Medline Articles on Asthma
Additional comments on the New England Journal article:
Manual therapy for asthma.
Hondras MA, Linde K, Jones AP. Western States Chiropractic College, 2900 NE 132nd Avenue, Portland, Oregon, USA, 97230-3099.
Cochrane Database Syst Rev 2000;2:CD001002
BACKGROUND: A variety of manual therapies with similar postulated biologic mechanisms of action are commonly used to treat patients with asthma. Manual therapy practitioners are also varied, including physiotherapists, respiratory therapists, chiropractic and osteopathic physicians. A systematic review across disciplines is warranted. OBJECTIVES: To evaluate the evidence for the effects of manual therapies for treatment of patients with bronchial asthma. SEARCH STRATEGY: Trials were searched in computerized general (EMBASE, CINAHL and MEDLINE) and specialized databases (Cochrane Complementary Medicine Field, Cochrane Rehabilitation Field, ICL, and MANTIS). In addition, bibliographies from included studies were assessed, and authors of known studies were contacted for additional information about published and unpublished trials. Date of most recent search: December 1998. SELECTION CRITERIA: Trials were included if they: (1) were randomised; (2) included asthmatic children or adults; (3) examined one or more types of manual therapy; and (4) included clinical outcomes. DATA COLLECTION AND ANALYSIS: All three reviewers independently extracted data and assessed trial quality using a standard form. MAIN RESULTS: From an initial 316 unique citations, 48 full text articles were retrieved and evaluated, which resulted in nine citations to five RCTs (290 patients) suitable for inclusion. Trials could not be pooled statistically because studies that addressed similar interventions used disparate patient groups or outcomes. The methodological quality of one of two trials examining chiropractic manipulation was good and neither trial found significant differences between chiropractic spinal manipulation and a sham manoeuvre on any of the outcomes measured. Quality of the remaining three trials was poor. One small trial compared massage therapy with a relaxation control group and found significant differences in many of the lung function measures obtained. However, this trial had poor reporting characteristics and the data have yet to be confirmed. One small trial compared chest physiotherapy to placebo and one small trial compared footzone therapy to a no treatment control. Neither trial found differences in lung function between groups. REVIEWER'S CONCLUSIONS: There is insufficient evidence to support the use of manual therapies for patients with asthma. There is a need to conduct adequately-sized RCTs that examine the effects of manual therapies on clinically relevant outcomes. Future trials should maintain observer blinding for outcome assessments, and report on the costs of care and adverse events. Currently, there is insufficient evidence to support or refute the use of manual therapy for patients with asthma.
A comparison of active and simulated chiropractic manipulation as adjunctive treatment for childhood asthma.
Balon J, Aker PD, Crowther ER, Danielson C, Cox PG, O'Shaughnessy D, Walker C, Goldsmith CH, Duku E, Sears MR. Division of Graduate Studies and Research, Canadian Memorial Chiropractic College, Toronto, ON, Canada.
N Engl J Med 1998 Oct 8;339(15):1013-20
BACKGROUND: Chiropractic spinal manipulation has been reported to be of benefit in nonmusculoskeletal conditions, including asthma. METHODS: We conducted a randomized, controlled trial of chiropractic spinal manipulation for children with mild or moderate asthma. After a three-week base-line evaluation period, 91 children who had continuing symptoms of asthma despite usual medical therapy were randomly assigned to receive either active or simulated chiropractic manipulation for four months. None had previously received chiropractic care. Each subject was treated by 1 of 11 participating chiropractors, selected by the family according to location. The primary outcome measure was the change from base line in the peak expiratory flow, measured in the morning, before the use of a bronchodilator, at two and four months. Except for the treating chiropractor and one investigator (who was not involved in assessing outcomes), all participants remained fully blinded to treatment assignment throughout the study. RESULTS: Eighty children (38 in the active-treatment group and 42 in the simulated-treatment group) had outcome data that could be evaluated. There were small increases (7 to 12 liters per minute) in peak expiratory flow in the morning and the evening in both treatment groups, with no significant differences between the groups in the degree of change from base line (morning peak expiratory flow, P=0.49 at two months and P=0.82 at four months). Symptoms of asthma and use of 3-agonists decreased and the quality of life increased in both groups, with no significant differences between the groups. There were no significant changes in spirometric measurements or airway responsiveness.CONCLUSIONS: In children with mild or moderate asthma, the addition of chiropractic spinal manipulation to usual medical care provided no benefit.(SEE EDITORIAL COMMENTS BELOW
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 Kuchera (3) and Stanton and Mein (4) 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.
Douglas G. Richards, Ph.D.
Eric A. Mein, M.D.
Carl D. Nelson, D.C.
Virginia Beach, VA 23454
1. 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;74:757-60.
2. Purdy WR, Frank JJ, Oliver B. Suboccipital dermatomyotomic stimulation and digital blood flow. J Am Osteopath Assoc 1996;96:285-9.
3. 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.
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 (beta)-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.
Brian V. Jongeward, D.C.
701 DeMers Ave.
Grand Forks, ND 58201
1. 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;339:1013-20.
2. Physicians' current procedural terminology. 4th ed. Chicago: American Medical Association, 1997.