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The evolution and importance of spinal and chiropractic research
Review
Journal articles Abstractstakenfrom publishedsources
section
55
Tavola T, Gala C, Conte G, Invernizzi G. Traditional Chinese acupuncture in tension-type headache:a controlled study.Pain 1992;48: 325-329.
+ 30patientswith tension-type headache wererandomly chosen to undergo a trial of traditional ChineseacuGENERAL punctureandshamacupuncture. 5 measures wereusedto assesssymptomseverityandtreatmentresponse: intensity, durationandfrequencyof headachepain episodes, Franklin D. Medical practitioners’ attitudesto comheadache index and analgesicintake, The 5 measures plementarymedicine. Comp Med Res 1992;6: 69wereassessed duringa4-weekbaselineperiod,after4 and 71. 8 weeksof treatment,and1,6, and12monthsthereafter. Beforethestartofthestudy,eachpatientwasadministered + A questionnaire wassentto all generalpractitioners theh4MFI. Split-plotANOVAs showedthat,compared andclinicalhospitalconsultants in theWestDorsetHealth to baseline,at 1monthaftertheendof treatmentandfor Districtto exploretheirattitudeto, andpracticeof, com- a 1Zmontb follow-up,the frequencyof headache epiplementarymedicine. The responses wereanalysedby sodes,analgesic consumption andtheheadache index(but group(GP/consultant), dateof registration,andsex.The notthedurationor intensityof headache episodes)signiresponseratewaslowerthanin similar surveysin other ficantlydecreased overtime; however,no differencebeareas(61%). Only 14%of the responders practisedany tweenacupuncture andplacebotreatmentwasfound.No form of complementary medicineand40%(53%of those singleMMFI scalepredictedtheresponseto treatment, registered in or after1970)wishedsomeform of training. but themeanMMFI profile of acupuncture non-respon85%of responders hadreferredpatientsto osteopaths at dersshowedthepresence of ‘ConversionV’. onetime oranother,53%tochiropractors, 56%to homoeopaths.65% to acupuncturists and 47%to hypnotherapists. The total numberof referralsin 1989to the disciplinesstudiedwasrelativelysmallapartfrom osteo- BIOFEEDBACK pathy(n= 525).87%of theresponders supported theright of lay personsto practicecomplementary medicine. Whitehead WE. BiofeedbacktreatmentofgastroinComplementary servicesarenotwidelyusedby doctors testinaldisorders.BiofeedSelf-Reg 1992;17:59-76 in WestDorset.Recommendations am madeto suggest (60refs). takingadvantage of thoseserviceswhereappropriate.
ACUPUNCTURE Shoukang L. Acupuncturetherapyin skin diseases; 1. Int J Clin Acup 1992;3: 67-72. + Prominenttherapeuticeffecthasbeenshownin the applicationof acupuncture therapyfor skindiseases.Especiallyfor cutaneous pruritus,it oftenhasinstanteffect. Besideantipruriticeffect,acupuncture canalsocheckthe exacerbation of disease,improvegeneralfitness,ameliorateandeliminatevariousdermatological damages.Acupuncturetherapy is not only effective for common ailments,suchas urticaria,eczema,dermatitis,herpes zosterandalopecia,butalsofairly efficaciousfor hard-tocureskindiseases,suchassclerdoma,vitiligo, psoriasis, andlupuserythematosus. In acupuncture therapy,which is but oneof themeasures in thecombinedtreatmentfor skin diseases,the principleof diagnosisandtreatment basedon syndromedifferentiationshouldneverbe overlookedin clinicalpractice.
+ Biofeedbackhashada greaterimpacton gastroenterologythanon any othermedicalspeciality.Biofeedback is the treatmentof choicefor many of the most commontypes of fecal incontinence,and preliminary studiessuggestthat it is likely to becomea preferred methodfor treatingpatientswith constipationrelatedto inability to relaxthestriatedpelvicfloor musclesduring defecation.This dysfunctionmayaccountfor upto 50% of patientswith chronicconstipation.Thermalbiofeedbackformspartof amulticomponent behavioraltreatment for irritablebowelsyndromethatis reportedto beeffective, andotherpromisingapplicationsof biofeedback for gastrointestinal disordersareunderinvestigation. CHIROPRACTIC Haldeman S. The evolution and importanceof spinal and chiropractic research. J Manip Physiol Tberap 1992; 15:31-35. + From its discoveryin 1895to its currentstatus,in whichtheWorldFederationof Chiropracticmeetingmay be considereda prestigiousinternationalscientificcon-
56 Cbmplementary Therapies in Medicine : Review section
ference,theevaluationof chiropracticcanbeviewedasa compressionof thephaseswhich medicalandscientific evolutionhavefollowedovera muchlongerperiod.Chiropractictheorystartedprimarilyasavitalisticphilosophy justifyingits treatmentwhilethemedicalscientificcommunity was rejectingvitalism Both chiropracticand medicalspinespecialistswentthrougha periodof speculativetheoryin the first half of this centurybasedupon eitherperceivedneurologicalor pathologicalobservations. This wasa periodof single-theorypreoccupation by chiropractors (thesubluxation)andmedicalspecialists (disc hemiation)which broughttheseprofessionsinto conflict. The pastdecadehasled to greaterscientific explorationbybothprofessions, withmorenationalscientific discussionsof the causesand treatmentof spinal problems.The nextdecade.however,appearslikely to requiregreateremphasison socialresearchinto clinical effectiveness of treatments, preventionof backpain,patient satisfactionandquality assurance.This evolution shouldbe consideredthenormalmaturationof a health careprofession. Hsieh C-YJ, Phillips RB, Adams AH, Pope MH.
KoesBW, BouterLM, vanMamerenH et al.A blinded randomized clinical trial of manual therapy and physiotherapy for chronic back and neck complaints: physical outcome measures. JManipPhysioTherap1992;
15:16-23(20refs). + In a blindedrandomizedclinical trial, we compared effectivenessof manualtherapy,physiotherapy(continued)treatmentby thegeneralpractitioner,andaplacebo therapy(detunedultrasoundand detunedshort wave diathermy)forpatients(n = 256)with chronicnonspecific back and neck complaints. The physical outcome measures(spinalmobility andphysicalfunctioning)are presented for 3.6 and12weeksfollow-up. Manualtherapyshoweda fasterandlargerimprovementin physical functioningcomparedto the otherthreetherapies.The changesin spinalmobility amongthefour studygroups appearto besmallandshowuoconsistentpattern. Waalen JK. Case study research designs: their place in chiropractic.J Can Chirop Assoc 1992;36: 29-32.
Casestudiesinvolveutilizingadistinctresearch approach. They areoftenconfusedwith casereports,caseseries, casesusedin rounds,andcaseswithoutcontrolgroupsor baselinemeasures.Thecasestudyapproach canprovide trial. J Manip Physio Tberap 1992; 15:4-9. a wayto investigatebroadchiropracticissues,policies,or + The revisedOswestrylow back pain questionnaire practicesin their real settings.Casestudyresearchde(ROLBPQ)and Roland-Morrisactivity scale(RMAS) signsare appropriatein both clinical and non clinical werecomparedin a randomizedcontrolledtrial of chiro- settings.Theyrequiregoodconceptualskills notelaborpracticmanipulation,strokingmassage, corsetandtrans- ateequipment;extensive‘thinking’timebutnotsophisticatedstatisticalanalysis;anda well-designed casestudy cutaneousmuscular stimulation (TMS). This trial protocolbutnocontrolgroupsor randomizedtrials. employedspecificinclusionand exclusioncriteria,includingnon specificlow backpain for a durationof 3 weeksto 6 monthsandagesbetween18and55. We had theopportunityto ask85patientsto answerthequestion- HERBAL MEDICINE naires. 63 patients,who completedthe initial andfoal evaluations, wereusedfor dataanalysis.BothROLBPQ Sheehan MP, Atherton DJ. A controlled trial of andRMAS showedgoodinternalconsistencyandalpha traditional Chinesemedicinal plants in widespread coefficientsrangingfrom 0.77to 0.93. Bothinstruments showeda significantdifferencebetweenthechiropractic non-exudativeatopic eczema. Br J Derrnatol 1992; manipulationandmassage groups@< 0.05).RMAS was 126: 179-184. ableto furthershowsignificantdifferencesbetweenthe chiropracticmanipulationandTMS groups,andbetween + Severeandwidespreadatopiceczemaoftenfails to respond,adequately to currentavailabletherapies.Folthecorsetandmassage groups,buttheROLBPQfailedto lowing the observation of substantialbenefitin patients do so. RMAS alsoshowedthatchiropracticmanipulation receiving oral treatment with daily decoctionsof tradihadabetterbutnonsignificantresultthancorset,possibly tional Chinese medicinal plants, weundertookaplacebodueto insufficientsamplesizeand/ordurationof treatcontrolled double-bIind trial of a specificprescription ment. Weconcludethatbothinstrumentsarereliablefor formulated for widespread non-exudative atopiceczema. measuringlow backpaindisability,andchiropractic man47 children were given active treatment and placeboin ipulationhad a superiorshort-termbenefitwhencomrandom order, each for 8 weeks, with an intervening paredto strokingmassageandTMS in subacute low back painpatients.In addition,it appears thatRMAS is prefer- 4-weekwash-outperiod. 37 childrentoleratedthetreatto activetreatablein a clinicaltrial situationfor subacute low backpain mentandcompletedthe study.Response ment was superior to response to placebo, and was becauseit is more sensitivethan ROLBPQto detect clinically valuable. There was no evidence of haematochanges. Functional outcomesof low backpain: comparison offour treatment groups in a randomized controlled
Journal articles Abstractstakenfrom publishedsources
section
55
Tavola T, Gala C, Conte G, Invernizzi G. Traditional Chinese acupuncture in tension-type headache:a controlled study.Pain 1992;48: 325-329.
+ 30patientswith tension-type headache wererandomly chosen to undergo a trial of traditional ChineseacuGENERAL punctureandshamacupuncture. 5 measures wereusedto assesssymptomseverityandtreatmentresponse: intensity, durationandfrequencyof headachepain episodes, Franklin D. Medical practitioners’ attitudesto comheadache index and analgesicintake, The 5 measures plementarymedicine. Comp Med Res 1992;6: 69wereassessed duringa4-weekbaselineperiod,after4 and 71. 8 weeksof treatment,and1,6, and12monthsthereafter. Beforethestartofthestudy,eachpatientwasadministered + A questionnaire wassentto all generalpractitioners theh4MFI. Split-plotANOVAs showedthat,compared andclinicalhospitalconsultants in theWestDorsetHealth to baseline,at 1monthaftertheendof treatmentandfor Districtto exploretheirattitudeto, andpracticeof, com- a 1Zmontb follow-up,the frequencyof headache epiplementarymedicine. The responses wereanalysedby sodes,analgesic consumption andtheheadache index(but group(GP/consultant), dateof registration,andsex.The notthedurationor intensityof headache episodes)signiresponseratewaslowerthanin similar surveysin other ficantlydecreased overtime; however,no differencebeareas(61%). Only 14%of the responders practisedany tweenacupuncture andplacebotreatmentwasfound.No form of complementary medicineand40%(53%of those singleMMFI scalepredictedtheresponseto treatment, registered in or after1970)wishedsomeform of training. but themeanMMFI profile of acupuncture non-respon85%of responders hadreferredpatientsto osteopaths at dersshowedthepresence of ‘ConversionV’. onetime oranother,53%tochiropractors, 56%to homoeopaths.65% to acupuncturists and 47%to hypnotherapists. The total numberof referralsin 1989to the disciplinesstudiedwasrelativelysmallapartfrom osteo- BIOFEEDBACK pathy(n= 525).87%of theresponders supported theright of lay personsto practicecomplementary medicine. Whitehead WE. BiofeedbacktreatmentofgastroinComplementary servicesarenotwidelyusedby doctors testinaldisorders.BiofeedSelf-Reg 1992;17:59-76 in WestDorset.Recommendations am madeto suggest (60refs). takingadvantage of thoseserviceswhereappropriate.
ACUPUNCTURE Shoukang L. Acupuncturetherapyin skin diseases; 1. Int J Clin Acup 1992;3: 67-72. + Prominenttherapeuticeffecthasbeenshownin the applicationof acupuncture therapyfor skindiseases.Especiallyfor cutaneous pruritus,it oftenhasinstanteffect. Besideantipruriticeffect,acupuncture canalsocheckthe exacerbation of disease,improvegeneralfitness,ameliorateandeliminatevariousdermatological damages.Acupuncturetherapy is not only effective for common ailments,suchas urticaria,eczema,dermatitis,herpes zosterandalopecia,butalsofairly efficaciousfor hard-tocureskindiseases,suchassclerdoma,vitiligo, psoriasis, andlupuserythematosus. In acupuncture therapy,which is but oneof themeasures in thecombinedtreatmentfor skin diseases,the principleof diagnosisandtreatment basedon syndromedifferentiationshouldneverbe overlookedin clinicalpractice.
+ Biofeedbackhashada greaterimpacton gastroenterologythanon any othermedicalspeciality.Biofeedback is the treatmentof choicefor many of the most commontypes of fecal incontinence,and preliminary studiessuggestthat it is likely to becomea preferred methodfor treatingpatientswith constipationrelatedto inability to relaxthestriatedpelvicfloor musclesduring defecation.This dysfunctionmayaccountfor upto 50% of patientswith chronicconstipation.Thermalbiofeedbackformspartof amulticomponent behavioraltreatment for irritablebowelsyndromethatis reportedto beeffective, andotherpromisingapplicationsof biofeedback for gastrointestinal disordersareunderinvestigation. CHIROPRACTIC Haldeman S. The evolution and importanceof spinal and chiropractic research. J Manip Physiol Tberap 1992; 15:31-35. + From its discoveryin 1895to its currentstatus,in whichtheWorldFederationof Chiropracticmeetingmay be considereda prestigiousinternationalscientificcon-
56 Cbmplementary Therapies in Medicine : Review section
ference,theevaluationof chiropracticcanbeviewedasa compressionof thephaseswhich medicalandscientific evolutionhavefollowedovera muchlongerperiod.Chiropractictheorystartedprimarilyasavitalisticphilosophy justifyingits treatmentwhilethemedicalscientificcommunity was rejectingvitalism Both chiropracticand medicalspinespecialistswentthrougha periodof speculativetheoryin the first half of this centurybasedupon eitherperceivedneurologicalor pathologicalobservations. This wasa periodof single-theorypreoccupation by chiropractors (thesubluxation)andmedicalspecialists (disc hemiation)which broughttheseprofessionsinto conflict. The pastdecadehasled to greaterscientific explorationbybothprofessions, withmorenationalscientific discussionsof the causesand treatmentof spinal problems.The nextdecade.however,appearslikely to requiregreateremphasison socialresearchinto clinical effectiveness of treatments, preventionof backpain,patient satisfactionandquality assurance.This evolution shouldbe consideredthenormalmaturationof a health careprofession. Hsieh C-YJ, Phillips RB, Adams AH, Pope MH.
KoesBW, BouterLM, vanMamerenH et al.A blinded randomized clinical trial of manual therapy and physiotherapy for chronic back and neck complaints: physical outcome measures. JManipPhysioTherap1992;
15:16-23(20refs). + In a blindedrandomizedclinical trial, we compared effectivenessof manualtherapy,physiotherapy(continued)treatmentby thegeneralpractitioner,andaplacebo therapy(detunedultrasoundand detunedshort wave diathermy)forpatients(n = 256)with chronicnonspecific back and neck complaints. The physical outcome measures(spinalmobility andphysicalfunctioning)are presented for 3.6 and12weeksfollow-up. Manualtherapyshoweda fasterandlargerimprovementin physical functioningcomparedto the otherthreetherapies.The changesin spinalmobility amongthefour studygroups appearto besmallandshowuoconsistentpattern. Waalen JK. Case study research designs: their place in chiropractic.J Can Chirop Assoc 1992;36: 29-32.
Casestudiesinvolveutilizingadistinctresearch approach. They areoftenconfusedwith casereports,caseseries, casesusedin rounds,andcaseswithoutcontrolgroupsor baselinemeasures.Thecasestudyapproach canprovide trial. J Manip Physio Tberap 1992; 15:4-9. a wayto investigatebroadchiropracticissues,policies,or + The revisedOswestrylow back pain questionnaire practicesin their real settings.Casestudyresearchde(ROLBPQ)and Roland-Morrisactivity scale(RMAS) signsare appropriatein both clinical and non clinical werecomparedin a randomizedcontrolledtrial of chiro- settings.Theyrequiregoodconceptualskills notelaborpracticmanipulation,strokingmassage, corsetandtrans- ateequipment;extensive‘thinking’timebutnotsophisticatedstatisticalanalysis;anda well-designed casestudy cutaneousmuscular stimulation (TMS). This trial protocolbutnocontrolgroupsor randomizedtrials. employedspecificinclusionand exclusioncriteria,includingnon specificlow backpain for a durationof 3 weeksto 6 monthsandagesbetween18and55. We had theopportunityto ask85patientsto answerthequestion- HERBAL MEDICINE naires. 63 patients,who completedthe initial andfoal evaluations, wereusedfor dataanalysis.BothROLBPQ Sheehan MP, Atherton DJ. A controlled trial of andRMAS showedgoodinternalconsistencyandalpha traditional Chinesemedicinal plants in widespread coefficientsrangingfrom 0.77to 0.93. Bothinstruments showeda significantdifferencebetweenthechiropractic non-exudativeatopic eczema. Br J Derrnatol 1992; manipulationandmassage groups@< 0.05).RMAS was 126: 179-184. ableto furthershowsignificantdifferencesbetweenthe chiropracticmanipulationandTMS groups,andbetween + Severeandwidespreadatopiceczemaoftenfails to respond,adequately to currentavailabletherapies.Folthecorsetandmassage groups,buttheROLBPQfailedto lowing the observation of substantialbenefitin patients do so. RMAS alsoshowedthatchiropracticmanipulation receiving oral treatment with daily decoctionsof tradihadabetterbutnonsignificantresultthancorset,possibly tional Chinese medicinal plants, weundertookaplacebodueto insufficientsamplesizeand/ordurationof treatcontrolled double-bIind trial of a specificprescription ment. Weconcludethatbothinstrumentsarereliablefor formulated for widespread non-exudative atopiceczema. measuringlow backpaindisability,andchiropractic man47 children were given active treatment and placeboin ipulationhad a superiorshort-termbenefitwhencomrandom order, each for 8 weeks, with an intervening paredto strokingmassageandTMS in subacute low back painpatients.In addition,it appears thatRMAS is prefer- 4-weekwash-outperiod. 37 childrentoleratedthetreatto activetreatablein a clinicaltrial situationfor subacute low backpain mentandcompletedthe study.Response ment was superior to response to placebo, and was becauseit is more sensitivethan ROLBPQto detect clinically valuable. There was no evidence of haematochanges. Functional outcomesof low backpain: comparison offour treatment groups in a randomized controlled