Effect of Spinal Manipulation of Upper Cervical Vertebrae on Blood Pressure: Results of a Pilot Sham-Controlled Trial

Vertebral Subluxation and Systems Biology: An Integrative Review Exploring the Salutogenic Influence of Chiropractic Care on the Neuroendocrine-Immune System

In this paper we synthesize an expansive body of literature examining the multifaceted influence of chiropractic care on processes within and modulators of the neuroendocrine-immune (NEI) system, for the purpose of generating an inductive hypothesis regarding the potential impacts of chiropractic care on integrated physiology. Taking a broad, interdisciplinary, and integrative view of two decades of research-documented outcomes of chiropractic care, inclusive of reports ranging from systematic and meta-analysis and randomized and observational trials to case and cohort studies, this review encapsulates a rigorous analysis of research and suggests the appropriateness of a more integrative perspective on the impact of chiropractic care on systemic physiology. A novel perspective on the salutogenic, health-promoting effects of chiropractic adjustment is presented, focused on the improvement of physical indicators of well-being and adaptability such as blood pressure, heart rate variability, and sleep, potential benefits that may be facilitated through multiple neurologically mediated pathways. Our findings support the biological plausibility of complex benefits from chiropractic intervention that is not limited to simple neuromusculoskeletal outcomes and open new avenues for future research, specifically the exploration and mapping of the precise neural pathways and networks influenced by chiropractic adjustment.

Evidence on the use of alternative substances and therapies in hypertension

OBJECTIVE

Review of some of the best-known biological and non-biological complementary/alternative therapies/medicines (CAM) and their relationship with blood pressure (BP) and hypertension (HT).

SEARCH STRATEGY

Narrative review assessing a recent series of systematic reviews, meta-analyses, and clinical trials published in recent years, focusing on the effects of CAM on BP and HT.

SELECTION OF STUDIES

We searched EMBASE, MEDLINE, Cochrane Library and Google Scholar, obtaining a total of 4336 articles, finally limiting the search to 181 after applying filters.

SYNTHESIS OF RESULTS

Some studies on biological therapies show some usefulness in BP reduction with an adequate benefit-risk balance, although there is a scarcity of high-quality trials that support these results. Some mind-body therapies have shown hypothetical benefit; in contrast, others lack robust evidence.

CONCLUSIONS

Although some therapies present a reasonable risk-benefit ratio, they should in no case replace pharmacological treatment when indicated.

A systematic review of Tuina for cervical hypertension: A protocol for systematic review and meta-analysis

BACKGROUND

Cervical hypertension is a secondary form of hypertension with a high incidence rate. As the main etiology of cervical hypertension is related to cervical spondylosis, commonly used antihypertensive drugs have poor efficacy in the treatment of cervical spondylosis, and improving the symptoms of cervical spondylosis can effectively reduce blood pressure. Massage can effectively improve the symptoms of patients with cervical hypertension, but there has been no systematic review of massage treatment for cervical hypertension. This study aimed to evaluate the efficacy and safety of massage in patients with cervical hypertension.

METHODS

Before February 10, 2022, a systematic literature search was conducted using the following databases: Embase, SinoMed (previously called the Chinese Biomedical Database), China Science and Technology Journal Database for Chinese Technical Periodicals, Chinese National Knowledge Infrastructure, and Wanfang Data. Review Manager software (version 5.3) will be used for statistical analysis. Quality and risk assessments of the included studies were performed, and the outcome indicators of the trials were observed.

RESULTS

This meta-analysis further confirmed the beneficial effects of massage in patients with cervical hypertension.

CONCLUSION

This study investigated the efficacy and safety of massage therapy in patients with cervical hypertension, providing clinicians and patients with additional options for the treatment of this disease.

Chiropractic Management of a Symptomatic Patient Who Previously Had Surgery for Cauda Equina Syndrome

Objective

The purpose of this report is to describe the outcomes of chiropractic care for a patient after surgery for cauda equina syndrome.

Clinical Features

Following surgery for cauda equina syndrome caused by a herniated lumbar disc at L5/S1, a 28-year old woman presented for chiropractic care with an 18-month history of lower back pain. She had bilateral L5 and S1 dermatome pain and paraesthesia; saddle anesthesia; bilateral leg weakness in the L4, L5, and S1 myotomes; and urinary incontinence.

Intervention and Outcome

The patient received a variety of chiropractic manipulative techniques including cervical and thoracic spine manipulation, instrumented adjustments to the lumbar spine, and drop technique to the sacroiliac joints. Trigger point therapy was performed on the gluteus medius, quadratus lumborum, and piriformis muscles bilaterally. After 12 months, the patient reported a reduction in lower back and radicular leg pain, was able to reduce her use of opioid medications, and experienced improved lower limb function following chiropractic care.

Conclusion

The patient responded favorably to a course of chiropractic care for symptoms remaining after surgery for cauda equina syndrome.

Extrapolating Beyond the Data in a Systematic Review of Spinal Manipulation for Nonmusculoskeletal Disorders: A Fall From the Summit

OBJECTIVE

The purpose of this article is to discuss a literature review-a recent systematic review of nonmusculoskeletal disorders-that demonstrates the potential for faulty conclusions and misguided policy implications, and to offer an alternate interpretation of the data using present models and criteria.

METHODS

We participated in a chiropractic meeting (Global Summit) that aimed to perform a systematic review of the literature on the efficacy and effectiveness of mobilization or spinal manipulative therapy (SMT) for the primary, secondary, and tertiary prevention and treatment of nonmusculoskeletal disorders. After considering an early draft of the resulting manuscript, we identified points of concern and therefore declined authorship. The present article was developed to describe those concerns about the review and its conclusions.

RESULTS

Three main concerns were identified: the inherent limitations of a systematic review of 6 articles on the topic of SMT for nonmusculoskeletal disorders, the lack of biological plausibility of collapsing 5 different disorders into a single category, and considerations for best practices when using evidence in policy-making. We propose that the following conclusion is more consistent with a review of the 6 articles. The small cadre of high- or moderate-quality randomized controlled trials reviewed in this study found either no or equivocal effects from SMT as a stand-alone treatment for infantile colic, childhood asthma, hypertension, primary dysmenorrhea, or migraine, and found no or low-quality evidence available to support other nonmusculoskeletal conditions. Therefore, further research is needed to determine if SMT may have an effect in these and other nonmusculoskeletal conditions. Until the results of such research are available, the benefits of SMT for specific or general nonmusculoskeletal disorders should not be promoted as having strong supportive evidence. Further, a lack of evidence cannot be interpreted as counterevidence, nor used as evidence of falsification or verification.

CONCLUSION

Based on the available evidence, some statements generated from the Summit were extrapolated beyond the data, have the potential to misrepresent the literature, and should be used with caution. Given that none of the trials included in the literature review were definitively negative, the current evidence suggests that more research on nonmusculoskeletal conditions is warranted before any definitive conclusions can be made. Governments, insurers, payers, regulators, educators, and clinicians should avoid using systematic reviews in decisions where the research is insufficient to determine the clinical appropriateness of specific care.

The global summit on the efficacy and effectiveness of spinal manipulative therapy for the prevention and treatment of non-musculoskeletal disorders: a systematic review of the literature

Background

A small proportion of chiropractors, osteopaths, and other manual medicine providers use spinal manipulative therapy (SMT) to manage non-musculoskeletal disorders. However, the efficacy and effectiveness of these interventions to prevent or treat non-musculoskeletal disorders remain controversial.

Objectives

We convened a Global Summit of international scientists to conduct a systematic review of the literature to determine the efficacy and effectiveness of SMT for the primary, secondary and tertiary prevention of non-musculoskeletal disorders.

Global summit

The Global Summit took place on September 14–15, 2019 in Toronto, Canada. It was attended by 50 researchers from 8 countries and 28 observers from 18 chiropractic organizations. At the summit, participants critically appraised the literature and synthesized the evidence.

Systematic review of the literature

We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, the Cumulative Index to Nursing and Allied Health, and the Index to Chiropractic Literature from inception to May 15, 2019 using subject headings specific to each database and free text words relevant to manipulation/manual therapy, effectiveness, prevention, treatment, and non-musculoskeletal disorders. Eligible for review were randomized controlled trials published in English. The methodological quality of eligible studies was assessed independently by reviewers using the Scottish Intercollegiate Guidelines Network (SIGN) criteria for randomized controlled trials. We synthesized the evidence from articles with high or acceptable methodological quality according to the Synthesis without Meta-Analysis (SWiM) Guideline. The final risk of bias and evidence tables were reviewed by researchers who attended the Global Summit and 75% (38/50) had to approve the content to reach consensus.

Results

We retrieved 4997 citations, removed 1123 duplicates and screened 3874 citations. Of those, the eligibility of 32 articles was evaluated at the Global Summit and 16 articles were included in our systematic review. Our synthesis included six randomized controlled trials with acceptable or high methodological quality (reported in seven articles). These trials investigated the efficacy or effectiveness of SMT for the management of infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine. None of the trials evaluated the effectiveness of SMT in preventing the occurrence of non-musculoskeletal disorders. Consensus was reached on the content of all risk of bias and evidence tables. All randomized controlled trials with high or acceptable quality found that SMT was not superior to sham interventions for the treatment of these non-musculoskeletal disorders. Six of 50 participants (12%) in the Global Summit did not approve the final report.

Conclusion

Our systematic review included six randomized clinical trials (534 participants) of acceptable or high quality investigating the efficacy or effectiveness of SMT for the treatment of non-musculoskeletal disorders. We found no evidence of an effect of SMT for the management of non-musculoskeletal disorders including infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine. This finding challenges the validity of the theory that treating spinal dysfunctions with SMT has a physiological effect on organs and their function. Governments, payers, regulators, educators, and clinicians should consider this evidence when developing policies about the use and reimbursement of SMT for non-musculoskeletal disorders.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12998-021-00362-9.

Chiropractic care for hypertension: Review of the literature and study of biological and genetic bases

Background and aim:

Hypertension is a multifactorial condition that is among the leading causes of mortality worldwide. Regulation of blood pressure greatly depends upon the activity of the autonomic nervous system. Alterations in the autonomic nervous system can lead to hypertension. In addition to nervous system control and individual physiologic state, various genes can directly influence autonomic responses. The complexity of blood pressure control is reflected in the 20-30% of individuals resistant to traditional pharmacological treatment, this indicates the need for alternative interventions. This article provides an integrative review and discussion of the key neurophysiologic and genetic factors that contribute to blood pressure regulation, the autonomic nervous system (ANS) and manual therapy literature, and the manual therapy and blood pressure literature.

Methods:

To assess the effects of chiropractic on the management of hypertension we searched articles published from 1980 to 2019 in PubMed, the Index to Chiropractic Literature and CINAHL, using the keywords: chiropractic, spinal manipulation, hypertension, and blood pressure.

Results:

We found 38 original studies that analyzed the effect of chiropractic therapy on hypertension. Of these studies, 10 were case reports and the statistical significance of the effects of chiropractic on blood pressure was not evaluated on these articles, so we focused on the remaining 28 articles.

Conclusions:

The results of the review relative to chiropractic care were promising, but often contradictory, suggesting more research should be done. In consideration of the complexity of ANS blood pressure control, an evaluation of patient presenting physiologic and genetic characteristics is recommended and could provide valuable insight relative to the likelihood of patient blood pressure related responsiveness to care (www.actabiomedica.it)

A systematic review and meta-analysis on effect of spinal mobilization and manipulation on cardiovascular responses

Background: Spinal pain or misalignment is a very common disorder affecting a significant number of populations resulting in substantial disability and economic burden. Various manual therapeutic techniques such as spinal manipulations and mobilizations can be used to treat and manage pain and movement dysfunctions such as spinal mal-alignments and associated complications. These manual therapeutic techniques can affect the cardiovascular parameters.

Objective: The objective of this systematic review and meta-analysis is to assess the effect of spinal manipulation and mobilization on cardiovascular parameters.

Methods: We conducted a systematic review and meta-analysis to assess the effects of spinal mobilization and manipulation on cardiovascular responses. Mean changes in Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP) and Heart Rate (HR) were primary outcome measures. RevMan 5.3 software was used for the meta-analyses. Quality of the included studies was assessed by PEDro Rating scale. Risk of bias was assessed by Cochrane collaboration tool of risk of bias.

Results: Results of meta-analysis showed that there was statistically significant decrease in SBP ([Formula: see text], 95% [Formula: see text], 0.08; [Formula: see text]) with moderate heterogeneity ([Formula: see text], [Formula: see text]) in experimental group as compared to control group. There was statistically non-significant decrease in DBP ([Formula: see text], 95% [Formula: see text], 0.69; [Formula: see text]) with high heterogeneity ([Formula: see text], [Formula: see text]), Change HR was statistically non-significant ([Formula: see text], 95% [Formula: see text], 3.11; [Formula: see text]) with moderate heterogeneity ([Formula: see text], [Formula: see text]). Exclusion of short duration studies in sensitivity analysis revealed a statistically significant change in DBP ([Formula: see text], 95% [Formula: see text], [Formula: see text]; [Formula: see text]). However, the result was statistically non-significant for HR after sensitivity analysis.

Conclusion: Spinal manipulations and mobilizations may result in significant decrease of systolic as well as diastolic Blood Pressure.

Nondrug therapies for hypertensive patients complicated with cervical spondylosis: A systematic review and meta-analysis

PURPOSE

The aim of this study was to systematically evaluate the efficacy and safety of nondrug therapies for hypertensive patients complicated with cervical spondylosis.

METHODS

Randomized controlled trials (RCTs) concerned with nondrug therapies for hypertensive patients complicated with cervical spondylosis were identified by searching 5 English and Chinese databases. Study selection, data extraction, and risk of bias assessment were conducted independently by 2 authors. RevMan 5.3 software was used for meta-analysis with effect estimate presented as relative risk (RR) and mean difference (MD) with a 95% confidence interval (CI).

RESULTS

A total of 13 studies involving 929 patients were included. The majority of the included trials were assessed to be of high clinical heterogeneity and high risk of bias. The results of meta-analysis showed that there was a significant improvement in the effectiveness rate of cervical vertebra symptoms (RR = 1.67, 95% CI [1.33, 2.10], P < .0001), effectiveness rate of blood pressure lowering (RR = 1.35, 95% CI [1.06, 1.71], P = .02), systolic blood pressure reduction (MD = -11.05, 95% CI [-14.12, -7.98] mmHg, P < .0001), and diastolic blood pressure reduction (MD = -6.96, 95% CI [-8.89, -5.04] mmHg, P < .00001). Nondrug therapies had no significant difference compared with drugs in the effectiveness rate of overall improvement (RR = 1.3, 95% CI [0.93, 1.82], P = .12). There were no serious adverse effects related to nondrug therapies in the included trials.

CONCLUSION

The results show sound advantages of nondrug therapies over conventional medicine or sham procedure in efficacy. However, the evidence remains weak because of the high clinical heterogeneity and high risk of the included trials. Therefore, further thorough investigation, large-scale, proper-designed, randomized trials of nondrug therapies for hypertension complicated with cervical spondylosis are warranted.

PROSPERO REGISTRATION NUMBER

CRD2019123175.

Neurophysiological Effects of High Velocity and Low Amplitude Spinal Manipulation in Symptomatic and Asymptomatic Humans: A Systematic Literature Review

STUDY DESIGN

Systematic review.

OBJECTIVE

To summarize the evidence of neurophysiological effects of spinal manipulative therapy (SMT) with a high velocity low amplitude thrust (HVLA-SMT) in asymptomatic and symptomatic humans.

SUMMARY OF BACKGROUND DATA

HVLA-SMT is effective in reducing back pain, but its mode of action is not fully understood.

METHODS

A systematic literature search (until July 2018) was conducted by a professional librarian in seven databases (Medline (OvidSP), Premedline (PubMed), EMBASE, Cochrane, CINAHL, PEDro, and Scopus). Two authors selected the studies according to the a priori described criteria and scored study quality. Only controlled studies of at least moderate quality were included. Effects of HVLA-SMT on a particular outcome measure were defined as more than one study showing a significantly greater effect of HVLA-SMT compared with the control intervention.

RESULTS

From the 18 studies included (932 participants in total), there was evidence only for an association between HVLA-SMT and changes in the autonomic nervous system, reflected in changes in heart rate variability and skin conductance. Most studies focused on healthy volunteers and none related neurophysiologic changes to pain reduction.

CONCLUSION

This systematic review points to HVLA-SMT affecting the autonomic nervous system. The effects seem to depend on the spinal level of HVLA-SMT application and might differ between healthy volunteers and pain patients. There is a need for high-quality studies that include patients, well characterized for pain duration and outcome measure baseline values, and address the relation between changes in neurophysiology and pain.

LEVEL OF EVIDENCE

2.

Safety Events and Privilege Utilization Rates in Advanced Practice Physical Therapy Compared to Traditional Primary Care: An Observational Study

Introduction

The general practitioner shortage in the United States coupled with a growing number of Americans living with disability has fueled speculation of non-physician providers assuming a greater role in musculoskeletal healthcare. Previous physician shortages have been similarly addressed, and expanding physical therapy (PT) scope of practice may best serve to fill this need. Resistance to expanding PT practice focuses on patient safety as PTs assume the roles traditionally performed by primary care providers. While studies have shown advanced practice PT to be safe, none have compared safety events in advanced practice PT compared to primary care to determine if there are increased patient risks. Therefore, the purpose of our study is to examine the rate of safety events and utilization of services in an advanced practice PT clinic compared to a primary care clinic. A secondary aim of our study was to report safety events associated with spinal manipulation and dry needling procedures.

Materials and Methods

Productivity and safety data were retrospectively collected from Malcolm Grow Medical Center from 2015 to 2017 for the Family Health Clinic (FHC) and an advanced practice Physical Therapy Clinic (PTC). Chi-square tests for independence, risk ratios (RR) and 95% confidence intervals (95%) were used to compare the relationship between the frequency of (1) patient encounters and clinical procedures and (2) clinical procedures and safety events.

Results

Seventy-five percent (12/16) of safety events reported in the PTC were defined as near misses compared to 50% (28/56) within the FHC (RR 1.5; 95% CIs: 1.0 to 2.2). Safety events were more likely to reach patients in the FHC compared to the PTC (RR 1.9; 95% CIs: 0.8 to 4.7). Safety events associated with minor harm to patients was n = 4 and n = 3 in the FHC and PTC respectively. No sentinel events, intentional harm events, nor actual events with more than minor harm were reported in either clinic. Significant relationships indicated that prescriptions, laboratory studies, imaging studies and referrals, were all more likely to be ordered in the FHC than the PTC (p < 0.01). The PTC ordered one diagnostic imaging study for every 37 encounters compared to one in every 5 encounters in the FHC. The PTC similarly referred one patient to another healthcare provider for every 52 encounters, fewer than the one per every 3 encounters in the FHC. There was a significant relationship between encounters and diagnoses, indicating a higher number of diagnoses per encounter in the FHC, though the difference of 0.31 diagnoses per encounter may not be clinically meaningful (p < 0.01). A total of 1,818 thrust manipulations and 2,910 dry needling procedures were completed without any reported safety events.

Conclusion

These results suggest advanced practice PT has a similar safety profile to primary care. The authority to order musculoskeletal imaging and refer to other clinicians were among the most commonly utilized privileges and may be of primary importance when establishing an advanced practice PT clinic. These results support research showing advanced practice PT may lead to reductions in specialty referrals, diagnostic imaging, and pharmaceutical interventions.

The profile of chiropractors managing patients with low back-related leg pain: analyses of 1907 chiropractors from the ACORN practice-based research network

Background

Approximately 60% of people with low back pain also have associated leg pain symptoms. Guidelines for low back pain recommend non-pharmacological approaches, including spinal manipulation - a therapy provided by chiropractors. However, limited empirical data has examined the characteristics of chiropractors managing patients with low back-related leg pain (LBRLP). Our objective is to describe the prevalence, profile and practice characteristics of Australian chiropractors who often treat LBRLP, compared to those who do not often treat LBRLP.

Methods

This is a cross-sectional analysis of a nationally representative sample from the Australian Chiropractic Research Network (ACORN). This study investigated the demographic and practice characteristics as well as clinical management of chiropractors who ‘often’ treated patients with LBRLP compared to those who treated LBRLP ‘never/rarely/sometimes’. Multiple logistic regression models identified independent factors associated with chiropractors who ‘often’ treated patients with LBRLP.

Results

A total of 1907 chiropractors reported treating patients experiencing LBRLP, with 80.9% of them ‘often’ treating LBRLP. Chiropractors who ‘often’ treated LBRLP were more likely to manage patients with multi-site pain including axial low back pain (OR = 21.1), referred/radicular neck pain (OR = 10.8) and referred/radicular thoracic pain (OR = 3.1). While no specific management strategies were identified, chiropractors who ‘often’ treated LBRLP were more likely to discuss medication (OR = 1.8), manage migraine (OR = 1.7) and degenerative spine conditions (OR = 1.5), and treat women during pregnancy (OR = 1.6) and people with work-related injuries (OR = 1.5), compared to those not treating LBRLP frequently.

Conclusions

Australian chiropractors frequently manage LBRLP, although the nature of specific management approaches for this condition remains unclear. Further research on the management of LBRLP can better inform policy makers and educators interested in upskilling chiropractors to deliver safe and effective treatment of LBRLP.

Effect of chiropractic treatment on primary or early secondary prevention: a systematic review with a pedagogic approach

Introduction

The chiropractic vitalistic approach to the concept of 'subluxation' as a cause of disease lacks both biological plausibility and possibly proof of validity. Nonetheless, some chiropractors purport to prevent disease in general through the use of chiropractic care. Evidence of its effect is needed to be allowed to continue this practice. The objective of this systematic review was therefore to investigate if there is any evidence that spinal manipulations/chiropractic care can be used in primary prevention (PP) and/or early secondary prevention in diseases other than musculoskeletal conditions.

Method

We searched PubMed, Embase, Index to Chiropractic Literature, and some specialized chiropractic journals, from inception to October 2017, using terms including: "chiropractic", "subluxation", "wellness", "prevention", "spinal manipulation", "mortality". Included were English language articles that indicated that they studied the clinical preventive effect of or benefit from manipulative therapy/chiropractic treatment in relation to PP and/or early treatment of physical diseases/morbidity in general, other than musculoskeletal disorders. Also, population studies were eligible. Checklists were designed in relation to the description of the reviewed articles and some basic quality criteria. Outcomes of studies were related to their methodological quality, disregarding results from those unable to answer the research questions on effect of treatment.

Results

Of the 13.099 titles scrutinized, 13 articles were included (eight clinical studies and five population studies). These studies dealt with various disorders of public health importance such as diastolic blood pressure, blood test immunological markers, and mortality. Only two clinical studies could be used for data synthesis. None showed any effect of spinal manipulation/chiropractic treatment.

Conclusion

We found no evidence in the literature of an effect of chiropractic treatment in the scope of PP or early secondary prevention for disease in general. Chiropractors have to assume their role as evidence-based clinicians and the leaders of the profession must accept that it is harmful to the profession to imply a public health importance in relation to the prevention of such diseases through manipulative therapy/chiropractic treatment.

Atlantoaxial Misalignment Causes High Blood Pressure in Rats: A Novel Hypertension Model

Atlantoaxial disorders are often correlated with hypertension in practice. In order to study the relationship between atlantoaxial disorder and hypertension, we attempted to construct an animal model. In this work, we presented an animal model where their atlantoaxial joints were misaligned. We investigated the changes of blood pressure before and after treatments of the modeled rats. We had the following results. (1) SBP and DBP of each surgery group were significantly higher than those of control and sham groups. (2) After the second operation (the fixture was removed), SBP and DBP of both surgery groups decreased and got closer to the control and sham groups after 7 days. (3) Heart rates got significantly higher in both surgery groups, compared to control and sham groups. (4) The blood Ach levels of the surgery groups were significantly lower than those of control and sham groups. With these results, we concluded that we successfully constructed cervical atlantoaxial disorder models in rats that showed hypertension symptom. However, the underlying mechanism connecting atlantoaxial disorder and hypertension still requires further study.