Invited Commentary: Self-Reported Nonmusculoskeletal Responses to Chiropractic Intervention: A Multination Survey by Leboeuf-Yde et al - Chiropractic Treatment for Visceral Disorders

Invited Commentary: Self-Reported Nonmusculoskeletal Responses to Chiropractic Intervention: A Multination Survey by Leboeuf-Yde et al
Received 7 January 2004
Brian Budgell, DC, MSca
Journal of Manipulative and Physiological Therapeutics
Volume 28, Issue 5, Pages 365-366 (June 2005)
Elsevier

Article Outline
Ô References

Ô Copyright

A large body of credible clinical evidence more than adequately vindicates the use of spinal manipulation in the treatment of a range of musculoskeletal disorders.1, 2, 3 Furthermore, even in the absence of a robust physiological explanation, health professionals of whatever ilk can generally accept that a prudently applied force might alter the behavior of a joint and thereby provide at least some relief of musculoskeletal symptoms.

On the other hand, the use of spinal manipulation in the management of patients with visceral disorders is a highly politicized and emotive issue. Although it appears that many chiropractic practitioners are comfortable with the concept of using spinal manipulation to address a subset of visceral disorders,4 there is also recognition that care of nonmusculoskeletal complaints may alienate other health professions and threaten the credibility of the chiropractic profession in the public eye.5, 6, 7, 8

With the growing influence of evidence-based care, it is expected that questions concerning the appropriate matching of clinical techniques and patient cohorts would be illuminated increasingly by reference to scientific evidence. Unfortunately, few original data articles address nonmusculoskeletal responses to chiropractic care.

A fairly recent and comprehensive survey of original data articles has reported papers describing the use of spinal manipulation in the treatment of only 39 visceral disorders.9 In 27 of 39 instances, the use of spinal manipulative therapy to treat a particular visceral disorder was supported by a single paper. Fifteen of these 27 papers referred to a single patient. Hence, for 15 of 39 disorders cited in the literature, the use of spinal manipulation was supported by experience with a single patient. The majority of articles were in support of only 6 complaints: 8 papers concerned visual deficits, 6 papers referred to chronic pelvic pain and dysmenorrhea, and 4 different papers focused on asthma, enuresis, and premenstrual syndrome. Particular authors or groups of authors dominated certain topics, suggesting that the numerical distribution of papers according to disease reflected the interests of the authors rather than the prevalence of the conditions or their importance in chiropractic practice.

Currently, very little primary data are available concerning clinical outcomes, and such studies that do exist are generally of a poor quality. At this point, it would be difficult to advocate based on evidence alone, anything beyond the experimental use of spinal manipulation in the treatment of perhaps 1 or 2 nonmusculoskeletal complaints.10, 11

The paper by Leboeuf-Yde et al in this issue of the JMPT (June 2005) draws attention to a serious and additional concern about the integrity of our body of knowledge concerning nonmusculoskeletal responses to spinal manipulation. Are clinical trials justifiable at this time, given our very limited epidemiological data?

Whereas chiropractic management of nonmusculoskeletal disorders may have been an important component of chiropractic practice in our past, it is a trivial portion of modern practice. It represents no more than a few percent of new patient presentations,12, 13, 14 without addressing whether the practitioner chooses to take on a given case and is able to achieve useful results. We have scarce information about which complaints patients actually seek care for and which complaints appear to respond in the real-world setting.

In the absence of epidemiological studies indicating what conditions chiropractors treat, regardless of reported outcomes, it is reasonable to question whether it is currently rational and economically justifiable to conduct clinical trials. The results of Leboeuf-Yde et al are not consistent with an earlier literature review,9 which would seem to have suggested a more likely role for chiropractic in the management of visual and gynecologic complaints, or even asthma. Instead, Leboeuf-Yde's analysis, based on a sample of almost 6000 patient questionnaires, suggests that digestive and general respiratory difficulties might provide more fertile ground for investigation. On this point, however, the authors take pains to point out that their study indicates associations between treatment and changes in symptoms. Notwithstanding the term Ïnonmusculoskeletal responses,Ó this study was not designed to determine, nor is there any implication of, cause and effect.

On this basis, certain past and ongoing high-profile investigations may provide clinical answers for which there were no real-world clinical questions. If, instead of investing limited research funds in politically attractive clinical trials, we had instead funded less emotive groundwork epidemiology, we might be further ahead. It is probably fair to describe the current approach to investigating chiropractic management of visceral disorders as Ïbackward.Ó This applies not just to clinical studies, but also to the neglect of basic physiological investigations.

Although it may seem expedient to fund research that proves chiropractic ÏworksÓ for this or that clinical entity, we need to outgrow our folk medicine mentality and start to ask how and why chiropractic works, and when it does. Would it harm chiropractic to make a few contributions to the common body of knowledge of all of the health sciences? In addition, would it harm chiropractic to ask honest questions about what we do not know, instead of trying to prove what we think we know? Is not the chiropractic management of patients with visceral disorders important enough to approach with honesty?

Congratulations to Leboeuf-Yde et al for a very unsexy paper, which provides a basis on which to propose future clinical studies with intelligence and integrity.

References
1. 1Anderson R, Meeker WC, Wirick BE, Mootz RD, Kirk DH, Adams A. A meta-analysis of clinical trials of spinal manipulation. J Manipulative Physiol Ther. 1992;15:181Ò194. MEDLINE

2. 2Koes BW, Assendelft WJ, van der Heijden GJ, Bouter LM. Spinal manipulation for low back pain. An updated systematic review of randomized clinical trials. Spine. 1996;21:2860Ò2871[discussion 2872-2873]. MEDLINE | CrossRef

3. 3Pengel HM, Maher CG, Refshauge KM. Systematic review of conservative interventions for subacute low back pain. Clin Rehabil. 2002;16:811Ò820. MEDLINE | CrossRef

4. 4Jamison JR, McEwen AP, Thomas SJ. Chiropractic adjustment in the management of visceral conditions: a critical appraisal. J Manipulative Physiol Ther. 1992;15:171Ò180. MEDLINE

5. 5Jamison J. Chiropractic referral: in search of criteria upon which medical practitioners agree to refer for chiropractic care. Chiropr Aust. 1995;25:13Ò18.

6. 6Willis E. Chiropractic in Australia. J Manipulative Physiol Ther. 1991;14:59Ò69. MEDLINE

7. 7Jamison J. Preventative chiropractic and the chiropractic management of visceral conditions: is the cost to chiropractic acceptance justified by the benefit to health care. Chiropr J Aust. 1991;21:95Ò101.

8. 8Coburn D. Legitimacy at the expense of narrowing scope of practice; chiropractic in Canada. J Manipulative Physiol Ther. 1991;14:14Ò21. Abstract | Full Text | Full-Text PDF (202 KB) | MEDLINE

9. 9Budgell BS. Spinal manipulative therapy and visceral disorders. Chiropr J Aust. 1999;29:123Ò128.

10. 10Proctor ML, Hing W, Johnson TC, Murphy PA. Spinal manipulation for primary and secondary dysmenorrhoea. The Cochrane Database of Systematic Reviews 2001, issue 4. Art no.: CD002119. DOI: 10.1002/14651858. CD002119. pub2.

11. 11Hondras MA, Linde K, Jones AP. Manual therapy for asthma. (Cochrane Review)In: The Cochrane Library, issue 4. Chichester, UK: John Wiley & Sons, Ltd; 2003;.

12. 12Ebrall P. A descriptive report of the case-mix within Australian chiropractic practice. Chiropr J Aust. 1992;23:92Ò97.

13. 13Hawk CL, Long CR, Boulanger KT. Prevalence of non-musculoskeletal complaints in chiropractic practice: report from a practice-based research program. J Manipulative Physiol Ther. 2001;24:157Ò169. MEDLINE | CrossRef

14. 14Hartvigsen J, Boding-Jensen O, Hviid H, Grunnet-Nilsson N. Danish chiropractic patients then and nowÛa comparison between 1962 and 1999. J Manipulative Physiol Ther. 2003;26:65Ò69. Abstract | Full Text | Full-Text PDF (107 KB) | MEDLINE | CrossRef

a School of Health Sciences, Faculty of Medicine, Kyoto University, Kyoto, Japan

Submit requests for reprints to: Brian Budgell, DC, School of Health Sciences, Faculty of Medicine, Kyoto University, Kyoto, Japan

PII: S0161-4754(05)00108-9

doi:10.1016/j.jmpt.2005.04.008

© 2005 National University of Health Sciences. Published by Elsevier Inc. All rights reserved.