A Comparison of Active and Simulated Chiropractic Manipulation as Adjunctive Treatment for Childhood Asthma

A Comparison of Active and Simulated Chiropractic Manipulation as Adjunctive Treatment for Childhood Asthma

The New England Journal of Medicine
October 8, 1998; Vol 339; No 15; pp. 1013-1020

Jeffery Balon, MD; Peter D Aker, DC; Edward R Crowther DC; Clark Danielson, MPA; P Gerard Cox, MB; Denise O’Shaughnessy; Corinne Walker; Charles H Goldsmith, PhD; Eric Duku, MSc; Malcolm R Sears, MB: This study cites 45 references.

Supported by grants from the Consortium for Chiropractic Research, the Chiropractic Foundation for Spinal Research, the National Chiropractic Mutual Insurance Company (administered by the Foundation for Chiropractic Education and Research), and the Canadian Chiropractic Protective Association.

The study was approved by the research committee of St. Joseph’s Hospital in Hamilton, Ontario.

It is a randomized, controlled trial of chiropractic spinal manipulation for children with mild or moderate asthma.

Eighty children who had continuing symptoms of asthma despite usual medical therapy were randomly assigned to receive either active (n=38) or simulated (n=42) chiropractic manipulation for four months.

The children were 7 to 16 years of age, had asthma for more than one year, and had symptoms requiring the use of a bronchodilator at least three times weekly.

“All the chiropractors had at least five years of clinical experience, ran successful private practices, and had had apparent success, on the basis of anecdotal evidence, in treating patients with pediatric asthma.”

The subjects visited the chiropractor three times weekly for four weeks, twice weekly for four weeks, then weekly for eight weeks.

“All the chiropractors used the diversified technique in common use in Canada and the United States, which involves manual contact with spinal or pelvic joints followed by a low-amplitude, high-velocity directional push often associated with joint opening, creating a cavitation, or ‘pop.’”

The primary outcome measure was the change from base line in the peak expiratory flow (in liters per minute) measured in the morning, before the use of a bronchodilator, at two and four months.

Secondary outcome measures were the changes in airway responsiveness, symptoms of asthma, the need for inhaled b-agonists, the use of oral corticosteroids, quality of life, and overall satisfaction with treatment.

A BACKGROUND STORY

Mike was a 25 year old anesthesia technologist working at a local hospital. Mike suffered from chronic asthma. His primary approach to his asthma was standard medical interventions: drugs and inhalers; they were not working. On a recommendation, he tried chiropractic care; in a manner of months, his chronic asthma symptoms completely resolved. Mike is now a practicing chiropractor.

KEY POINTS FROM THIS ARTICLE:

1) “Chiropractic spinal manipulation has been reported to be of benefit in non-musculoskeletal conditions, including asthma.”

2) A theoretical basis for expecting benefit from chiropractic manipulation in persons with asthma includes:

• “Reflex irritation of somatic and autonomic nerves at the spinal and nerve-root levels is caused by vertebral subluxation, defined as a palpable restriction of a spinal joint as evidenced by the loss of joint play with surrounding muscle tightness, pain, and tenderness.”
• “Chiropractic theory states that the correction of subluxation by manipulation, with restoration of normal mechanical and nerve function, should improve airway function and aid in the resolution of asthma.”

3) Real chiropractic group:

• “Active chiropractic treatment consisted of manipulation (adjustments) with the subject prone, lying on one side, and supine, in conjunction with the administration of gentle soft-tissue therapy to the overlying tissues.”

4) Simulated chiropractic group:

• “The subject lay prone while soft-tissue massage and gentle palpation were applied to the spine, paraspinal muscles, and shoulders.”
• “A distraction maneuver was performed by turning the subject’s head from one side to the other while alternately palpating the ankles and feet.”
• “The subject was positioned on one side, a nondirectional push, or impulse, was applied to the gluteal region, and the procedure was repeated with the subject positioned on the other side.”
• “The subject was placed in the prone position, and a similar impulse was applied bilaterally to the scapulae.”
• “The subject was then placed supine, with the head rotated slightly to each side, and an impulse applied to the external occipital protuberance.”
• “Low-amplitude, low-velocity impulses were applied in all these nontherapeutic contacts, with adequate joint slack so that no joint opening or cavitation occurred.”
• “Hence, the comparison of treatments was between active spinal manipulation as routinely performed by chiropractors and hands-on procedures without adjustments or manipulation.”

5) Findings:

• “The increases in the quality of life were greater than the minimally important differences in both groups at two months and four months, but there were no significant differences between the groups.”
• “Symptoms of asthma and use of b-agonists decreased and the quality of life increased in both groups, with no significant differences between the groups.” [Very Important]
• Improvements in the peak expiratory flow occurred in both groups, from about (7 to 12 liters per minute).
• “Among the 80 subjects enrolled in this study of the efficacy of chiropractic manipulation as adjunct treatment for childhood asthma, there was a substantial improvement in symptoms and quality of life and a reduction in b-agonist use.” [Key Point: “substantial improvement”]
  • “However, these changes did not differ significantly between the active-treatment and simulated-treatment groups.”
  • “There were no clinically important or statistically significant differences in subjective or objective outcomes between the groups.”
  • “The ratings of symptom severity (on a visual-analogue scale) decreased by 34 percent for all the subjects, but there was no [objective] improvement in lung function.”
  • “Hence, the addition of chiropractic spinal manipulation to usual medical care for four months had no effect on the control of childhood asthma.” [Really? A problematic conclusion]
• “Changes in overall quality-of-life scores and scores for activity, symptoms, and emotional domains were measured by the Pediatric Asthma Quality of Life Questionnaire.”
  • “All changes are positive, representing improvement.” [Key Point]
• “Changes in overall quality-of-life scores and scores for activity, symptoms, and emotional domains were measured by the Pediatric Asthma Quality of Life Questionnaire.”
  • “All changes are positive, representing improvement.” [Key Point]

6) Conclusions By Authors:

• “Hence, the addition of chiropractic spinal manipulation to usual medical care for four months had no effect on the control of childhood asthma.” [Really? A problematic conclusion]
• “In children with mild or moderate asthma, the addition of chiropractic spinal manipulation to usual medical care provided no benefit.”

7) Conclusions With Discussion:

• “It is unlikely that the simulated treatment had benefit other than nonspecific effects, which were found in both groups.” [I disagree; I believe that this study shows that the simulated treatment had benefit in the simulated (sham) group].
• “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.” [I believe that this is such a study].

COMMENTS FROM DAN MURPHY

When this study was published in 1998, I was very critical of the conclusions of the authors, and I wrote a rebuttal. I remain very critical. I am reviewing my rebuttal points below because they are relevant to the findings of a new study published in 2024, which will be my next Article Review 2-2025:

A short-coming of this article is that there is no control group, and hence this question cannot be answered:

What changes would have been observed in a group that did not receive real chiropractic care nor simulated chiropractic care?

It should be recalled that all of the children in this study were chronic asthma sufferers; all were using bronchodilators and oral corticosteroids. Yet, these prior medically managed children achieved:

• Meaningful increases in the quality of life.
• Meaningful reductions in the incidence of and severity (by 34%) of asthma.
• Meaningful reductions in the use of use of bronchodilators and oral corticosteroids.
• Improvements in the peak expiratory flow.
• “A substantial improvement in symptoms and quality of life and a reduction in b-agonist use.”

Because these improvements were observed in both the real chiropractic group and the sham chiropractic group, the authors concluded that chiropractic care offered no benefit to children with chronic asthma.

My observation would be that the simulated chiropractic care used in this study was a very poor sham intervention. I would argue that the extensive mechanical-based interventions used in the sham group was not a well thought out sham. I would argue that mechanically based chiropractic care does not necessarily require high-velocity low amplitude joint cavitation to be of physiological value. We are all aware of the many low-force chiropractic techniques that do not use joint cavitation, yet they help many, many people.

I would have concluded that both high-velocity low amplitude joint cavitation and non-joint cavitation mechanical care is superior to standard medical care for children with chronic asthma.

Please see:
Article Review 2-2025:
Acute Effect of Vertebral Manipulation Technique on the Autonomic Nervous System