Let's Get off the Tracks

There is a prevailing theory that research is completely objective. Ideally, in the best case scenario that is so. Regretfully, to complicate things, research is always relative to who is doing the research; what the motives of the researchers are; who is funding the research, etc. As we chiropractors stand on the train tracks and see the train (medical self interests) approach, we appear to wonder, "Are we approaching the train, or is the train approaching us?" This bit of enlightenment would occur just before we were run over.

Recently on the front page of most major newspapers, an article about chiropractic's ineffectiveness was displayed. The October 8, 1998 Los Angeles Times had "Chiropractic Success on Back Pain Disputed in Study. Health: Treatment Is Called No More Effective Than Benign Neglect." As chiropractic treatment of musculoskeletal pain is questioned, also pointed out is research questioning the value of chiropractic treatment for asthma. The Times article quoted Dr. Paul Shekelle, a West Los Angeles internist, RAND Corporation analyst and co-author of several dispassionate studies of chiropractic. The internist hopes these two articles will "temper some of the irrational exuberance on the part of the chiropractic community and their patients for spinal manipulation."

It is obvious that the medical approach, or those who benefit from debunking chiropractic care, is to view chiropractic treatment of asthma based on the null hypothesis. That is, "How can we prove that chiropractic is of no help to the asthma patient?" Most chiropractors perform research based primarily on, "How can we prove that the patients with asthma that we are helping have benefited from chiropractic care? What methods improve outcomes, and how can we improve our chiropractic techniques so that they are more effective in caring for the asthma patient?" As you might imagine, these points of reference usually lead to different conclusions, often diametrically opposed.

At least now chiropractic is beginning to have some research to combat those who automatically assume that visceral conditions are not the terrain of the chiropractic profession. However, with our advancement in the research community we must also welcome all results of studies questioning chiropractic care and respond to them open-mindedly. Research related roadblocks or obstacles to chiropractic's advancement must be looked on as opportunities for growth.

There have been some studies that are being used to question the care of chiropractic for asthma:

Balon J, et al. A comparison of active and simulated chiropractic manipulations as adjunctive treatment for childhood asthma. New England Journal of Medicine, October 8, 1998;339(15):1013-20. The authors concluded that: "In children with mild or moderate asthma, the addition of chiropractic spinal manipulations to usual medical care provided no benefit." Ninety-one children were used in this study; 11 chiropractors were chosen to participate.

Nielsen NH, et al. Chronic asthma and chiropractic spinal manipulations: a randomized clinical trial. Clin Exp Allergy Jan 1995;25(1):80-8. In this study is was concluded that: "Using the crossover analysis, no clinically important statistically significant differences were found between the active and sham chiropractic interventions on any of the main or secondary outcome measures. Objective lung function did not change during the study, but over the course of the study, nonspecific bronchial hyperÈreactivity improved by 36% and patient-rated asthma severity decreased by 34% compared with the baseline values."

Jamison JR, et al. Chiropractic adjustment in the management of visceral conditions: a critical appraisal. Journal of Manipulative and Physiological Therapeutics Mar-Apr 1992;15(3):171-80. Their objective was to "establish whether Australian chiropractors regard spinal adjustment as an intervention option for patients presenting with visceral conditions and to ascertain the preferred level of adjustment for patients presenting with migraine, asthma, hypertension or dysmenorrhea." They concluded that "chiropractors continue to use spinal adjustment in the management of visceral conditions despite this intervention being regarded as an obstacle to the recommendation of public finding for chiropractic services in Australia."

Vallone S, Fallon JM. Treatment protocols for the chiropractic care of common pediatric conditions: otitis media and asthma. Journal of Clinical Chiropractic Pediatrics 1997;2(1):113-5. In this survey of 33 chiropractors enrolled in the first year of a three-year postgraduate course in chiropractic pediatrics, several interesting patterns emerged. "The first was that of the primary therapeutic modalities employed by the chiropractors, spinal adjusting was the most common modality used for both asthma and otitis media. The second was that a pattern emerged identifying certain areas of the spine to which adjustments were most frequently applied for each of these two conditions. The third was a significant number of non-spinal adjustment modalities were employed by the survey group and that these modalities are used with a high frequency."

Questioned in another study was whether those patients that sought alternative health care for asthma did so because they were unhappy with "orthodox" medicine. Donnelly WJ, et al. Are patients who use alternative medicine dissatisfied with orthodox medicine? Medical Journal of Australia May 13, 1985;142(10):539-41. Donnelly noted that "approximately 45% of asthmatic families and 47% of nonasthmatic families had consulted an alternative medicine practitioner at some time. The most popular form of alternative medicine was chiropractic ..." The findings of the study did not "support the view that patients who use alternative medicine are those who are disgruntled with orthodox medicine."

There have been some studies supportive of chiropractic therapies and/or manipulative treatment for asthma which were published in peer-reviewed journals:

Vange B. Contact between preschool children with chronic diseases and the authorized health services and forms of alternative therapy [in Danish]. Ugeskr Laeger Jul 10 1989;151(28):1815-8. In this study, a survey was performed and it was determined that one-third of the sick children had received alternative care as opposed to medical treatment. "The majority had consulted chiropractors. Seventy-three percent of the parents reported that the treatment had been of benefit to their child. Among parents of asthmatic children who had received chiropractic treatment, 92% considered this treatment beneficial. A tendency was observed towards less satisfaction with medical treatment, information and general guidance concerning the illness among families who sough alternative treatment."

Gillespie BR, Barnes JF. Diagnosis and treatment of TMJ, head and asthmatic symptoms in children. Cranio Oct 1990;8(4):342-9. The authors suggest that "the normal physiologic tension of the TMJ muscles, fascia, ligament and associated structures is critical for the health of children. Pathologic strain patterns in the soft tissues can be a primary cause of headaches, neck aches, throat infections, ear infections, sinus congestion and asthma." Treatment modalities are presented from both dental and physical therapy viewpoints to relieve and restore structural balance to the TMJ muscles, fascia, ligaments and associated structures which are believed to aid the prior mentioned visceral conditions.

Paul FA, Buser BR. Osteopathic manipulative treatment applications for the emergency department patient. Journal of the American Osteopathic Association Jul 1996(7):403-9. "The emergency department setting offers osteopathic physicians multiple opportunities to provide osteopathic manipulative treatment as either the primary therapy or as an adjunct to the intervention." The authors determined that asthma was among some "of the illnesses in which osteopathic manipulative therapy should be implemented as part of the management plan."

Bronfort G. Asthma and chiropractic. Europ Jrnl of Chiropractic Apr 1996;44(1):1-7. "The paper provides a brief overview of the current understanding of chronic asthma and its treatment in adults and children and discusses the potential role of chiropractic in the management of this condition. A summary of the results of a recently published randomized trial on the efficacy of chiropractic spinal manipulation in adult asthmatics is presented as well as information on two ongoing clinical studies of the effect of chiropractic co-management of chronic childhood asthma."

Gioia A. Chiropractic treatment of childhood asthma. Journal of the American Chiropractic Association Oct 1996;33(10):35-6.

Killinger L. Chiropractic care in the treatment of asthma. Palmer Journal of Research Sep 1995;2(3):74-7. This paper presents a case study of an 18-year-old subject with a two-year history of bronchial asthma. The patient received chiropractic care during a five-year period. The greatest improvement in health status was reported in the weeks immediately following the chiropractic adjustments. "This case is interesting in that trauma to the cervical vertebra coincided with the onset of asthma and the chiropractic care focused on those regions coincided with improvement in that condition."

Lines D. A wholistic approach to the treatment of bronchial asthma in chiropractic practice. Chiro Journal of Australia Mar 1993;23(1):4-8. "Three studies involving two children and a mature adult with established diagnoses of bronchial asthma are presented." This paper suggests a "broad-based management approach may lead to higher rates of response to chiropractic treatment of asthma, as well as providing greater long-term relief for its victims."

Nilsson N, Christiansen B. Prognostic factors in bronchial asthma in chiropractic practice. Jrnl of the Australian Chiro Assn Sep 1988;18(3):85-7. "A retrospective case record based study of asthmatic sufferers treated by chiropractic was carried out to determine the characteristics which correlate with a beneficial outcome following treatment of asthmatic sufferers by a chiropractor. There was evidence that some asthmatic sufferers obtain perceived (subjective) benefit following spinal adjustment (manipulations). Those most likely to report a benefit had less severe asthma, young ages of asthmatic onset and had an average of five treatments over an average of one month."

Lines D, et al. Effects of soft tissue technique and Chapman's neurolymphatic reflex stimulation on respiratory function. Jrnl of the Australian Chiro Assn Mar 1990;20(1):17-22. This study evaluated "thirty asymptomatic subjects treated on four separate occasions with soft tissue technique and Chapman's neurolymphatic reflex stimulation for the diaphragm. Spirometric assessment of respiratory function before and after each treatment was performed. Five of these subjects reported a past history of asthma or bronchitis." The results of the study indicated "that traditional chiropractic soft tissue and reflex techniques may have therapeutic value in the treatment of patients who exhibit below average respiratory function."

It is high time that chiropractic gets off the tracks of approaching trains. The chiropractic profession is building our own train, but we need more material and fuel to have it move at any speed. Instead of standing still as another train runs us over, we need to take charge of our situation. No matter what it takes, we need to do or fund the research that is needed to maintain and advance our position in health care. This is not for our self-aggrandizement or financial benefit, but because the conservative care we offer can give the greatest help without the side effects of drugs or surgery. We must, however, make careful diagnoses, refer for medical care when necessary, co-treat and use "negative" research findings concerning chiropractic to help us grow and improve. After all, the Los Angeles Times article gave me the impetus to sit down and write this.