(1) McKelvey SE, Hayek R, Ali S. Asthma and chiropractic. A multi-centre approach. Proceedings 5th Biennial Congress, Auckland, NZ. World Federation of Chiropractic, May 17–22 1999: 166–7.
Score on Down’s and Black Checklist: 7
McKelvey et al,17
conducted a 6-week single blind cross study, reported as an abstract only, on 32 patients diagnosed with asthma and under medical management. Peak flow, spirometry, and salivary samples were recorded from each subject. Subjects were treated with an adjustive manoeuvre that was accompanied by an audible joint cavitation or an examination with little or no intervention. There was no statistically significant difference in group spirometry readings before and after treatment. Clinically important subjective improvements include reduced number of asthma attacks and reduced medication use reported by all subjects in the trial.
(2) Balon J, Aker PD, Crowther ER, Danielson C, Cox GP, O’Shaugnessy D, Walker C, Goldsmith CH, et al. A comparison of active and simulated chiropractic manipulation as adjunctive treatment for childhood asthma. N Engl J Med. 1998 Oct 8; 339 (15):1013–1020.
Score on Down’s and Black Checklist: 22
Balon et al5
conducted a randomized controlled trial on 91 children aged 7–16 who had continuing symptoms of asthma despite medical treatment. Subjects were randomly assigned to receive either active or simulated chiropractic manipulation for four months. Peak expiratory flow was measured from a change in base line. Of the 91 children, 80 had outcome data that could be evaluated. Small increases in both treatment groups were noted, with no statistically significant difference between groups with reference to a change in baseline measurements. Asthma symptoms and use of β-agonists decreased and quality of life increased in both groups with no statistically significant difference between groups. The authors concluded that children with mild to moderate asthma would not benefit from the inclusion of chiropractic spinal manipulation to usual medical care.
(3) Graham RL, Pistolese RA. An impairment rating analysis of asthmatic children under chiropractic care. J Vertebral Subluxation Research. 1997; 1 (4): 1–8.
Score on Down’s and Black Checklist: 7
Graham and Pistolese10
conducted a self-reported impairment study on 81 children aged 1–17 before and after a two month period of chiropractic care. Significant reduction (improvement on the modified Oswestry rating scale) was reported for 90.1% of subjects after 60 days of chiropractic treatment. Girls reported less improvement after care compared to boys, however significant decreases in impairment ratings were reported for both sexes.
(4) Bronfort G, Evans RL, Kubic P, Filkin P. Chronic pediatric asthma and chiropractic spinal manipulation: A prospective clinical series and randomized clinical pilot study. J Manipulative Physiol Ther. 2001; 21 (6): 369–377.
Score on Down’s and Black Checklist: 20
Bronfort et al8
conducted a prospective clinical case series and observer blinded randomized controlled trial on 36 patients aged 6–17 with mild and moderate persistent asthma. Patients were randomly assigned to receive either active spinal manipulation or sham spinal manipulation. At the conclusion of the 12-week intervention, lung function tests and patient-rated day and night-time symptoms showed little or no change. A 20% reduction in β-bronchodilator use was seen, quality of life scores increased by 10% to 28%, and asthma severity rating showed a 39% reduction. The changes in patient-rated severity remained unchanged at 12-month post treatment follow-up.
(5) Nielsen NH, Bronfort G, Bendix T, Madsen F, Weeke B. Chronic asthma and chiropractic spinal manipulation a randomized clinical trial. Clinical and Experimental Allergy. 1995; 25: 80–88.
Score on Down’s and Black Checklist: 20
Nielson et al17
conducted a randomized patient and observer blinded cross-over trial on 31 patients aged 18–44 suffering from chronic asthma. Patients were randomized to receive either active chiropractic spinal manipulative treatment or sham spinal manipulative treatment two times per week for four weeks. No clinically important or statistically significant differences were found between active and sham manipulations on forced expiratory volume, use of inhaled bronchodilators, patient-rated asthma severity, and non-specific bronchial reactivity. Non specific bronchial hyperreactivity improved by 36% and patient-rated asthma severity decreased by 34%.
(6) Leboeuf-Yde C, Pedersen EN, Bryner P, Cosman D, Hayek R, Meeker WC, et al. Self-reported nonmusculoskeletal responses to chiropractic intervention: A multination survey. J Manipulative Physiol Ther. 2005; 28: 294–302.
Score on Down’s and Black Checklist: 15
Leboeuf-Yde et al14
conducted a multination survey from 385 chiropractors on 5607 patients receiving spinal manipulation with or without additional therapy. Positive reactions in non-musculoskeletal symptoms were reported by 2–10% of patients. Of these patients, 27% noted positive reactions in non-musculoskeletal symptoms and also noted improved breathing. Variables identified that may influence the outcome included: patients informed that the reactions may occur (odds ratio [OR] 1.5); treatment directed to the upper cervical spine (OR 1.4); treatment directed to the lower thoracic spine (OR 1.3) and; female sex (OR 1.3).
(7) Gibbs AL. Chiropractic co-management of medically treated asthma. Clin Chiropractic. 2005; 8: 140–144.
Score on Down’s and Black Checklist: 9
conducted a case series on three patients with asthma treated with chiropractic manipulation to the upper thoracic spine two times per week for six weeks. All three cases resulted in increased objective changes in peak flow using a spirometer. As well, increased subjective data was noted in all patients from a recorded asthma diary.
(8) Green A. Chronic asthma and chiropractic spinal manipulation: a case study. Br J Chiropractic. 2000; 4 (2): 32–35.
Score on Down’s and Black Checklist: 5
conducted a case study on one patient aged 43 years old with asthma diagnosed at 38 years of age. The subject was treated with spinal manipulation to the lower cervical spine, upper thoracic spine, and costovertebral joints. Trigger-point therapy and post-isometric relaxation techniques were used to the hypertonic musculature. Initial spirometry measurements demonstrated a peak expiratory flow of 430 L/min. Over a 12-month treatment period, there was an increase in the peak flow from 430 to 550 L/min. As well, the subject noted a decrease in medication use.
None of the studies indicated any adverse effects or evidence of harm (other than exacerbations of asthma) to patients treated by chiropractors. Studies by Balon5
were the only ones to mention adverse effects/reactions as part of the article and to formally state that there were no adverse events. All other articles included in this study did not mention adverse effects. None of the included articles included a comprehensive list of possible adverse effects from the intervention.
Quality of Articles
depicts the quality scoring of each of the included articles. The overall level of disagreement of the evaluators, after independent rating, was 3.2% (7/216). These differences were rectified through discussion. The methodological quality of the articles was poor to good. The highest score on the Downs and Black3
scoring system was 22/27, achieved by the Balon et al5
study. The studies by Bronfort et al,8
Nielsen et al,17
and Leboeuf-Yde et al14
achieved moderate quality ratings of 20, 20, and 15 respectively. The other four studies9–11,16
all rated poorly (<11) in methodological quality.
Table 3 Article quality scoring using a scoring method adapted from Downs and Black3
The included studies yielded good to low quality ratings on the Down and Black3
scoring checklist. The poor and moderate ratings were primarily due to problems with external validity (questions 11 and 12, ), which addresses the representativeness of the findings of the study and determines whether they can be generalized to the population from which the study subjects were derived. Poor and moderate ratings were also due to a lack of randomization to groups, blinding of subjects or those measuring the outcomes.