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The effect of spinal manipulation on pain and prostaglandin levels in women with primary dysmenorrhea
Abstracts with cocaine abuse. The efficacy of auricular (ear) acupuncture in reducing cocaine/crack craving and consumption was examined via a single blind, placebo experiment. One hundred and fifty individuals seeking treatment for cocaine/crack abuse were randomly assigned to receive either experimental or placebo acupuncture treatments. Treatments were provided in an outpatient setting for a one-month period. Placebo treatments involved acupuncture at ear locations not used for drug treatment. Subjects provided urine specimens for drug content analysis after each acupuncture session. Urinalysis results over the one-month study period favoured the experimental group. Experimental subjects in treatment over 2 weeks had significantly lower cocaine metabolite levels relative to placebo subjects in treatment for a comparable period. Treatment retention with both groups was similar. Relative to pretreatment usage, a significant decrease in cocaine consumption was reported by both groups. Self-report outcomes did not indicate significant between-groups differences.
Washburn AM, Fullilove RE, Fullilove MT et al. Acupuncture heroin detoxification: a single-blind clinical trial Journal of Substance Abuse Treatment 1993; 10(4): 345-351. The increasing prevalence of HIV infection among injection drug users mandates the development of innovative treatments. While extensive clinical experience suggests that acupuncture detoxification is both safe and acceptable to those in withdrawal, little research has been conducted to assess its efficacy as a treatment modality. In this first controlled study of acupuncture heroin detoxification, 100 addicted persons were randomly assigned, in a single-blind design, to the standard auricular acupuncture treatment used for addiction or to a 'sham' treatment that used points that were geographically close to the standard points. Attrition was high for both groups, but subjects assigned to the standard treatment attended the acupuncture clinic more days and stayed in treatment longer than those assigned to the sham condition. Additionally, attendance varied inversely with selfreports of frequency of drug use, suggesting that those with lighter habits found the treatment modality more helpful. Limitations of the study are discussed. Clement-JonesV, McLoughlinL, LowryP, BesserG, Rees L, Wen L. Acupunctureand heroin addicts;changesin metenkephalin and beta-endorphinin blood and cerebrospinalfluid.Lancet 1979; 2: 380-382. Wen HL, Teo SW.Experiencein the treatmentof drug addictionby electro-acupuncture.ModernMedicinein Asia 1975; 11: 23-24. Han JS, Zhang RL. Suppressionof morphine abstinence syndromeby body electroacupunctureof differentfrequencies in rats. Drug & AlcoholDependence 1993; 31(2): 169-175. Ho WKK, HsiangLai Wen,Lam S, Ma L. The influenceof electro-acupunctureon naloxone-inducedmorphine withdrawalin mice:elevationof brain opiate-likeactivity. European Journal of Pharmacology1978;49: 197-199. ChoyYM, Tso WW, Fung KP, LeungKC, Tsang YF, Lee CY, Tsang D. Suppressionof narcotic withdrawalsand plasma ACTH by auricularelectroacupuncture.Biochemicaland BiophysicalResearchCommunications1978;82(1): 305-309.
189
OSTEOPATHY AND CHIROPRACTIC Osteopathy and chiropractic were originally developed as total systems of medicine. Practitioners believed that all (or nearly all) disease is caused by structural misalignments, with chiropractors focusing on the spine in particular. These beliefs were underpinned by idiosyncratic understandings of physiology and pathology. Modern practitioners tend to concentrate on the treatment of musculoskeletal conditions, back pain in particular, and tend to shy away from any all-embracing causal link between structure and disease. That said, practitioners are unhappy being thought of exclusively as 'back mechanics' and say that they can often provide a useful service for nonmusculoskeletal conditions. Dysmenorrhea (pain during menstruation) is a good example of a condition which is not normally thought of as musculoskeletal, but which osteopaths and chiropractors say they can often treat successfully. On reflection, it seems reasonable that manipulation of the bones and soft-tissue of the pelvis area might be of benefit for a condition which often involves cramping and muscle pain. But other conditions which practitioners treat seem less obviously related to the musculoskeletal system. These include hypertension, infantile colic, atelectasis (improper inflation of the lungs) and duodenal ulcer. Though research on the osteopathic and chiropractic treatment of such diseases remains in its infancy, there have been at least some encouraging results. How would we develop our understanding of (i) the role of osteopathy and chiropractic and (ii) the physiopathology of disease were these results to be confirmed? SELECTED REFERENCES
Kokjohn K, Schmid DM, Triano J J, Brennan PC. The effect of spinal manipulation on pain and prostaglandin levels in women with primary dysmenorrhea. Journal of Manipulative and Physiological Therapeutics 1992; 15(5): 279-285. Objective: The primary objectives of this study were to compare the effect of spinal manipulation vs sham manipulation on (a) circulating plasma levels of the prostaglandin F2a metabolite, 15-keto- 13,14-dihydroprostaglandin (KDPGF2a); (b) perceived abdominal and back pain; and (c) perceived menstrual distress in women with primary dysmenorrhea. Design: This randomized clinical pilot study investigated the outcome measures before and after either a spinal manipulation treatment (SMT) or a sham manipulation. Setting: All subjects were treated at the National College Chiropractic clinic, a private chiropractic clinic in the suburban Chicago area. Participants: Forty-five women with a history of primary dysmenorrhea were recruited from the local community. The volunteers ranged in age from 20-49 (mean age = 30.3 years), and were entered into the study between April 1990 and
190
Complementary Therapies in Medicine
January 1991. Twenty-four were randomly assigned to the spinal manipulation group and 21 were assigned to the sham group. Interventions: Subjects treated with spinal manipulation were placed in a side-lying position with the bottom leg straight and the top leg flexed at the knee and hip. They received a high-velocity, short lever, low-amplitude thrust to all clinically relevant vertebral levels within T10 and L5-S1 and the sacroiliac joints. In the sham manipulation, subjects were placed in a side-lying position with both hips and knees flexed. Their manipulation consisted of a similar thrust administered to the midline base of the sacrum. Outcome measures: Perceived abdominal and back pain were measured with a visual analog scale, and menstrual distress was measured with the Menstrual Distress Questionnaire. Both were administered 15 rain before and 60 rain after treatment. Blood samples were collected by venipuncture for the determination of plasma levels of KDPGF2a at the same times. The plasma was then assayed for KDPGF2a by radioimmunoassay. Results: Analysis of covariance and paired Student's t-tests were used for the statistical evaluation. Immediately after treatment, the perception of pain and the level of menstrual distress were significantly reduced by SMT. This reduction was associated with a significant reduction in plasma levels of KDGPF2a in the SMT group. A significant and similar reduction in plasma KDPGF2a also occurred in the sham group, indicating that a placebo effect was associated with a single sham intervention. Conclusions: This randomized pilot study suggests that SMT may be an effective and safe nonpharmacological alternative for relieving the pain and distress of primary dysmenorrhea. However, the large change in KDPGF2a observed in both treatment groups clearly indicates that further studies with more subjects, studied over a longer time frame, are needed to resolve the question of a placebo effect.
Morgan JP, Dickey JL, Hunt HH, Hudgins PM. A controlled trial of spinal manipulation in the management of hypertension. Journal of the American Osteopathic Association 1985; 85(5): 308-313. An 18-weekl controlled trial of the influence on blood pressure of a fixed protocol of manipulative treatment in hypertensive adults was made. Twenty-nine subjects were randomly assigned to two treatment groups. The patients in group I received weekly spinal manipulation of the occipitoatlantal joint, T1 through T5, and T l l through L1; those in group II received sham manipulation in the form of soft tissue massage of T6 through T10 and from L4 to the sacrum. Manipulative procedures were crossed over after the sixth week, and both types of treatment were stopped after the twelfth week. Results of the study failed to demonstrate that either of the manipulative treatments could reduce or control elevated systemic blood pressure in the study population. Yates RG, Lamping DL, Abram NL. Effects of chiropractic treatment on blood pressure and anxiety: a randomized controlled trial. Journal of Manipulative and Physiological Therapeutics 1988; 11(6): 484488. Klougart N, Nilsson N, Jacobsen J. Infantile colic treated by chiropractors: a prospective study of 316 cases. Journal of Manipulative and Physiological Therapeutics 1989; 12(4): 281-288. 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 and Physiological Therapeutics 1991; 14(2): 110-115. Sleszynski SL, Kelso AF. Comparison of thoracic manipulation with incentive spirometry in preventing postoperative atelectasis. Journal of the American Osteopathic Association 1993; 93(8): 834-838, 843-845. Pikalov AA, Kharin V~. Use of spinal manipulative therapy in the treatment of duodenal ulcer: a pilot study. Journal of Manipulative and Physiological Therapeutics 1994; 17(5): 310-313. Cleary C, Fox JR Menopausal symptoms: an osteopathic investigation. Complementary Therapies in Medicine 1994; 2(4): 181-186.
Washburn AM, Fullilove RE, Fullilove MT et al. Acupuncture heroin detoxification: a single-blind clinical trial Journal of Substance Abuse Treatment 1993; 10(4): 345-351. The increasing prevalence of HIV infection among injection drug users mandates the development of innovative treatments. While extensive clinical experience suggests that acupuncture detoxification is both safe and acceptable to those in withdrawal, little research has been conducted to assess its efficacy as a treatment modality. In this first controlled study of acupuncture heroin detoxification, 100 addicted persons were randomly assigned, in a single-blind design, to the standard auricular acupuncture treatment used for addiction or to a 'sham' treatment that used points that were geographically close to the standard points. Attrition was high for both groups, but subjects assigned to the standard treatment attended the acupuncture clinic more days and stayed in treatment longer than those assigned to the sham condition. Additionally, attendance varied inversely with selfreports of frequency of drug use, suggesting that those with lighter habits found the treatment modality more helpful. Limitations of the study are discussed. Clement-JonesV, McLoughlinL, LowryP, BesserG, Rees L, Wen L. Acupunctureand heroin addicts;changesin metenkephalin and beta-endorphinin blood and cerebrospinalfluid.Lancet 1979; 2: 380-382. Wen HL, Teo SW.Experiencein the treatmentof drug addictionby electro-acupuncture.ModernMedicinein Asia 1975; 11: 23-24. Han JS, Zhang RL. Suppressionof morphine abstinence syndromeby body electroacupunctureof differentfrequencies in rats. Drug & AlcoholDependence 1993; 31(2): 169-175. Ho WKK, HsiangLai Wen,Lam S, Ma L. The influenceof electro-acupunctureon naloxone-inducedmorphine withdrawalin mice:elevationof brain opiate-likeactivity. European Journal of Pharmacology1978;49: 197-199. ChoyYM, Tso WW, Fung KP, LeungKC, Tsang YF, Lee CY, Tsang D. Suppressionof narcotic withdrawalsand plasma ACTH by auricularelectroacupuncture.Biochemicaland BiophysicalResearchCommunications1978;82(1): 305-309.
189
OSTEOPATHY AND CHIROPRACTIC Osteopathy and chiropractic were originally developed as total systems of medicine. Practitioners believed that all (or nearly all) disease is caused by structural misalignments, with chiropractors focusing on the spine in particular. These beliefs were underpinned by idiosyncratic understandings of physiology and pathology. Modern practitioners tend to concentrate on the treatment of musculoskeletal conditions, back pain in particular, and tend to shy away from any all-embracing causal link between structure and disease. That said, practitioners are unhappy being thought of exclusively as 'back mechanics' and say that they can often provide a useful service for nonmusculoskeletal conditions. Dysmenorrhea (pain during menstruation) is a good example of a condition which is not normally thought of as musculoskeletal, but which osteopaths and chiropractors say they can often treat successfully. On reflection, it seems reasonable that manipulation of the bones and soft-tissue of the pelvis area might be of benefit for a condition which often involves cramping and muscle pain. But other conditions which practitioners treat seem less obviously related to the musculoskeletal system. These include hypertension, infantile colic, atelectasis (improper inflation of the lungs) and duodenal ulcer. Though research on the osteopathic and chiropractic treatment of such diseases remains in its infancy, there have been at least some encouraging results. How would we develop our understanding of (i) the role of osteopathy and chiropractic and (ii) the physiopathology of disease were these results to be confirmed? SELECTED REFERENCES
Kokjohn K, Schmid DM, Triano J J, Brennan PC. The effect of spinal manipulation on pain and prostaglandin levels in women with primary dysmenorrhea. Journal of Manipulative and Physiological Therapeutics 1992; 15(5): 279-285. Objective: The primary objectives of this study were to compare the effect of spinal manipulation vs sham manipulation on (a) circulating plasma levels of the prostaglandin F2a metabolite, 15-keto- 13,14-dihydroprostaglandin (KDPGF2a); (b) perceived abdominal and back pain; and (c) perceived menstrual distress in women with primary dysmenorrhea. Design: This randomized clinical pilot study investigated the outcome measures before and after either a spinal manipulation treatment (SMT) or a sham manipulation. Setting: All subjects were treated at the National College Chiropractic clinic, a private chiropractic clinic in the suburban Chicago area. Participants: Forty-five women with a history of primary dysmenorrhea were recruited from the local community. The volunteers ranged in age from 20-49 (mean age = 30.3 years), and were entered into the study between April 1990 and
190
Complementary Therapies in Medicine
January 1991. Twenty-four were randomly assigned to the spinal manipulation group and 21 were assigned to the sham group. Interventions: Subjects treated with spinal manipulation were placed in a side-lying position with the bottom leg straight and the top leg flexed at the knee and hip. They received a high-velocity, short lever, low-amplitude thrust to all clinically relevant vertebral levels within T10 and L5-S1 and the sacroiliac joints. In the sham manipulation, subjects were placed in a side-lying position with both hips and knees flexed. Their manipulation consisted of a similar thrust administered to the midline base of the sacrum. Outcome measures: Perceived abdominal and back pain were measured with a visual analog scale, and menstrual distress was measured with the Menstrual Distress Questionnaire. Both were administered 15 rain before and 60 rain after treatment. Blood samples were collected by venipuncture for the determination of plasma levels of KDPGF2a at the same times. The plasma was then assayed for KDPGF2a by radioimmunoassay. Results: Analysis of covariance and paired Student's t-tests were used for the statistical evaluation. Immediately after treatment, the perception of pain and the level of menstrual distress were significantly reduced by SMT. This reduction was associated with a significant reduction in plasma levels of KDGPF2a in the SMT group. A significant and similar reduction in plasma KDPGF2a also occurred in the sham group, indicating that a placebo effect was associated with a single sham intervention. Conclusions: This randomized pilot study suggests that SMT may be an effective and safe nonpharmacological alternative for relieving the pain and distress of primary dysmenorrhea. However, the large change in KDPGF2a observed in both treatment groups clearly indicates that further studies with more subjects, studied over a longer time frame, are needed to resolve the question of a placebo effect.
Morgan JP, Dickey JL, Hunt HH, Hudgins PM. A controlled trial of spinal manipulation in the management of hypertension. Journal of the American Osteopathic Association 1985; 85(5): 308-313. An 18-weekl controlled trial of the influence on blood pressure of a fixed protocol of manipulative treatment in hypertensive adults was made. Twenty-nine subjects were randomly assigned to two treatment groups. The patients in group I received weekly spinal manipulation of the occipitoatlantal joint, T1 through T5, and T l l through L1; those in group II received sham manipulation in the form of soft tissue massage of T6 through T10 and from L4 to the sacrum. Manipulative procedures were crossed over after the sixth week, and both types of treatment were stopped after the twelfth week. Results of the study failed to demonstrate that either of the manipulative treatments could reduce or control elevated systemic blood pressure in the study population. Yates RG, Lamping DL, Abram NL. Effects of chiropractic treatment on blood pressure and anxiety: a randomized controlled trial. Journal of Manipulative and Physiological Therapeutics 1988; 11(6): 484488. Klougart N, Nilsson N, Jacobsen J. Infantile colic treated by chiropractors: a prospective study of 316 cases. Journal of Manipulative and Physiological Therapeutics 1989; 12(4): 281-288. 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 and Physiological Therapeutics 1991; 14(2): 110-115. Sleszynski SL, Kelso AF. Comparison of thoracic manipulation with incentive spirometry in preventing postoperative atelectasis. Journal of the American Osteopathic Association 1993; 93(8): 834-838, 843-845. Pikalov AA, Kharin V~. Use of spinal manipulative therapy in the treatment of duodenal ulcer: a pilot study. Journal of Manipulative and Physiological Therapeutics 1994; 17(5): 310-313. Cleary C, Fox JR Menopausal symptoms: an osteopathic investigation. Complementary Therapies in Medicine 1994; 2(4): 181-186.