What to Adjust for Bedwetting?

Chiropractors since D.D. Palmer¹ have insisted that adjustive intervention is a remedy for children who wet the bed. However, there is no substantive experimental evidence to support this contention. On the contrary, there seems to be growing reason to believe that adjusting has no effect in this pediatric disorder, although a good case can be made that an adequate trial has yet to be conducted. Leboeuf et al.,² and Reed et al.,³ who have provided the only large scale trials of adjusting for enuresis, were not able to produce permanent arrest of enuresis beyond what would be expected on the basis of maturation and spontaneous remission. Several caveats apply, in that interns have been employed as adjusters and might therefore provide less than skilled care, and because the duration of care in these studies has been rather brief, certainly of lesser duration that would be recommended for the well-established behavioral methods for bedwetters.⁴

Surely, there is room for further study, but there is also good reason to be cautious in making claims for enuresis. Unfortunately, many in the profession have not been critical in asserting the utility of manipulation for the relief of bedwetting. The several case reports of enuresis and related lower urinary tract dysfunctions^5-8 that are available have been overweighted,⁹ and a larger study² (n=171 patients) has been trivialized as a "small group".⁵ Fysh¹⁰ has suggested that "all children who are bedwetters [should be] evaluated for the possibility of spinal problems as underlying cause."

Why should all children who bedwet have their spines examined? Peet¹¹ offers the traditional wisdom that "improper nerve supply to the bladder can cause enuresis," but I am unaware of data to suggest that subluxation is an etiology for enuresis. Perhaps there is some unique spinal dysfunction that predisposes to enuresis, but Barge¹² indicates his inability to identify an enuresis-causing subluxation:

"-- there is really no way to tell if a child is simply slow in the development of the phrenic reflex, or if a subluxation is the direct cause of the problem. Chiropractic x-rays and examination can help pinpoint spinal problems, but the only real way to see if chiropractic care will help nocturnal enuresis is to actually try it."

Irrespective of whether one can justify radiating children's spines to determine the adjustment-worthiness of a health problem that responds readily to other, more conservative health care methods (i.e., behavioral intervention), one is still left to wonder what should be adjusted. Some DCs have adopted a strategy involving adjustment of whatever seems to be fixed, subluxated or otherwise adjustment-worthy.² Others have suggested "keys" to spinal manipulation in enuresis. For instance, Peet¹¹ recommends attention to the atlas-axis, the second and third sacral segments, and any apparently relevant level of the lumbar spine. Similarly, Carl S. Cleveland Sr., DC, long-time faculty member and administrator at the National College of Chiropractic in the first half of the chiropractic century, advised doctors to attend to the 11th and 12th thoracic, the first, second and fifth lumbar and the sacroiliac joints.¹⁴ Another osteopath, Robuck,⁸ also believed that the lower lumbar vertebrae and the sacroiliac joints were affected in bedwetters, and noted the significance that Andrew T. Still, father of osteopathy, had attributed to the proper function of the symphysis pubis in enuresis. Gemmell and Jacobson⁶ noted their attention to the lumbosacral junction in the patient under their care, while Fysh¹⁰ and Borregard¹⁵ mention the sacral segments in childhood dysfunction of the lower urinary tract. Parra and Bonci¹³ noted that Clarence Gonstead, DC, attributed enuresis to dysfunction of the second sacral segment, while Australian chiropractor McKellow⁷ thought that the ilium should be attended to.

So what's the answer? What should the DC adjust to help children who chronically wet the bed? Glib answers might include "the spine" or "somewhere between heads and tails." In truth, however, no one knows, nor are there strong clinical science reasons to believe that enuretics need be adjusted at all. Moreover, in light of the miserable results that our preliminary studies of this phenomenon have suggested, the more conservative (compared to ionizing radiation) and demonstrably more effective procedures of the behavioral psychologist^16-20 ought to be the preferred course, at least at this moment in time. Again, it's not impossible that future research, using skilled, experienced, licensed chiropractors rather than interns (if there are any DCs out there who are willing to commit their time for a controlled trial), in well planned trials conducted over longer periods of time (perhaps six months rather than a few weeks) and with outcome measures based upon thorough review of the literature⁴ ... it is not impossible that future research may suggest the relative benefit of adjustive care vs. other conservative interventions.

But what should the DC adjust at this point in time? Attitude! I know, we've been talking for nearly a century about how chiropractic is a "well developed science," but that's nonsense. But the old war stories will not carry us much further. Certainly, few if any scientists are swayed by such rhetoric, and third-party payers are not impressed. Moreover, if chiropractic's market share (10 percent of the population?) is any index, the traditional chiropractic rhetoric has not been very convincing to the general public. Write it off to abuse by organized medicine if you wish, but we've been strutting around without data for nearly a century, and we still have only 10 percent of the market. The best press we've ever received has come on the coat tails of research by non-chiropractors.²¹

If we won't even consider that a problem like childhood nocturnal enuresis may be more amenable to other approaches, even in the face of hard data, than we have no chance of maturing as a legitimate health science discipline. If the best we can do is wave our silent-killer subluxation flag in front of the television audience, then we shouldn't expect much from society. Perhaps we should wonder if we deserve more?

Then again, who cares? It just WORKS!

References

1. Palmer DD (Ed.): The Magnetic Cure 1896 (Jan); Number 15 (Palmer College Archives).

    

2. Leboeuf C, Brown P, Herman A, Leembruggen K, Walton D, Crisp TC. Chiropractic care of children with nocturnal enuresis: a prospective outcome study. Journal of Manipulative & Physiological Therapeutics 1991 (Feb); 14(2):110-5.

    

3. Reed WR, Beavers S, Reddy SK, Kern G. Chiropractic management of primary nocturnal enuretic children. Proceedings of the ICA National Conference on Chiropractic and Pediatrics, October 1993, Palm Springs, CA.

    

4. Butler RJ. Establishment of working definitions in nocturnal enuresis. Archives of Disease in Childhood 1991; 66:267-271.

    

5. Bachman T, Lantz C. Management of pediatric asthma and enuresis with probably traumatic etiology. Proceedings of the ICA National Conference on Chiropractic & Pediatrics 1991; pp. 14-22.

    

6. Gemmell HA, Jacobson BH. Chiropractic management of enuresis: time-series descriptive design. Journal of Manipulative & Physiological Therapeutics 1989 (Oct); 12(5):386-9.

    

7. McKellow BM. Enuresis and encopresis. New Zealand Medical Journal 1984, August, pp. 26-8.

    

8. Robuck SV. The interosseous lesion as a causative factor in enuresis and other bladder disturbances in children. Journal of the American Osteopathic Association 1936 (Oct); 36:73-4.

    

9. Howe CA. Chiropractic approaches to pregnancy and pediatric care. In Plaugher G, Lopes MA (Eds.): Textbook of Clinical Chiropractic: a Specific Biomechanical Approach. Baltimore: William and Wilkins, 1993.

    

10. Fysh PN. Chiropractic management of enuresis. Dynamic Chiropractic, July 30, 1993, pp. 12-3.

     

11. Peet J. Enuresis (bed wetting): restoring normal function. Baby Talk: The Baby Adjuster's Newsletter 1993 (April 15); 2(2):1-4.

     

12. Barge FH. Bed wetting (nocturnal enuresis) explained and chiropractic's approach to the problem. LaCrosse, Wisconsin, patient pamphlet, undated.

     

13. Parra AK, Bonci MA. Etiology, treatment and management of enuresis: a review. ACA Journal of Chiropractic 1989 (Dec); 26(12):25-8.

     

14. Wells BF. Enuresis and the spine. National College Journal of Chiropractic 1939 (Sept); 12(3):21-2.

     

15. Borregard PE. Neurogenic bladder and spina bifida occulta: a case report. Journal of Manipulative and Physiological Therapeutics 1987 (June); 10(3):122-3.

     

16. Doleys DM, Meredith RL. Urological disorders. Chapter 13 in Doleys DM. Meredith RL, Ciminero AR (Eds.): Behavioral medicine: assessment and treatment strategies. New York: Plenum Press, 1982.

     

17. Fordham KE, Meadow SR. Controlled trial of standard pad and bell alarm against mini alarm for nocturnal enuresis. Archives of Disease in Childhood 1989; 64:651-6.

     

18. Forsythe WI, Butler RJ. Fifty years of enuretic alarms. Archives of Disease in Childhood 1989; 64:879-85.

     

19. Kaplan SL, Breit M, Gauthier B, Busner J. A comparison of three nocturnal enuresis treatment methods. Journal of the American Academy of Child and Adolescent Psychiatry 1989 (March); 28(2):282-6.

     

20. Miller K, Goldberg S, Atkin B. Nocturnal enuresis: experience with long-term use of intranasally administered desmopressin. Journal of Pediatrics 1989 (April); 114(4, Pt. 2): 723-6.

     

21. Meade TW, Dyer S, Browne W, Townsend J, Fran AO. Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. British Medical Journal 1990 (June); 300:1431-7.