reported, dependency on drugs, quality of life, etc.
A number of databases were searched including Cochrane, MEDLINE, CINAHL, AMED, Alt Healthwatch, Chiropractic Index, Mantis, etc, for literature between January 1980 and March 2009. Several searches were found and the searches had to be further refined. Down and Black developed a checklist that had 27 items for assessing the findings of the randomized and non-randomized studies. What was used in this study was a modified Down Black questionnaire, so that the maximum score obtained was 27. The quality scores that were included were 20 good, 11-20 moderate and 11 poor. Each author individually studied each of the searches and rated the articles.
Lowry 1995, reports that since 1995, chiropractors associations have been trying to use spinal manipulation for treating other disorders, other than back problems including asthma and enuresis. Many chiropractors in Canada had a conservative view of Chiropractic and held that disorders other than back conditions should not be attempted with chiropractic. In Canada the pediatrician community is against the idea of having chiropractors treating other disorders in infant and children. Parents also need to be cautious in using the services of the chiropractors in such instances. However, critics also say that evidences for the effectiveness and safety of chiropractic on asthma, bedwetting, ear infections and infantile colic should be researched rather than merely discarding the idea of using chiropractic. Other critics feel that implementing chiropractic and delaying for the use of other medical treatments may be serious.
Chiropractors can play a vital role in the development of the infant and the child, and various infants are at the risk of facing developmental problems associated with the spine and the backbone. Some experts in chiropractic feel that using the benefits of chiropractic for infantile colic and middle ear infections can in fact be effective and hence offer cheaper solutions to the healthcare system. Many experts feel that the spine of children are young and hence are more effective to manipulation. A simple point mentioned in the study regarding the effectiveness of chiropractic in asthma is that chiropractic spinal manipulation can help loosen the muscles in the back and in this way relieve asthma. However, as asthma is an inflammatory disease, spinal adjustments cannot help overcome inflammation.
Jamison, 1992 (Chiropractic adjustment in the management of visceral conditions a critical appraisal, 1992) tried to determine if Australian chiropractors consider spinal manipulation as an effective and safe option in treating patients affected with visceral disorders such as asthma, hypertension and dysmenorrhea. This was a survey study that was distributed to several chiropractors in Australia. The outcome measures were that the practitioner had to find certain usefulness of chiropractic in managing a visceral disorder. The chiropractor had to comment on the personal experience for treating the visceral disorder and the manner in which adjustment had to be done to treat the visceral disorder.
A systematic review was conducted by Ernst, E, to determine if spinal manipulation was effective in the treatment of asthma. Most of the internet searches drawn from websites of famous American, Canadian and British Chiropractor associations stress upon that spinal manipulation are effective in the treatment of bronchial asthma. DD Palmer the founder of chiropractic in fact said that most diseases including asthma was caused out of subluxation of the spine and adjustments were required to correct these disturbances. However, till today, not much systematic reviews have been conducted to assert this fact. This study by Ernst tries to review the various RCTs conducted on spinal manipulation for the treatment of asthma. Ernst searches various internet databases in September 2008 including Medline, Ovid, CINAHL, AMED, EMBASE, etc, marrying the concepts of asthma and spinal manipulation. No limits as such were used. The criteria for selection were that the study had to determine the effectiveness of spinal manipulation in the treatment of asthma. Any study that did not include spinal manipulation was excluded. The studies had to present some sort of a measureable endpoint. The Jadad Score was utilized to review the data.
Figrue 8. Jadad Rating Scale
Results
Graham 2000 found that huge number of patients in the US considered complementary and alternative treatments for asthma (33 of the population). However, literature of such treatment and their effectiveness, role and safety in treating asthma or atopy is not known, due to a lack of scientific basis for these systems to use evidence based criteria. Alternative and complementary therapies have a huge role to offer in the treatment of asthma as the same is an allergic disorder. Very few studies have been conducted to determine the role of complementary and alternative therapy in treating asthma. The current level of evidence regarding CAM to treat asthma and other allergic disorders is rather insufficient to create clear practice guidelines. Some of the flaws noted with CAM techniques include-
Figure 9. Flaws Noted with Studies conducted in CAM
Some of the physicians are lacking knowledge of which alternative therapy is available and the same if advisable can be used. Hence, there needs to be certain amount of awareness amongst the professionals of which other forms of treatment could be used (Graham 2000).
Bronfort (2001) found that it was capable to blind the patients to either group. After the intervention was performed for 3 months, there was no improvement in the lung function test results, recorded symptoms. The patient said that they composed 20 less of the bronchodilator and the quality of life improved by 10-28. The severity of asthma reduced by about 39. The parents and the guardians reported smaller improvements compared to the patient. The child patients felt that the improvement in quality of life and reduction in the severity of asthma remained unchanged over the next one year. Neither lung function nor hyper responsive improved. The effects of improvement in the patient-related quality of life and the reduction of the severity of asthma is not likely to be due spinal manipulation therapy itself, but also related to other aspects of the medical management of the patient. However, further studies are needed to determine the effect of spinal manipulation therapy on asthma.
In Nielsen 2010, cross over analysis was used to determine the effectiveness of treatment of the active Spinal manipulation with that of sham spinal manipulation. There were no important differences between the primary and secondary outcomes between both the forms of manipulation. There were no changes with the lung function test outcomes, but the patient reported lesser severity of asthma by about 34 and the bronchial hyper reactivity improved by 36. However, the study did not prove that spinal manipulation was better than sham manipulation to manage adults with asthma for four-week duration.
In Hondras 2009, more than 473 articles were considered, but 68 were reviewed and included in the study that fulfilled the criteria of inclusion. However, at the end, on three RCTs were considered in the study, which organized a total of 156 patients. These three studies included Balon 1998, Field 1998 and Nielsen 1995. The first two determined manual therapy in asthmatic children, whereas the later studied manual therapy in adults. None of the trials found an appreciable difference between manual therapy and sham maneuvers based on the outcome measures. There was a difference between massage therapy and relaxation therapy with respect to lung function outcomes, but the same could not be considered as the reporting characteristics of the trial was not proper. However, in the end, there was inconclusive data regarding the effectiveness of spinal manipulation in the treatment of asthma. Some of the measures that were present were not clinically important.
In Kaminskyj 2010, more than 150 articles were initially obtained from the various databases. Finally 13 articles were finalized, out of which 8 articles were included which were 1 case study, 1 survey, 2 RCTs, 1 randomized patientobserver blinded cross-over trial, 1 self-reported questionnaire and 1 single blind cross study. The quality scores of the various studies ranged from 5 to 22 out of a maximum of 27, which were good to low as per the Down Black criteria. The main aim of chiropractic in asthma was to help increase the lung space, mobilize the ribs, improve the blood and lymphatic supply to the lungs, and improve the nerve supply, so that the symptoms of asthma could be improved. According to this study, chiropractic did not only include spinal manipulation but also breathing exercises and soft tissue therapy. Most the data obtained were from trials that lacked good quality and hence although the effect of chiropractic care on asthma had found to be useful, the results were questionable. Hence, their therapeutic benefit could not be determined. The effectiveness of chiropractic care on asthma is said to be multi-factorial depending on several objective and subjective outcome measures.
Figure 10. Subjective Objective Outcome Measures
The articles lacked detail of the position of the manipulation and the type of therapy used. Hence, the procedure could not be used on other patients and hence the studies could not be utilized to develop guidelines. Besides, in some of the studies the children had received some drugs before the chiropractic treatment and hence, this could have altered the results of the chiropractic therapy. In some children who were co-managed with chiropractic, there were beneficial effects to a very mild extent. Most of the benefits that were noted were subjective in nature and very little objective benefits. Chiropractors use various outcome measures which need to be further standardized. There needs to be certain guidelines on the effective use of spinal manipulation in the treatment of asthma and further to utilize the same in the beneficial treatment of the patient.
Lowry 1995 find that Canadian Chiropractic students are often told to treat asthmatics back rather than the entire condition which is inflammatory in nature. This should be irrespective of the fact that chiropractic would cure asthma by itself, but at least offer some relief to the symptoms. In many other conditions such as bedwetting and middle ear infections, chiropractic may not offer a cure, but can be used to help lower the symptoms. X-rays in chiropractic are only needed in case of back problems and not to treat non-musculoskeletal disorders.
In Jamison 1992, about 22 of the 1300 odd chiropractors actually provided a response to the survey tool. More than 50 of the practitioners held that spinal manipulation had a useful role in the treatment of visceral disorders such as asthma, dysmenorrhea and hypertension. The extent to which it could be effective varied from one condition to another and often on the level to which adjustment could be done. In the 1990s, there was very little public funding for chiropractic to be used in visceral disorders. However, more detailed studies are required to determine the role of chiropractic in several visceral disorders especially asthma.
Ernst E (2009) obtained 35 articles that fulfilled the selection criteria. From this, 8 were duplicates, 4 were excluded as the data was not original, 14 were again excluded as the data was not randomized and finally 6 were excluded as there was no spinal manipulation involved. This left the researchers with just 3 RCTs. The data that is currently available suggests that spinal manipulation is not effective in the treatment of asthma and there was no significant difference compared to sham manipulation.
The previous studies that were conducted in fact were false positive results. The three studies that were finally included were Neilsen (1995), Balon (1998) and Bronfort (2001). Usually in real practice, the need to use spinal manipulation is not always made on the basis of effectiveness, but also on the basis of safety and cost-effectiveness. Rare complications to spinal manipulation do occur, and mild side-effects are more common. The authors also feel that as the RCTs available to them currently are rather insufficient, the data available is not conclusive enough to make a decision whether spinal manipulation is effective for the treatment of asthma. Several studies were excluded by Ernst 2009, basically for the reason of not meeting with the scientific protocol but demonstrating a positive outcome. The authors also found that many journals that published data on complementary and alternative techniques in fact did not follow the scientific protocol nor did publish any kind of negative result. Overall greater amount of data was required to demonstrate that spinal manipulation was effective in the treatment of asthma, but the current data demonstrated that spinal manipulation was in fact not effective in the treatment of asthma.
Conclusion Recommendations
From the eight studies that form a part of the literature review, it is important to determine what action points need to form a part of guidelines for implementation into chiropractic. To ensure that any kind of alternative therapy warrants some amount of success, chiropractors, physicians, nurses and specialists should have an idea of various forms of complementary and alternative treatment and should be able to apply the same to the patient to provide herhim with the most holistic form of treatment. This is not only applicable in the case of asthma, but in any disorder in order to manage the patient as a whole. Large number of patients may consider using CAM, and it is important that the branches of CAM have a scientific basis rather than a mere magical or unscientific background.
Some of the studies found that there was no improvement in the lung function test results, but there was a slight improvement in the quality of life, lesser use of bronchodilators or inhalers, and reduced severity of asthma as defined by the patient. The parents and guardians noted much lesser improvements in quality of life and severity of asthma compared to the child patient. However, it is not clear whether spinal manipulation has a direct improvement on the quality of life and reduced severity of asthma. The mechanism of the same needs to be more closely understood, and at the same time clear criteria needs to be defined to enable understanding how asthmatics are benefited.
Although spinal manipulation may have some benefits at improving the quality of life, improving the lung function parameters, reducing the severity of asthma, lowering the consumption of medications, etc, it has been found that these criteria are similar to sham manipulation compared with spinal manipulation in asthmatics, raising a huge concern of the scientific basis of spinal manipulation. This was observed on a short duration of 4-weeks of therapy.
Spinal manipulation is aimed at increasing the motion of the rib cage, improving the quality of life by improved lung function, increasing the oxygen content in arterial blood and improving the lymphatic return of the blood. Through chest percussion, vibration and mobilization of the patient, the bronchial secretions can be moved to the central airways thus helping the patient in expectoration and cough. In asthmatics, manual therapy in general may not seem to be superior to sham maneuvers and hence, spinal manipulation may be of no use. However, closer research needs to be performed to understand the exact mechanism by which spinal manipulation works.
With time, more and more chiropractors are using spinal manipulation for non-musculoskeletal disorders and are using a greater number of treatments along with traditional massage sessions (such as nutritional therapy, exercises, etc). Chiropractors in asthma aim to increase the lung space, mobilize the ribs, improve the blood and lymphatic supply to the lungs, and improve the nerve supply, so that the symptoms of asthma could be improved.
The use of chiropractic for disorders other than back and neck disorders needs to be made based on evidences and scientific data and not act as an unjustified limit to practice. Chiropractic not only offers benefits but is also a cheaper and safer option if applied appropriately. Common sense suggests that chiropractic helps to loosen the muscles of the back and in this way help the lungs to function better. Even if the effect is similar to sham manipulation, chiropractic can be used as it is proven to have certain benefits rather than damage to the patient. However, it also needs to be taken into consideration that asthma is an inflammatory disorder and hence spinal manipulation cannot reduce inflammation. Chiropractic can be used in the co-management with asthma with other forms of medical treatment.
In general, chiropractors are of the opinion that spinal manipulation is effective for visceral disorders including asthma, through their experience of the use of the same. Such opinions can further be developed to create guidelines so that the effectiveness of such therapy can be reaped into successes.
Data that is currently available on spinal manipulation for asthma is not sufficient to create useful professional guidelines that can be followed. The studies need to follow a scientific basis of blinding, removing all biases, and ensuring that certain inclusion and exclusion criteria are followed. The studies should be long-term and should have a sufficient study size and good design.
Today, chiropractic is one of the most widely used forms of healthcare intervention and is gaining huge acceptance throughout the world for its effectiveness in treating neck pain and back pain. Thousands and thousands of people from across the world have reported to gain benefits from chiropractic. Chiropractic spinal manipulation was first introduced by Daniel D Palmer in 1895, where he had first cured a patient of deafness through spinal manipulation. He initiated the Palmer Chiropractic School. Later, a lawyer from Oklahoma had opened a competing chiropractic school, and developed another school of thought. Willard Carver strongly believed that chiropractic needed to incorporate other modes of treatment such as nutrient therapy, herbal treatments, etc, which when combined with chiropractic would be more effective. This is still a competing school of thought in chiropractic. Most of the scientific branches of medicine work on the principle on scientific evidences. However, chiropractic gained popularity even before scientific evidences were drawn out. Many people started schools of chiropractic, but the practice of chiropractic did not be based on any kind of theory. It was only in the 1970s that scientific research in the field of chiropractic began and slowly a proper program to train and develop chiropractic research was being developed.
Spinal manipulation is a treatment technique in which the spine and its interrelationship with the nervous system are seen as a mean of restoring health. Chiropractic involves modifying subluxated vertebrae that have changed their position in the spine. It is said that due to the subluxation, the nerve that are present near the spine are impeded and are responsible for various disease and pain syndromes. Spinal manipulation is a technique in which these vertebrae are put back into position so that their function is restored. There is no evidence to show that pain is relieved by altering the position of the spine, although there is evidence that spinal manipulation resulting in loosening and easing the vertebrae. Another idea that has been proven by studies is that spinal manipulation results in better responses from the nerves, leading to a positive effect on the central nerves system, causing an improvement in pain relief.
Spinal manipulation is used to treat several muscular skeletal disorders, nervous disorders and the effect of these disorders over general health. Spinal manipulation is often used to treat neuro-musculoskeletal disorders that affect the arms, legs, neck, back and also headaches. Spinal manipulation can be used to treat acute as well as chronic disorders, and can also be used during pregnancy to manage pain during breech positioning of the baby. Besides, spinal manipulation can also be used to treat frequent common colds, infantile colic and respiratory disorders. In children who frequently fall and injure themselves, pain in the back, neck and legs is common, and often spinal manipulation can be utilized to manage back and neck problems such as pain, stiffness, soreness, discomfort, etc.
Chiropractic can be utilized both on an outpatient or an inpatient basis, and in certain instances, an inpatient can be advocated spinal manipulation as part of hisher rehabilitation. The chiropractor would be using their hands to manipulate the joints, especially the spine so as to improve function, restore integrity of the spine and lower pain. Patients during the process of spinal adjustments hear a popping sound that is heard due to release of gas bubbles from between the joints that may be present in the lubrication fluid of the joint. The release of these gas bubbles does not cause pain in anyway. A joint consists of the surface of the bone that fit into each other and is lined by a smooth cartilage that is enclosed in the joint capsule. A fluid fills and lubricates the movements of the joint. As gases are dissolved in this fluid, during the stretching of the joint capsule some amount of gases are released which helps to reduce the pressure within the joint.
The process of manipulation is considered to be safest and the most non-invasive of any that is available for the treatment of neuro-musculoskeletal disorders that are available, provided the same is performed by a qualified chiropractor. However, no intervention is free from potential adverse effects. Minor discomfort following chiropractic is common and occurs (but disappears) within 24 hours of treatment. Some people may experience a temporary rise in the symptoms along with fatigue, discomfort, headache, radiating pain at the site of manipulation, etc. Usually serious complications are rare and are associated with cervical spine manipulation. It is common in people affected with stroke, serious pinching or trauma of the nerve, fracture of the vertebrae, tracheal damage, disc herniation, etc. Often the vertebral artery at the base of the neck is damaged leading to stroke (NYU Longone MEdical Centre, 2010).
Figure 1. Serious Rare Complications of Spinal Manipulation
Studies performed to identify those at a high-risk for stroke during spinal manipulation have been inconclusive. However, the rate of serious complications following spinal manipulation is very rare, and occurs at the rate of 1 in every million cases. In patients receiving spinal manipulation for the neck, the rate of morbidity (complication) is about 1 in 100,000 and mortality of about 1 in 400,000. On the other hand, non-invasive allopathic treatment such as NSAIDS Administration, etc, has a 10 times higher complication rate.
For patients undergoing spinal manipulation, a proper history should be taken, with the mode of onset of the symptoms, aggravating and relieving factors, and any red flags (physical pathology in which spinal manipulation has been contraindicated such as severe trauma, thoracic pain, cancers, HIV, drug abuse, structural deformities, etc). The practitioner should also note any important medical history, drugs or past history that would include any condition in which spinal manipulation should not be performed (The Pain Clinic, 2009). These include-
Figure 2. Contraindications of Spinal Manipulation
It is also important to determine the yellow flags of the patient, which includes a mental assessment to identify the presence of anxiety, depression or any other mental disorder in which the patient would not cooperate towards the performance of the procedure. If the patient would not cooperate for spinal manipulation, the success of the treatment is unlikely.
Today more than 100 people around the world are affected with asthma. Chiropractic is one of the three most popular complementary and alternative medicine therapies (CAM). Since a long-time, chiropractors have been reporting successes at treating non-musculoskeletal disorders. Today with a greater expansion in the interventions of chiropractic, it has expanded from merely therapeutic spinal manipulation to greater prescription of nutrients and administering exercises. However, there are two schools of thought in the role of the chiropractors in managing asthma (Chiropractic care for patients with asthma A systematic review of the literature, 2010).
Figure 3. Two Schools of Thought of Spinal Chiropractors
This depends on the role chiropractic plays on asthma. There may several mechanisms by which chiropractic works on asthma-
Figure 4. Mechanisms by which Chiropractic works in Asthma
In the past several studies have been conducted to determine the role of spinal manipulation treatment over several issues in asthma including-
Figure 5. Effectiveness of Chiropractic in Asthma
In Australia, there is a several fold increase in the number of patients seeking management of asthma from non-allopathic professionals. More than 45 of the Australians seek alternative treatment of asthma, and most often it is the chiropractic that advice is sought from. Most of the Australians are equally satisfied with the treatment provided by the alternative practitioner. There has been a lot of controversy regarding the use of beta-agonists and corticosteroids in the treatment of asthma as more and more alternative techniques are showing better results. However, in many instances, alternative therapies also fail, causing a deterioration in the lung function and as such a scientific background is required to develop guidelines for managing asthma using alternative techniques. Australian chiropractors make assumptions regarding the use of spinal manipulation in the treatment of asthma ( A Comparison of Active and Simulated Chiropractic Manipulation as Adjunctive Treatment for Childhood Asthma, 1998).
Figure 6. How Asthma Occurs
In this study, a literature review would be conducted of the various studies that used spinal manipulation in the treatment of asthma (either alone or in combination with other forms of treatment), to determine the effectiveness and safety of spinal manipulation for asthma.
Description
The study was a literature review of spinal manipulation being used in the treatment of asthma (either alone or in combination with other forms of treatment), to determine the effectiveness and safety of spinal manipulation for asthma. The various databases searched were Pubmed, Cochrane, BMJ, TRIPS Database, SUM Search, Google Scholar.
A total of about 78 studies were identified from the 5 Internet databases, and from these, 8 of the most relevant studies were identified and included as a part of the review for this dissertation.
Graham 2000 (Complementaryalternative medicine in the treatment of asthma, 2000) tried to provide allergists and immunologists with knowledge of complementary and alternative forms of medicine that could be used in treating their patients. Such specialists could have an idea of what forms of alternative therapy are existing so that patients willing or demanding alternative therapy can effectively obtain the same. It is also important to take into consideration the various cultural issues whilst using alternative or complementary therapy. In this paper, the role of complementary and alternative therapy beyond chiropractic and spinal manipulation is taken into consideration, as chiropractors should also have an idea of the various other forms of therapy that can be applicable for treating conditions such as asthma. Not only should the chiropractor have such knowledge, but also the physician, nurse and specialists. Graham used Medline searches to obtain data on complementary and alternative forms of therapy on asthma and atopy. Several articles were obtained and further filtered out. The articles that were included were randomized and double-blind placebo-controlled studies.
Bronfort (2001) (Chronic pediatric asthma and chiropractic spinal manipulation a prospective clinical, 2001) conducted a study to determine the ability of chiropractic spinal manipulation therapy in managing medically the children suffering from asthma and improve the important clinical outcomes. The study also tried to determine if a comprehensive RCT could be conducted and determine the difference with a sham spinal manipulation procedure. In the US, many parents feel it safe and effective to use the services of the chiropractors for managing asthma in their children. This was a pilot study, with the possibility of using a prospective design in future. The observers were blinded and the clinical trial was conducted in a randomized basis. The follow-up period was about 1 year. The study was basically conducted in primary care settings, outpatient department of a college and a childcare hospital. The study included about 36 patients between the ages of 6 to 17 years. The patients were recruited to the active spinal manipulation therapy group or the sham spinal manipulation therapy group, and had to undergo 20 appointments during a 3 month period. The patient had to undergo chiropractic in addition to their regular medical treatment. The outcomes were determine through pulmonary function tests, quality of life factors that could be determined by the patient or the parent, the peak expiratory flow rates and also studying the recorded symptoms of the day and night of the patient recorded in a diary.
Nielsen (2010) (Chronic asthma and chiropractic spinal manipulation a randomized clinical trial, 2010) conducted a study to determine the effectiveness of chiropractic in treating chronic asthma along with other drugs used for maintenance therapy. The patients that were used in the trial were outpatients belonging to the national university Hospital of Copenhagen Denmark. About 31 patients between the ages of 18 to 44 years were included in the study and the patients who were using bronchodilators and corticosteroid inhalers were included in the study. The study excluded those patients who had received oral corticosteroids, immunotherapy or spinal manipulation during the last five years. The patients were put into either group active manipulation therapy or sham manipulation therapy for 1 month, twice weekly, and were then moved into the opposing group to receive the treatment for another 1 month. The phase between treatments was given a 2 week break. The outcome measures that were determined included-
Figure 7. Outcome Measures
Hondras, MA (2009) was a study that tried to determine the evidence available of the effect of manual therapies for patients affected with bronchial asthma. The author has felt that though medicines are effective in the treatment of asthma, having a non-medicine treatment would be a huge advancement in asthma management. Hondras felt that spinal manipulation is aimed at increasing the motion of the rib cage, improving the quality of life by improved lung function, increasing the oxygen content in arterial blood and improving the lymphatic return of the blood. Through chest percussion, vibration and mobilization of the patient, the bronchial secretions can be moved to the central airways thus helping the patient in expectoration and cough. Manual therapy was compared with other forms of treatment to determine the morbidity, mortality, physiological outcomes and side-effects in asthmatic patients. This review included only randomized and quasi-randomized studies where the patients were observed for at least 2 weeks. Child and adults patients suffering from asthma were included in the studies and patients affected with COPD were excluded.
Manual therapy such as manipulation, mobilization, massaging, physiotherapy, vibration and shaking were included and postural drainage alone was excluded from the study. The outcomes that were included in this study were pulmonary function, vital capacity, FEV1, FEV1FVC ratio, use of drugs, quality of life, subjective symptoms of asthma, hospitalization and length of stay, emergency visits, etc. A number of databases were searched for data including Cochrane, Chiropractic Research Archives Collection (CRAC), etc, from 2001 onwards. There were three reviewers for this study, who individually examined and extracted the data in the standardized template.
Kaminskyj 2010 conducted a systematic review of the literature to determine the rate of publishing and the quality of publishing studies on chiropractic especially spinal manipulation in patients suffering from bronchial asthma. The authors feel that chiropractic is one of the most often used form of CAM therapy and asthma is becoming a serious public hazard across the world. More and more chiropractors are using chiropractic for managing non-musculoskeletal conditions and are extending their treatment away from the traditional spinal manipulation therapy. The question being asked in this study was whether chiropractic is beneficial in the case of asthma and whether chiropractors have a role in the co-management or serve as primary healthcare providers for asthma. The outcome measures considered in this study was FEV, asthma severity self-reported, dependency on drugs, quality of life, etc.
A number of databases were searched including Cochrane, MEDLINE, CINAHL, AMED, Alt Healthwatch, Chiropractic Index, Mantis, etc, for literature between January 1980 and March 2009. Several searches were found and the searches had to be further refined. Down and Black developed a checklist that had 27 items for assessing the findings of the randomized and non-randomized studies. What was used in this study was a modified Down Black questionnaire, so that the maximum score obtained was 27. The quality scores that were included were 20 good, 11-20 moderate and 11 poor. Each author individually studied each of the searches and rated the articles.
Lowry 1995, reports that since 1995, chiropractors associations have been trying to use spinal manipulation for treating other disorders, other than back problems including asthma and enuresis. Many chiropractors in Canada had a conservative view of Chiropractic and held that disorders other than back conditions should not be attempted with chiropractic. In Canada the pediatrician community is against the idea of having chiropractors treating other disorders in infant and children. Parents also need to be cautious in using the services of the chiropractors in such instances. However, critics also say that evidences for the effectiveness and safety of chiropractic on asthma, bedwetting, ear infections and infantile colic should be researched rather than merely discarding the idea of using chiropractic. Other critics feel that implementing chiropractic and delaying for the use of other medical treatments may be serious.
Chiropractors can play a vital role in the development of the infant and the child, and various infants are at the risk of facing developmental problems associated with the spine and the backbone. Some experts in chiropractic feel that using the benefits of chiropractic for infantile colic and middle ear infections can in fact be effective and hence offer cheaper solutions to the healthcare system. Many experts feel that the spine of children are young and hence are more effective to manipulation. A simple point mentioned in the study regarding the effectiveness of chiropractic in asthma is that chiropractic spinal manipulation can help loosen the muscles in the back and in this way relieve asthma. However, as asthma is an inflammatory disease, spinal adjustments cannot help overcome inflammation.
Jamison, 1992 (Chiropractic adjustment in the management of visceral conditions a critical appraisal, 1992) tried to determine if Australian chiropractors consider spinal manipulation as an effective and safe option in treating patients affected with visceral disorders such as asthma, hypertension and dysmenorrhea. This was a survey study that was distributed to several chiropractors in Australia. The outcome measures were that the practitioner had to find certain usefulness of chiropractic in managing a visceral disorder. The chiropractor had to comment on the personal experience for treating the visceral disorder and the manner in which adjustment had to be done to treat the visceral disorder.
A systematic review was conducted by Ernst, E, to determine if spinal manipulation was effective in the treatment of asthma. Most of the internet searches drawn from websites of famous American, Canadian and British Chiropractor associations stress upon that spinal manipulation are effective in the treatment of bronchial asthma. DD Palmer the founder of chiropractic in fact said that most diseases including asthma was caused out of subluxation of the spine and adjustments were required to correct these disturbances. However, till today, not much systematic reviews have been conducted to assert this fact. This study by Ernst tries to review the various RCTs conducted on spinal manipulation for the treatment of asthma. Ernst searches various internet databases in September 2008 including Medline, Ovid, CINAHL, AMED, EMBASE, etc, marrying the concepts of asthma and spinal manipulation. No limits as such were used. The criteria for selection were that the study had to determine the effectiveness of spinal manipulation in the treatment of asthma. Any study that did not include spinal manipulation was excluded. The studies had to present some sort of a measureable endpoint. The Jadad Score was utilized to review the data.
Figrue 8. Jadad Rating Scale
Results
Graham 2000 found that huge number of patients in the US considered complementary and alternative treatments for asthma (33 of the population). However, literature of such treatment and their effectiveness, role and safety in treating asthma or atopy is not known, due to a lack of scientific basis for these systems to use evidence based criteria. Alternative and complementary therapies have a huge role to offer in the treatment of asthma as the same is an allergic disorder. Very few studies have been conducted to determine the role of complementary and alternative therapy in treating asthma. The current level of evidence regarding CAM to treat asthma and other allergic disorders is rather insufficient to create clear practice guidelines. Some of the flaws noted with CAM techniques include-
Figure 9. Flaws Noted with Studies conducted in CAM
Some of the physicians are lacking knowledge of which alternative therapy is available and the same if advisable can be used. Hence, there needs to be certain amount of awareness amongst the professionals of which other forms of treatment could be used (Graham 2000).
Bronfort (2001) found that it was capable to blind the patients to either group. After the intervention was performed for 3 months, there was no improvement in the lung function test results, recorded symptoms. The patient said that they composed 20 less of the bronchodilator and the quality of life improved by 10-28. The severity of asthma reduced by about 39. The parents and the guardians reported smaller improvements compared to the patient. The child patients felt that the improvement in quality of life and reduction in the severity of asthma remained unchanged over the next one year. Neither lung function nor hyper responsive improved. The effects of improvement in the patient-related quality of life and the reduction of the severity of asthma is not likely to be due spinal manipulation therapy itself, but also related to other aspects of the medical management of the patient. However, further studies are needed to determine the effect of spinal manipulation therapy on asthma.
In Nielsen 2010, cross over analysis was used to determine the effectiveness of treatment of the active Spinal manipulation with that of sham spinal manipulation. There were no important differences between the primary and secondary outcomes between both the forms of manipulation. There were no changes with the lung function test outcomes, but the patient reported lesser severity of asthma by about 34 and the bronchial hyper reactivity improved by 36. However, the study did not prove that spinal manipulation was better than sham manipulation to manage adults with asthma for four-week duration.
In Hondras 2009, more than 473 articles were considered, but 68 were reviewed and included in the study that fulfilled the criteria of inclusion. However, at the end, on three RCTs were considered in the study, which organized a total of 156 patients. These three studies included Balon 1998, Field 1998 and Nielsen 1995. The first two determined manual therapy in asthmatic children, whereas the later studied manual therapy in adults. None of the trials found an appreciable difference between manual therapy and sham maneuvers based on the outcome measures. There was a difference between massage therapy and relaxation therapy with respect to lung function outcomes, but the same could not be considered as the reporting characteristics of the trial was not proper. However, in the end, there was inconclusive data regarding the effectiveness of spinal manipulation in the treatment of asthma. Some of the measures that were present were not clinically important.
In Kaminskyj 2010, more than 150 articles were initially obtained from the various databases. Finally 13 articles were finalized, out of which 8 articles were included which were 1 case study, 1 survey, 2 RCTs, 1 randomized patientobserver blinded cross-over trial, 1 self-reported questionnaire and 1 single blind cross study. The quality scores of the various studies ranged from 5 to 22 out of a maximum of 27, which were good to low as per the Down Black criteria. The main aim of chiropractic in asthma was to help increase the lung space, mobilize the ribs, improve the blood and lymphatic supply to the lungs, and improve the nerve supply, so that the symptoms of asthma could be improved. According to this study, chiropractic did not only include spinal manipulation but also breathing exercises and soft tissue therapy. Most the data obtained were from trials that lacked good quality and hence although the effect of chiropractic care on asthma had found to be useful, the results were questionable. Hence, their therapeutic benefit could not be determined. The effectiveness of chiropractic care on asthma is said to be multi-factorial depending on several objective and subjective outcome measures.
Figure 10. Subjective Objective Outcome Measures
The articles lacked detail of the position of the manipulation and the type of therapy used. Hence, the procedure could not be used on other patients and hence the studies could not be utilized to develop guidelines. Besides, in some of the studies the children had received some drugs before the chiropractic treatment and hence, this could have altered the results of the chiropractic therapy. In some children who were co-managed with chiropractic, there were beneficial effects to a very mild extent. Most of the benefits that were noted were subjective in nature and very little objective benefits. Chiropractors use various outcome measures which need to be further standardized. There needs to be certain guidelines on the effective use of spinal manipulation in the treatment of asthma and further to utilize the same in the beneficial treatment of the patient.
Lowry 1995 find that Canadian Chiropractic students are often told to treat asthmatics back rather than the entire condition which is inflammatory in nature. This should be irrespective of the fact that chiropractic would cure asthma by itself, but at least offer some relief to the symptoms. In many other conditions such as bedwetting and middle ear infections, chiropractic may not offer a cure, but can be used to help lower the symptoms. X-rays in chiropractic are only needed in case of back problems and not to treat non-musculoskeletal disorders.
In Jamison 1992, about 22 of the 1300 odd chiropractors actually provided a response to the survey tool. More than 50 of the practitioners held that spinal manipulation had a useful role in the treatment of visceral disorders such as asthma, dysmenorrhea and hypertension. The extent to which it could be effective varied from one condition to another and often on the level to which adjustment could be done. In the 1990s, there was very little public funding for chiropractic to be used in visceral disorders. However, more detailed studies are required to determine the role of chiropractic in several visceral disorders especially asthma.
Ernst E (2009) obtained 35 articles that fulfilled the selection criteria. From this, 8 were duplicates, 4 were excluded as the data was not original, 14 were again excluded as the data was not randomized and finally 6 were excluded as there was no spinal manipulation involved. This left the researchers with just 3 RCTs. The data that is currently available suggests that spinal manipulation is not effective in the treatment of asthma and there was no significant difference compared to sham manipulation.
The previous studies that were conducted in fact were false positive results. The three studies that were finally included were Neilsen (1995), Balon (1998) and Bronfort (2001). Usually in real practice, the need to use spinal manipulation is not always made on the basis of effectiveness, but also on the basis of safety and cost-effectiveness. Rare complications to spinal manipulation do occur, and mild side-effects are more common. The authors also feel that as the RCTs available to them currently are rather insufficient, the data available is not conclusive enough to make a decision whether spinal manipulation is effective for the treatment of asthma. Several studies were excluded by Ernst 2009, basically for the reason of not meeting with the scientific protocol but demonstrating a positive outcome. The authors also found that many journals that published data on complementary and alternative techniques in fact did not follow the scientific protocol nor did publish any kind of negative result. Overall greater amount of data was required to demonstrate that spinal manipulation was effective in the treatment of asthma, but the current data demonstrated that spinal manipulation was in fact not effective in the treatment of asthma.
Conclusion Recommendations
From the eight studies that form a part of the literature review, it is important to determine what action points need to form a part of guidelines for implementation into chiropractic. To ensure that any kind of alternative therapy warrants some amount of success, chiropractors, physicians, nurses and specialists should have an idea of various forms of complementary and alternative treatment and should be able to apply the same to the patient to provide herhim with the most holistic form of treatment. This is not only applicable in the case of asthma, but in any disorder in order to manage the patient as a whole. Large number of patients may consider using CAM, and it is important that the branches of CAM have a scientific basis rather than a mere magical or unscientific background.
Some of the studies found that there was no improvement in the lung function test results, but there was a slight improvement in the quality of life, lesser use of bronchodilators or inhalers, and reduced severity of asthma as defined by the patient. The parents and guardians noted much lesser improvements in quality of life and severity of asthma compared to the child patient. However, it is not clear whether spinal manipulation has a direct improvement on the quality of life and reduced severity of asthma. The mechanism of the same needs to be more closely understood, and at the same time clear criteria needs to be defined to enable understanding how asthmatics are benefited.
Although spinal manipulation may have some benefits at improving the quality of life, improving the lung function parameters, reducing the severity of asthma, lowering the consumption of medications, etc, it has been found that these criteria are similar to sham manipulation compared with spinal manipulation in asthmatics, raising a huge concern of the scientific basis of spinal manipulation. This was observed on a short duration of 4-weeks of therapy.
Spinal manipulation is aimed at increasing the motion of the rib cage, improving the quality of life by improved lung function, increasing the oxygen content in arterial blood and improving the lymphatic return of the blood. Through chest percussion, vibration and mobilization of the patient, the bronchial secretions can be moved to the central airways thus helping the patient in expectoration and cough. In asthmatics, manual therapy in general may not seem to be superior to sham maneuvers and hence, spinal manipulation may be of no use. However, closer research needs to be performed to understand the exact mechanism by which spinal manipulation works.
With time, more and more chiropractors are using spinal manipulation for non-musculoskeletal disorders and are using a greater number of treatments along with traditional massage sessions (such as nutritional therapy, exercises, etc). Chiropractors in asthma aim to increase the lung space, mobilize the ribs, improve the blood and lymphatic supply to the lungs, and improve the nerve supply, so that the symptoms of asthma could be improved.
The use of chiropractic for disorders other than back and neck disorders needs to be made based on evidences and scientific data and not act as an unjustified limit to practice. Chiropractic not only offers benefits but is also a cheaper and safer option if applied appropriately. Common sense suggests that chiropractic helps to loosen the muscles of the back and in this way help the lungs to function better. Even if the effect is similar to sham manipulation, chiropractic can be used as it is proven to have certain benefits rather than damage to the patient. However, it also needs to be taken into consideration that asthma is an inflammatory disorder and hence spinal manipulation cannot reduce inflammation. Chiropractic can be used in the co-management with asthma with other forms of medical treatment.
In general, chiropractors are of the opinion that spinal manipulation is effective for visceral disorders including asthma, through their experience of the use of the same. Such opinions can further be developed to create guidelines so that the effectiveness of such therapy can be reaped into successes.
Data that is currently available on spinal manipulation for asthma is not sufficient to create useful professional guidelines that can be followed. The studies need to follow a scientific basis of blinding, removing all biases, and ensuring that certain inclusion and exclusion criteria are followed. The studies should be long-term and should have a sufficient study size and good design.
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