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Squeezes, No Wheezes? Spinal Manipulation and Asthma
Abstract & Commentary
By Russell H. Greenfield, MD, Editor
Synopsis: The conclusion of this systematic review, that spinal manipulation is of no benefit to patients with asthma, is acceptable when considered within its narrow framework. It is, however, irreparably hampered by the limited nature of the existing data, and an all too apparent bias.
Source: Ernst E. Spinal manipulation for asthma: A systematic review of randomised clinical trials. Respir Med 2009;103: 1791-1795.
The single U.K. author, well-known for having published numerous systematic reviews and meta-analyses on complementary and alternative therapies, turns to the subject of manual medicine, the stated goal being to critically evaluate and summarize available evidence (limited to randomized controlled trials, or RCTs) addressing the effectiveness of spinal manipulation for the treatment of asthma.
Data extraction and assessment of methodological quality (using the Jadad score) were each performed by two independent reviewers. Four electronic databases were searched (Amed, Embase, Medline, and Cinahl) without language restrictions, and bibliographies and departmental files were hand searched.
The literature searches yielded a total of 35 articles, only three of which met study criteria for inclusion. All three were deemed to be of high methodological quality. All were studies of chiropractic spinal manipulation (high-velocity, low-amplitude thrusts to dysfunctional segments) using sham-manipulation as the control intervention. Treatment periods ranged from 1 to 3 months, and lung function tests were performed in all studies to assess the impact of the interventions. Results were negative across all three studies, with no identifiable evidence that true manipulation was more effective than sham-manipulation in improving either subjective symptoms or lung function. The author concluded that spinal manipulation is not an effective treatment for asthma.
A significant number of practitioners of manual therapies believe that spinal manipulation can have positive clinical impact for people with asthma. This belief is girded by published case reports and uncontrolled trials reporting clinical efficacy. Positive outcomes have also been reported in small studies of osteopathic manipulation and massage therapy, though the studies are flawed methodologically. The few published RCTs that address spinal manipulation, however, all focusing specifically on chiropractic care, tell a different story as related through this systematic review, with consistently negative conclusions reported. It appears that chiropractic spinal manipulation is not effective in the setting of asthma, at least on the basis of three RCTs.
It remains possible, however, that other means of manual intervention may be appropriate and helpful in the setting of asthma. For example, many practitioners focus their efforts on the thoracic cage in an effort to enhance the bellows mechanism. This type of approach makes mechanistic sense, and anecdotal reports of its effectiveness make for a compelling hypothesis that should be tested. Relaxation therapy has been suggested to be of benefit for patients with asthma, which may partly explain the reported efficacy of massage therapy in this setting. Again, there is ample fodder to support sound research in this regard.
The author's conclusions are acceptable within narrow confines, especially due to the limited data available with which to perform the systematic review. What is problematic, however, is an apparent bias exhibited early in the paper and then repeated. The first sentence of the paper reads, "The notion that spinal manipulation is an effective treatment for asthma might seem far fetched to many experts ... ." Later, the author references a 12-year-old article he co-authored to support the following statement: "We know that journals of complementary and alternative medicine hardly ever publish negative results." A review of RCTs ideally leaves little room for partiality, but these statements produce doubt that weakens the paper beyond the limited research available to assess.
The requirement of repeated visits and the costs associated with isolated chiropractic spinal manipulation seem unwarranted in the setting of asthma. We await sound research to help delineate the place, if any, of other forms of manual intervention as a complement to the conventional care of asthma.