Related to Mel Siff's recent posting here are two abstracts and a
editorial along the same lines. The APTA's response to the PT article
can be found at apta.org.
Douglas M. White, PT, OCS
Milton, MA USA
The New England Journal of Medicine -- October 8, 1998 -- Volume 339,
Number 15
A Comparison of Active and Simulated Chiropractic Manipulation
as Adjunctive Treatment for Childhood Asthma
Jeffrey Balon, Peter D. Aker, Edward R. Crowther, Clark Danielson, P.
Gerard Cox, Denise O'Shaughnessy, Corinne Walker,
Charles H. Goldsmith, Eric Duku, Malcolm R. Sears
Abstract
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 (beta)-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. (N Engl J Med
1998;339:1013-20.)
Source Information
From the Division of Graduate Studies and Research, Canadian
Memorial Chiropractic College, Toronto (J.B.,
P.D.A., E.R.C.); the Department of Research, Los Angeles
College of Chiropractic, Los Angeles (C.D.); the
Firestone Regional Chest and Allergy Unit, St. Joseph's
Hospital, and the Department of Medicine, McMaster
University, Hamilton, Ont., Canada (P.G.C., D.O., C.W.,
M.R.S.); and the Department of Clinical Epidemiology
and Biostatistics and the Centre for Evaluation of Medicines,
Father Sean O'Sullivan Research Centre, St.
Joseph's Hospital and McMaster University, Hamilton, Ont.,
Canada (C.H.G., E.D.). Address reprint requests to
Dr. Sears at the Firestone Regional Chest and Allergy Unit,
St. Joseph's Hospital, 50 Charlton Ave. East,
Hamilton, ON L8N 4A6, Canada.
Related Editorial
The New England Journal of Medicine -- October 8, 1998 -- Volume 339,
Number 15
A Comparison of Physical Therapy, Chiropractic Manipulation,
and Provision of an Educational Booklet for the Treatment of
Patients with Low Back Pain
Daniel C. Cherkin, Richard A. Deyo, Michele Battie, Janet Street,
William Barlow
Abstract
Background and Methods. There are few data on the relative
effectiveness and costs of treatments for low back
pain. We randomly assigned 321 adults with low back pain that
persisted for seven days after a primary care visit
to the McKenzie method of physical therapy, chiropractic
manipulation, or a minimal intervention (provision of an
educational booklet). Patients with sciatica were excluded.
Physical therapy or chiropractic manipulation was
provided for one month (the number of visits was determined by
the practitioner but was limited to a maximum of
nine); patients were followed for a total of two years. The
bothersomeness of symptoms was measured on an
11-point scale, and the level of dysfunction was measured on
the 24-point Roland Disability Scale.
Results. After adjustment for base-line differences, the
chiropractic group had less severe symptoms than the
booklet group at four weeks (P=0.02), and there was a trend
toward less severe symptoms in the
physical-therapy group (P=0.06). However, these differences
were small and not significant after transformations
of the data to adjust for their non-normal distribution.
Differences in the extent of dysfunction among the groups
were small and approached significance only at one year, with
greater dysfunction in the booklet group than in the
other two groups (P=0.05). For all outcomes, there were no
significant differences between the physical-therapy
and chiropractic groups and no significant differences among
the groups in the numbers of days of reduced activity
or missed work or in recurrences of back pain. About 75
percent of the subjects in the therapy groups rated their
care as very good or excellent, as compared with about 30
percent of the subjects in the booklet group
(P<0.001). Over a two-year period, the mean costs of care were
$437 for the physical-therapy group, $429 for
the chiropractic group, and $153 for the booklet group.
Conclusions. For patients with low back pain, the McKenzie
method of physical therapy and chiropractic
manipulation had similar effects and costs, and patients
receiving these treatments had only marginally better
outcomes than those receiving the minimal intervention of an
educational booklet. Whether the limited benefits of
these treatments are worth the additional costs is open to
question. (N Engl J Med 1998;339:1021-9.)
Source Information
From the Group Health Center for Health Studies (D.C.C., J.S.,
W.B.), the Departments of Health Services
(D.C.C., R.A.D.), Family Medicine (D.C.C.), Medicine (R.A.D.),
and Biostatistics (W.B.) and the Center for
Cost and Outcomes Research (R.A.D.), University of Washington,
Seattle; and the Department of Physical
Therapy, University of Alberta, Edmonton, Canada (M.B.).
Address reprint requests to Dr. Cherkin at the Group
Health Center for Health Studies, 1730 Minor Ave., Suite 1600,
Seattle, WA 98101.
Related Editorial
The New England Journal of Medicine -- October 8, 1998 -- Volume 339,
Number 15
What Role for Chiropractic in Health Care?
On September 18, 1895, Daniel David Palmer manipulated the
spine of Harvey Lilliard, allegedly restoring Mr.
Lilliard's sense of hearing and founding the practice of
chiropractic. (1) From this beginning, despite decades of
persecution from government and organized medicine,
chiropractors have become the third largest group of health
professionals in the United States (after physicians and
dentists) who have primary contact with patients.
Chiropractors are licensed to practice in all 50 states,
Medicare covers chiropractic care for radiographically
proved subluxation of the vertebral spine, 45 states have
state-mandated benefits for chiropractic, and an
increasing number of insurance plans and managed-care
organizations are offering chiropractic benefits. (1) In the
last decade of the 20th century, chiropractic has begun to
shed its status as a marginal or deviant approach to care
and is becoming more mainstream. At this juncture, it seems
appropriate to ask what the role of chiropractic
should be in health care. There is a debate, both within the
chiropractic profession and outside of it, about whether
chiropractic should be considered a nonsurgical
musculoskeletal specialty or a broadly based alternative to
medicine. (1)
Chiropractic differs from traditional medicine in that it
eschews the use of pharmaceutical agents and surgery and
instead is based on the body's ability to heal itself. Central
to improving the body's ability to heal itself,
chiropractors assert, is the removal, or correction, of
malalignments of the spine (called subluxations) through the
use of spinal manipulation (called spinal adjustments).
Although chiropractic treatment frequently includes advice
about exercise, nutritional supplements, and lifestyle
counseling, spinal manipulation is the treatment that is used
most often, (2,3) and it is also the therapeutic method most
closely identified with the practice of chiropractic in the
United States.
What does the scientific literature tell us about the efficacy
of spinal manipulation? That spinal manipulation is a
somewhat effective symptomatic therapy for some patients with
acute low back pain is, I believe, no longer in
dispute. (4) The study by Cherkin and colleagues in this issue
of the Journal again confirms this finding. (5) Cherkin
et al. found that patients with low back pain who were
randomly assigned to chiropractic manipulation had a small,
marginally significant improvement in symptoms at four weeks
as compared with patients who received no therapy
other than an educational booklet. (5)
What is in dispute is the efficacy of spinal manipulation in
relation to other therapies. Previous studies have
compared spinal manipulation with a variety of other
therapies, including back exercises, bed rest, and
nonsteroidal antiinflammatory drugs. Some of these therapies,
such as bed rest, are actually worse than no therapy.
(6) Over the past 10 years, the importance of activity in
patients with back pain has been increasingly recognized;
therefore, Cherkin and colleagues compared chiropractic spinal
manipulation with another popular form of
treatment, the McKenzie method of physical therapy. In this
approach, patients are taught exercises that will
centralize their symptoms and taught to avoid movements that
will peripheralize them. Cherkin et al. found no
appreciable difference in outcomes between the two approaches.
The cost effectiveness of chiropractic care relative to other
care is also controversial. Some have tried
unconvincingly to estimate cost effectiveness on the basis of
nonrandomized studies and workers' compensation
data. (7) Cherkin and colleagues measured both the
effectiveness and the direct health care costs of chiropractic
care in a randomized study. They found that patients who
received chiropractic care and those who received
McKenzie physical therapy incurred about $280 more in costs
over the course of two years than patients who
received the educational booklet. Though they did not measure
indirect costs, such costs are unlikely to differ
appreciably according to the type of treatment, since the
numbers of days of reduced activity, days in bed, and
days of work lost were similar in all three groups. In
addition, the rate of recurrence and the percentages of
patients who sought care for back pain were similar among the
groups, casting doubt on the hypothesis that either
chiropractic care or McKenzie physical therapy saves money by
reducing the rate of relapse.
Because these data on direct costs are compatible with
observational data, (8,9) I conclude that chiropractic care
for low back pain, at least as practiced in the United States,
costs more than the usual supportive medical care
delivered by health maintenance organizations. Whether the
small symptomatic benefit and the enhanced
satisfaction of patients, as consistently reported by studies
of patients treated by chiropractors, are worth this cost
is debatable. Before we judge this approach too harshly,
however, we must remember that many existing medical
interventions currently paid for by insurance companies
provide equally small benefits or even none at all (for
example, ultrasonographic therapy for shoulder disorders (10)
and epidural injections of corticosteroids for
sciatica (11)). Consider, too, that the cost effectiveness of
chiropractic care could improve substantially. Since the
number of spinal manipulations needed to achieve the maximal
therapeutic effect is unknown, chiropractors may be
able to deliver fewer treatments and still achieve the same
results.
What about the use of spinal manipulation for other
musculoskeletal problems? There is evidence from randomized
clinical trials that spinal manipulation may be efficacious
for some patients with neck pain. (12,13) However,
neither the efficacy of manipulation relative to that of other
therapies nor the cost effectiveness of such therapy has
been established. Moreover, the use of cervical manipulation
arouses far greater concern about safety than the use
of lumbar manipulation.
The appropriateness of spinal manipulation for
nonmusculoskeletal conditions is the most divisive issue among
medical physicians and chiropractors. Physicians generally
accept the role of chiropractic in treating selected
musculoskeletal problems but adamantly oppose its use for
treating a diverse array of disorders, such as
hypertension, asthma, and otitis media, despite numerous case
reports from chiropractors of improvement in these
conditions with spinal manipulation. Hindering any rational
discussion has been the paucity of data from
randomized, controlled trials. Therefore, the study by Balon
and colleagues, which also appears in this issue of the
Journal, (14) is particularly welcome.
These courageous investigators tested the effect of spinal
manipulation as an adjunct to medical therapy for
children with stable asthma and found no significant
difference between groups in terms of physiologic outcomes,
symptoms, quality of life, or patients' satisfaction. Thus,
they concluded that the addition of chiropractic spinal
manipulation to medical therapy had no effect on the control
of childhood asthma. However, the proportion of
patients who seek chiropractic for conditions such as asthma
or other nonmusculoskeletal conditions is very small.
For example, treatment for conditions such as asthma or otitis
media accounts for less than 1 percent of patient
visits to chiropractors in the United States, whereas
treatment for back pain accounts for 40 to 60 percent of all
visits. (2,3) Therefore, the debate about the usefulness of
chiropractic care for nonmusculoskeletal conditions may
be largely academic.
What is the role of chiropractic in health care? In 1979 Dr.
Arnold Relman wrote an editorial for the Journal
entitled "Chiropractic: Recognized but Unproved." (15) Nearly
20 years later there appears to be little evidence to
support the value of spinal manipulation for
nonmusculoskeletal conditions. For this reason, I think it is currently
inappropriate to consider chiropractic as a broad-based
alternative to traditional medical care. However, for some
musculoskeletal conditions, chiropractic care does provide
some benefit to some patients. The challenge for
chiropractors is to demonstrate that they can achieve this
benefit at a cost that patients or health insurers are willing
to bear.
Paul G. Shekelle, M.D., Ph.D.
West Los Angeles Veterans Affairs Medical Center
Los Angeles, CA 90073
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
|
