Manual therapy for asthma.

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: We searched for trials in computerized general (EMBASE, CINAHL and MEDLINE) and specialized databases (Cochrane Complementary Medicine Field, Cochrane Rehabilitation Field, Index to Chiropractic Literature (ICL), and Manual, Alternative and Natural Therapy (MANTIS)). In addition, we assessed bibliographies from included studies, and contacted authors of known studies for additional information about published and unpublished trials. Date of most recent search: August 2004. 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 with observation periods of at least two weeks. DATA COLLECTION AND ANALYSIS: All three reviewers independently extracted data and assessed trial quality using a standard form. MAIN RESULTS: From 473 unique citations, 68 full text articles were retrieved and evaluated, which resulted in nine citations to three RCTs (156 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. 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. AUTHORS' 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.

Manual therapy for asthma.

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: February 2002. 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 393 unique citations, 59 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.

Manual therapy for asthma.

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. A further search conducted in July 2000 did not yield any more studies 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 critical appraisal of review articles on the effectiveness of conservative treatment for neck pain.

STUDY DESIGN: A criteria-based appraisal of review articles on neck pain. OBJECTIVES: To assess the methodologic quality, conclusions, and extent of concordance among reviews on the conservative treatment of neck disorders. SUMMARY OF BACKGROUND DATA: During the past decades there has been an increasing interest in summarizing and analyzing the available evidence on the effectiveness of conservative management of neck pain. Considering the growing number and quality of reviews, consumers may question which reviews to read and believe. METHODS: Computerized bibliographic databases were searched without language restriction. The reviews assessed had been published before January 1998, included neck pain and evaluated conservative therapies, and reported at least one controlled clinical trial. Identification, selection, and quality assessment were performed independently by two investigators. RESULTS: Of the 108 identified articles, 25 review articles were selected, of which 12 were systematic reviews. The reviews differed in their reporting of study population, interventions, and outcomes. Statistical pooling was performed in two high-quality systematic reviews, whereas in other reviews, the investigators explicitly decided not to pool data. The results of the current study show that the concordance among reviews varied. Regarding manipulation and traction, there is inconclusive evidence among reviews. Concordance regarding the effectiveness of other conservative interventions was absent. Many of the reviews displayed major methodologic flaws. CONCLUSIONS: Consumers should consider reports of reviews both carefully and critically, given the wide variety of review methodology, descriptive information, and final conclusions. There is a paucity of evidence from primary studies on neck pain. Therefore, more research is needed to allow systematic reviews to formulate stronger conclusions.

Manual therapy for asthma.

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.

Spinal manipulative therapy versus a low force mimic maneuver for women with primary dysmenorrhea: a randomized, observer-blinded, clinical trial.

Non-drug therapies for women with primary dysmenorrhea are primarily based on anecdotal evidence and small-scale clinical studies. This randomized, observer-blinded, clinical trial evaluated the efficacy of spinal manipulative therapy (SMT) in the treatment of women with primary dysmenorrhea. Women were recruited from the Chicago metropolitan area and evaluated for inclusion through four screening levels. One hundred thirty eight women, ages 18-45, with primary dysmenorrhea diagnosed by participating gynecologists, were randomly assigned to either SMT or a low-force mimic (LFM) maneuver. No treatment occurred at menstrual cycle 1. Treatment for both groups took place on day 1 of cycles 2, 3 and 4, and prophylactic treatment of three visits took place during the 7 days before cycles 3 and 4. Main outcome measures were the Visual Analog Scale (VAS) and plasma concentration of the prostaglandin F2alpha metabolite, 15-keto-13,14-dihydro-prostaglandin F2alpha (KDPGF2alpha), measured 15 min before treatment and 60 min after treatment on day 1 of four consecutive menstrual cycles. The Moos' Menstrual Distress Questionnaire (MDQ) was also administered after treatment on day 1 of each cycle. At cycle 2, the post-treatment VAS scores decreased for both groups, with no statistically significant difference in pre- to post-treatment scores between the two groups (P = 0.44). The changes in pre- to post-treatment KDPGF2alpha levels were not statistically different between the SMT and LFM groups (P = 0.15). No treatment effects were detected over the three cycles for VAS, KDPGF2alpha or MDQ (P = 0.65, P = 0.61 and P = 0.78, respectively). However, there were statistically significant linear time effects for VAS (P = 0.008), MDQ (P < 0.001), and borderline significance for KDPGF2alpha (P = 0.054); these decreases were not considered clinically meaningful. The LFM maneuver used in this study was designed to act as a 'placebo-like' control treatment in comparison with SMT. Although it is possible that the trial did not continue long enough for any placebo effect of the LFM to wash out, it seems more likely that this maneuver was indistinguishable from SMT. Therefore, the postulated superior benefit of high-velocity, short-lever, low-amplitude, high-force spinal manipulation to a low-force maneuver is not supported by the results of this study. 1999 International Association for the Study of Pain.

Outcomes research in chiropractic: the state of the art and recommendations for the chiropractic research agenda.

OBJECTIVE: To examine and document the state of the art in outcomes research in chiropractic, including the limitations of available data, and to make recommendations for further progress in this area. METHODOLOGY: An extensive search of the literature from 1990 through 1994 was undertaken using electronic databases (Medline, Index to Chiropractic Literature, EMBASE, and ERIC) and hand searches were conducted for relevant studies published in 1995. Publication in English, publication in a peer-reviewed journal, weight of evidence (study design) and measurement of patient-relevant outcomes were primary inclusion criteria. We prepared a draft with recommendation, rationale, actions required, responsible parties and expected outcomes for each seed statement. An outcomes workgroup, convened at the Research Agenda Work shop, added its perspective to the seed recommendations and actions required. Finally, the white paper authors prepared the final recommendations for outcomes research in chiropractic. RESULTS: This white paper presents six recommendations, emphasizing four general areas in which to develop the outcomes research agenda in chiropractic: research culture, infrastructure, opportunities and topics in outcomes research. CONCLUSION: The long-term goals of the chiropractic research agenda must be to advance the profession and to better meet the health needs of the public. Our final recommendations serve as a foundation for the development of proposals for future strategy with outcomes research a priority.

Manipulative therapy versus education programs in chronic low back pain.

STUDY DESIGN: A randomized trial was conducted on a representative sample of patients with untreated low back pain lasting 7 weeks or longer, or having more than 6 episodes in 12 months. OBJECTIVES: To contrast the effectiveness of manipulation, a manipulation mimic, and a back education program. Methodologic criticisms of earlier studies were addressed. SUMMARY OF BACKGROUND DATA: Published meta-analyses suggest clinical benefit from manipulation for acute patients. Data are inconclusive for patients having symptoms for longer than 1 month. METHODS: A total of 1267 consecutive patients were screened. Block randomization was used to assign 209 qualifying patients to treatment groups. Self-reported pain and activity tolerance served as primary outcome measures. Patients were assessed at enrollment, after 2 weeks of treatment, and again after 2 weeks without treatment. Multiple teams conducted recruitment, randomization, assessment, treatment, and data analysis independently without sharing information. Treatments were carefully described, monitored, and balanced for physician attention and physical contact effects. RESULTS: A total of 81.3% of subjects completed the study. Confounding factors and missing data were identified in approximately 20% of those completing the final follow-up. Analysis of the remaining data was carried out. A strong time effect under treatment was observed. Greater improvement was noted in pain and activity tolerance in the manipulation group. Immediate benefit from pain relief continued to accrue after manipulation, even for the last encounter at the end of the 2-week treatment interval. CONCLUSION: Time is a strong ally of the low back pain patient. In human terms, however, there appears to be clinical value to treatment according to a defined plan using manipulation even in low back pain exceeding 7 weeks' duration.

Lymphocyte profiles in patients with chronic low back pain enrolled in a clinical trial.

OBJECTIVE: Our earlier findings suggest that patients with musculoskeletal complaints have lower numbers and percentages of natural killer (NK) cells than asymptomatic subjects. This study examines patient lymphocyte profiles, as a secondary outcome measure, in a trial of manipulative therapies to treat chronic low back pain (LBP) of mechanical origin. DESIGN: The patients were compared in a randomized controlled trial. Baseline measures were collected at the initial visit; all patients were scheduled for 11 treatments in 14 days. Treatment consisted of either a high-force, high-velocity, low-amplitude manipulation procedure; a low-force, high-velocity, low-amplitude procedure or a series of educational lectures on lower back pain. Posttreatment measures were collected at the final treatment session; follow-up measures were obtained 2 wk later. SETTING: The study was conducted at a chiropractic teaching clinic in the suburban Chicago area. PARTICIPANTS: Individuals over 18 were eligible if they were new patients or repeat patients with a 6 month's hiatus, if the chief complaint was LBP of greater than 50 days' duration, if pain was elicited with palpation over one or more of the facet joints from the spinal levels between L1 and S1 and including the sacroiliac joints, and if there was absence of pain referral or if pain referral was only scleratogenous in nature. Criteria for excluding patients included hard neurologic signs, systemic disease potentially affecting the musculoskeletal system, contraindication to spinal manipulation such as osteoporosis, fracture or other bony pathology, or treatment with medication intended to relieve symptoms associated with their LBP. Eligibility was determined by a staff diagnostic team independent of the attending physician. Three hundred sixty-seven of 1,275 consecutive new patients met the eligibility criteria. Of these, 209 participated. These results are for 201 patients from whom flow cytometric data were obtained. OUTCOME MEASURES: Both absolute numbers and percentages of B-lymphocytes, T-lymphocytes, T-Helper (TH), T-Suppressor (TS) and NK lymphocytes were determined. Blood samples were collected at the same time that the primary outcome measures were obtained. Cells were stained with two-color monoclonal antibodies directed against specific cell surface antigens, and each lymphocyte subpopulation was quantified directly from lysed whole blood with a Coulter Epics Profile II flow cytometer. RESULTS: Thirty-five patients dropped out before the follow-up visit and technical problems resulted in the loss of data from 17 more and the exclusion of some subpopulation data. In all, 148 cases were analyzed for B cells, 146 for TH, TS and NK cells and 138 for cells that carried both the NK and TS marker. A one-way analysis of variance revealed no significant differences in the lymphocyte profiles at baseline among the three groups. All subpopulation baseline values were within reported reference ranges for normal adult populations. However, the percentage of NK cells (9.1%) was below the published minimum critical value. A repeated measures analysis of variance was used to determine whether treatment effects changed over time, that is, treatment-time interaction. The cell types for which the interaction tests were at or near statistical significance were: TH cells (p = .0208), total T cell percent (p = .0928) and absolute total T cells (p = .0908). Interaction tests for differences in either percent or absolute counts of B cells, TS cells, or NK cells were not statistically significant. CONCLUSIONS: This is the first report of lymphocyte profiles in patients with diagnosed chronic LBP. Our finding of a lower percentage of NK cells in these patients confirms our earlier finding that patients with musculoskeletal problems have a lower percentage of NK cells than do asymptomatic subjects. However, manipulative therapy was not shown to have a clinically significant effect on either the absolute n

The Hmax/Mmax ratio as an outcome measure for acute low back pain.

OBJECTIVE: To evaluate the use of the Hmax/Mmax (H/M) ratio as an outcome measure for acute low back pain and to determine the change of this ratio in acute low back pain patients treated with spinal manipulation. DESIGN: Randomized clinical trial. SETTING: Chiropractic college teaching clinic. PATIENTS: Thirty-six patients with acute low back pain (pain of less than 2 wk duration) were referred by clinicians of the teaching clinic. Eligibility criteria for inclusion into the study consisted of the following: a score of eight or more on the Oswestry questionnaire, 33 mm or greater on a 100-mm visual analog scale, no involvement in litigation related to the low back pain complaint, patient not pregnant and no physical or electrodiagnostic signs of nerve root entrapment. INTERVENTIONS: The patients were randomly assigned to either a treatment or control group. The treatment group (n = 17) received treatment deemed appropriate by the clinician as long as it included a side-lying manipulation to the appropriate level. The control group (n = 19) received detuned ultrasound, application of a cold pack and 15-30 sec of very gentle soft tissue massage. Patients were treated three to five times over a period of 10 days and were subsequently reevaluated. MEASUREMENTS: The Hmax/Mmax ratio was calculated from the results of electrodiagnostic testing of the posterior tibial nerve. Extension/flexion ratio of the trunk musculature, Oswestry score and Visual Analog Scale score were also measured. MAIN RESULTS: The mean difference between H/M ratios pre- and postintervention for the group treated by chiropractic methods was -0.101 on the left and -0.117 on the right. The mean difference for the control group was 0.038 on the left and 0.036 on the right. Although not statistically significant, trends suggest that at the time of final assessment, the group receiving chiropractic care had improved more than the control group. CONCLUSIONS: The H/M ratio was found to be within normal limits in subjects with acute low back pain. The H/M ratio showed greater change in the group which received spinal manipulation, but the change was subtle. The results indicate that the H/M ratio may be of limited value in clinical practice.

Enhanced neutrophil respiratory burst as a biological marker for manipulation forces: duration of the effect and association with substance P and tumor necrosis factor.

A critical need in assessing the clinical utility of manipulative therapy for back pain is the identification of biological changes associated with the forces applied by spinal manipulation. Such changes could then serve as markers for both sham treatment and manipulation. We determined the priming of polymorphonuclear neutrophils for an enhanced respiratory burst and its duration, the priming of mononuclear cells for enhanced endotoxin-stimulated tumor necrosis factor production and plasma levels of substance P following a single thoracic spine manipulation. There was a significant difference in the respiratory burst of polymorphonuclear neutrophils in response to a particulate challenge, depending on the time of blood sample collection. The response of polymorphonuclear neutrophils isolated from blood collected 15 min after manipulation was significantly higher than the response of cells isolated from blood collected 15 min before and 30 and 45 min after manipulation. Mononuclear cells were also primed for enhanced endotoxin-stimulated tumor necrosis factor production by spinal manipulation. Both of these priming effects were accompanied by a slight, but significant elevation in plasma substance P. The mean manipulation force associated with these biological effects was 878 +/- 99 N. These biological effects may provide a means of monitoring the delivery of both sham and manipulative treatment and, therefore, provide a crucial tool for understanding the efficacy of manipulative therapy.

Differences in treatment history with manipulation for acute, subacute, chronic and recurrent spine pain.

Preference for treatment protocols used in the care of spine disorders are based more upon clinical impressions than upon systematic study of the pathology or treatment efficacy. As social emphasis moves to cost containment strategies, quantitative data is necessary to give guidance for rational policy decisions. This study sets a description of the clinical experience obtained in a group practice, teaching clinic engaged in management of spine disorders. The same subjects were separately reported as being broadly representative of those seen in private using a cash payment policy. Clinical characteristics were quantified on 241 patients. A total of 149 volunteered to complete follow up evaluations. The total number of treatment sessions were tallied to case resolution on all 241 patients and were evaluated by stratifying them according to chronicity of the chief complaint. The range of treatment for all cases was 1-22. Chronic complaints required the most care, with a mean of 8.2 sessions (F = 2.833, p = .014). Thoracic disorders required approximately half the care as lordotic spine regions (F = 2.372, p = .04). No differences were observed based upon descriptive classifications of entrapment, mechanical or muscular pain. All but 25 cases reached resolution well within 6 wk, requiring a mean of 3.8 (range 1-11) additional treatment sessions.

Enhanced phagocytic cell respiratory burst induced by spinal manipulation: potential role of substance P.

The effect of spinal manipulation on the respiratory burst of polymorphonuclear neutrophils (PMN) and monocytes from treated adults was measured by zymosan-stimulated chemiluminescence (CL). Peripheral blood was collected 15 min before and 15 min after treatment (sham manipulation, thoracic spine manipulation, or soft tissue manipulation), the cells were isolated, challenged with a standardized, opsonized luminol-containing suspension of zymosan, and monitored for CL. Plasma from two subsets of subjects was radioimmunoassayed for Substance P (SP). PMN were also preincubated with SP in vitro over the dose range 5 x 10(-12) M to 5 x 10(-8) M and the CL response monitored. The CL responses of both PMN and monocytes from subjects who received spinal manipulation were significantly higher after than before treatment, and significantly higher than the response in sham or soft-tissue treated subjects. Measurement of the force applied by sham and spinal manipulation suggested a force threshold for the enhancement of the CL response. Plasma levels of SP before and after treatment in sham treated subjects did not differ significantly; however, elevated plasma SP was observed in subjects after spinal manipulation. Preincubation of PMN with 1 x 10(-11) M, 5 x 10(-11) M or 1 x 10(-10) M SP in vitro primed PMN for an enhanced respiratory burst when the cells were subsequently challenged.