Review of systematic reviews for chiropractic as a possible alternative to long acting beta agonists in asthma patients who are unresponsive to conventional therapy alone.
OBJECTIVE: This study evaluated whether chiropractic treatment was an alternative to long acting beta agonists in terms of improving quality of life and reducing rescue bronchodilator use.
METHODS: Chiropractic and long acting beta agonists were compared in non-pulmonary function measurements including quality of life scores and changes in rescue medication use. An inclusion and exclusion criteria was performed. Only data with low heterogeneity from cochrane literature reviews and meta-analysis were included. The reviews were found using the Revman 2008 software and by a search of the Pubmed and Google Scholar electronic database.
RESULTS: Chiropractic and long acting beta agonists showed similar scores for quality of life improvement (0.31/0.34) and in changes in rescue medication use (0.61/0.52).
CONCLUSION: There is a lack of evidence to support the use of Chiropractic as an alternative to LABA for asthma patients with severe exacerbation. However, the evidence supporting Chiropractic treatment for the improvement of quality of life and reduction of rescue medications is promising. Further randomized controlled trials evaluating the impact of chiropractic adjustments over non-pulmonary function measurements are needed to confirm these findings.
KEYWORDS: manual, therapy, long acting beta-agonist, safety, acute, asthma.
The national asthma education and prevention program reported the guidelines for the diagnosis and management of asthma in 2007. In their protocol, the treating physician should consider adjunct therapies for patients with a severe exacerbation or an FEV1 less than 40%.
In 2010, Kaminsky, et al, conducted a systematic review of eight articles and found that some asthmatic patients may benefit from chiropractic. (1) In 2012, Gleberzon, et al, conducted a systematic review of pediatric conditions and found that studies that monitored both subjective and objective outcome measures of relevance to both patients and parents tended to report the most favorable response to chiropractic therapy, especially among children with asthma. (2)
A few studies discussed the safety burden of long acting beta agonists in the treatment of asthma or COPD and one cohort study questioned their efficacy. In 2006, Salpeter, et al conducted a meta-analysis on the safety of long acting beta-agonists. The meta-analysis included 19 trials with 33,826 participants and found that long-acting beta-agonists increased exacerbations requiring hospitalization, and life-threatening exacerbations compared with placebo. (3) In 2007, Cazzola, et al, conducted a literature review and concluded that the salmeterol multi-centre asthma research trial (SMART) found more asthma deaths (13 vs 3) and life-threatening asthma events (37 vs 22) in the salmeterol-treated asthmatic patients, although it was documented that among African-Americans, five times as many deaths and near-deaths from asthma occurred in those given salmeterol than in those given placebo, and among patients with asthma not using an inhaled corticosteroid (ICS) as a preventive (controller) medication, again more deaths and near-deaths from asthma occurred in those given salmeterol than in those given placebo. (4) In 2010, Salpeter, et al, conducted another literature review that included 36,588 participants and found that long-acting beta-agonists increased catastrophic events two-fold. The review concluded that long-acting beta-agonists increase the risk for asthma-related intubations and deaths, even when used in a controlled fashion with concomitant inhaled corticosteroids. (5) Finally, in 2014, Lindenauer, et al, conducted a retrospective cohort study at 421 U.S. hospitals of patients hospitalized with exacerbations of COPD. The study concluded that long acting beta agonists are not associated with better clinical or economic outcomes. (6)
While the aforementioned studies discuss the safety burden and even the efficacy of long acting beta agonists as adjunct therapy for the treatment of asthma, none of these studies propose a safe and equally efficient treatment protocol.
The purpose of this study is to evaluate whether chiropractic treatment is a possible alternative to long acting beta agonists as adjunct therapy in the treatment of asthma.
Chiropractic and long acting beta agonists were compared in non-pulmonary function measurements including quality of life scores and changes in rescue medication use. A search of literature reviews for the treatment of asthma using chiropractic and long acting beta agonists was made using the Cochrane collaboration software program, Review Manager (RevMan) (RevMan 2008).
An inclusion and exclusion criteria was performed. Only literature reviews using data with low heterogeneity as stated by the author of the Cochrane literature review and meta-analysis were included.
A search of literature reviews, systematic reviews and meta-analysis using the pubmed and google scholar database was also performed. Since all the quantitative literature reviews for long acting beta agonists with the exception of Appleton, et al, had pooled results from both adults and children, the data compared in this study represent both children and adults.
For the comparison in non-pulmonary function measurements (quality of life and change in rescue medication use) between chiropractic treatment and long acting beta agonists the following was found: One review measured quality of life changes with chiropractic treatment, using the asthma quality of life questionnaire at four months of treatment WMD 0.31 (95% CI -0.12-0.74) while two reviews measured quality of life changes with long acting beta agonists using the asthma quality of life questionnaire with an average improvement of 0.34.
Finally, one review measured the changes in rescue bronchodilator medication use with chiropractic treatment -0.61 (95%CI -2.30, 1.08) while 4 reviews measured the changes in rescue bronchodilator medication use with long acting beta agonists with an average change of 0.52.
The plausibility of spinal manipulative treatment as an alternative treatment to long acting beta agonists for asthmatic patients who are unresponsive to conventional treatment was discussed in the introduction. Another plausible explanation has to do with the impact of chiropractic over bronchial hyper reactivity. Hondras, et al, conducted a literature review of randomized controlled trials where the effect of chiropractic treatment on bronchial hyperactivity was 0.15 and 0.21 after one and four months of treatment respectively. (7)
Regarding the practice patterns of chiropractors and asthma, one survey of 604 chiropractors in 2003 conducted by McDonald, et al, found that 75.5% of chiropractors had good clinical outcomes when performing spinal manipulative treatment to patients with allergic asthma. (9) Another survey in 2005, conducted by Leboeuf, et al, involved 5,607 patients from different countries where 27% of patients reported improvements in breathing and 17% reported improvements with asthma. (10) According to the Job Analysis of Chiropractic conducted by the National Board of Chiropractic Examiners in 2005 involving 2,167 chiropractors found that 70.7% of chiropractors comanaged asthma. (21)
Chiropractors are in a good position as alternative medicine physicians to provide nutritional supplementation in addition to spinal manipulative treatment. For women in late pregnancy who present with low back pain and have a medical history of extrinsic asthma, Omega 3 supplementation can be given for discogenic pain and as asthma prophylaxis for the unborn child since there is research supporting Omega 3 for asthma prophylaxis. (11) For children and adults with mild asthma, antioxidant therapy with vitamin C can be given to prevent exacerbations. (12) Finally, for both adults and children with mild asthma, patient education on restricting acetaminophen intake may prevent asthma exacerbations. (13)
A topic not mentioned in this study is an alternative treatment for LABA in terms of pulmonary functions. Pulmonary functions tests include peak expiratory flow (PEF) and forced expiratory volume (FEV1). Recent systematic reviews indicate that the average improvement in PEF and FEV 1 percent for intravenous magnesium in patients with asthma exacerbations was 17.4L/min and 4.41 respectively. (18) On the other hand, the average PEF and FEV 1 for long acting beta agonists is 14.89 L/min and 4.39 respectively. (16,17) Moreover, in 2003, Walters, et al, conducted a literature review of randomized controlled trials and found that through evaluation of 9 studies with a total of 1,181 patients the effect of long acting beta agonists over bronchial hyper-reactivity was 0.48. (8) This number is similar to the one for intravenous magnesium. In 2001, Schenk, et al, conducted a randomized controlled trial and found that in the magnesium group, the change in bronchial hyperactivity was 0.48 whereas there was no change in the placebo group. (19) Therefore, a possible substitution to LABA could be the combination of chiropractic treatment and intravenous magnesium.
There is a lack of evidence to support the use of Chiropractic as an alternative to LABA for asthma patients with severe exacerbation in terms of non-pulmonary function tests. However, the evidence supporting Chiropractic treatment for the improvement of quality of life and reduction of rescue medications is promising. Further randomized controlled trials evaluating the impact of chiropractic adjustments over non-pulmonary function measurements are needed to confirm these findings.
FIGURE 1 LABA vs. Chiropractic non-pulmonary functions measurements LABA CHIROPRACTIC QUALITY OF LIFE 0.34 0.31 CHANGE IN RESUCE MEDICATIONS 0.52 0.61 Note: Table made from bar graph.
(1.) Kaminskyj, A., Frazier, M., Johnstone, K., & Gleberzon, B. J. (2010). Chiropractic care for patients with asthma: A systematic review of the literature. The Journal of the Canadian Chiropractic Association, 54(1), 24
(2.) Gleberzon, B. J., Arts, J., Mei, A., & McManus, E. L. (2012). The use of spinal manipulative therapy for pediatric health conditions: a systematic review of the literature. The Journal of the Canadian Chiropractic Association, 56(2), 128.
(3.) Salpeter, S. R., Buckley, N. S., Ormiston, T. M., & Salpeter, E. E. (2006). Meta-analysis: effect of long-acting [beta]-agonists on severe asthma exacerbations and asthma-related deaths. Annals of internal medicine, 144(12), 904-912.
(4.) Cazzola, M., & Matera, M. G. (2007). Review: Safety of long-acting [beta]2-agonists in the treatment of asthma. Therapeutic advances in respiratory disease, 1(1), 35-46.
(5.) Salpeter, S. R., Wall, A. J., & Buckley, N. S. (2010). Long-acting beta-agonists with and without inhaled corticosteroids and catastrophic asthma events. The American journal of medicine, 123(4), 322-328.
(6.) Lindenauer PK, Shieh MS, Pekow PS, Stefan MS. Use and outcomes associated with long-acting bronchodilators among patients hospitalized for chronic obstructive pulmonary disease. Ann Am Thorac Soc. 2014; 11 (8): 1186-94.
(7.) Hondras MA, Linde K, Jones AP. Manual therapy for asthma. Cochrane Database Syst Rev. 2002;(4):CD001002.
(8.) Walters EH, Walters JA, Gibson MD. Inhaled long acting beta agonists for stable chronic asthma. Cochrane Database Syst Rev. 2003;(4):CD001385
(9.) William P. McDonald (Other Contributor). How Chiropractors Think and Practice, The Survey of North American Chiropractors. Institute for Social Research Ohio Northern University; 2003.
(10.) Leboeuf-yde C, Pedersen EN, Bryner P, et al. Self-reported nonmusculoskeletal responses to chiropractic intervention: a multination survey. J Manipulative Physiol Ther. 2005;28(5):294-302.
(11.) Klemens, C. M., Berman, D. R., & Mozurkewich, E. L. (2011). The effect of perinatal omega-3 fatty acid supplementation on inflammatory markers and allergic diseases: a systematic review*. BJOG: An International Journal of Obstetrics & Gynaecology, 118(8), 916-925.
(12.) Allen, S., Britton, J. R., & LeonardiBee, J. A. (2009). Association between antioxidant vitamins and asthma outcome measures: systematic review and meta analysis. Thorax, 64(7), 610619.
(13.) Etminan, M., Sadatsafavi, M., Jafari, S., Doyle-Waters, M., Aminzadeh, K., & FitzGerald, J. M. (2009). Acetaminophen Use and the Risk of Asthma in Children and Adults A Systematic Review and Metaanalysis. CHEST Journal, 136(5), 1316-1323.
(14.) Ducharme FM, Lasserson TJ, Cates CJ. Addition to inhaled corticosteroids of long-acting beta2-agonists versus anti-leukotrienes for chronic asthma. Cochrane Database Syst Rev. 2011;(5):CD003137. Walters EH,
(15.) Walters JA, Gibson PW. Regular treatment with long acting beta agonists versus daily regular treatment with short acting beta agonists in adults and children with stable asthma. Cochrane Database Syst Rev. 2002;(4):CD003901
(16.) Appleton S, Poole P, Smith B, Veale A, Lasserson TJ, Chan MM. Long-acting beta2-agonists for poorly reversible chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2006;(3):CD001104.
(17.) Ni chroinin M, Greenstone I, Lasserson TJ, Ducharme FM. Addition of inhaled long-acting beta2-agonists to inhaled steroids as first line therapy for persistent asthma in steroid-naive adults and children. Cochrane Database Syst Rev. 2009;(4):CD005307.
(18.) Kew KM, Kirtchuk L, Michell CI. Intravenous magnesium sulfate for treating adults with acute asthma in the emergency department. Cochrane Database Syst Rev. 2014;5:CD010909.
(19.) Schenk P, Vonbank K, Schnack B, Haber P, Lehr S, Smetana R. Intravenous magnesium sulfate for bronchial hyper reactivity: a randomized, controlled, double-blind study. Clin Pharmacol Ther. 2001 ;69(5):365-71
(20.) Examiners NB, Kollasch MW. Job Analysis of Chiropractic 2005, A Project Report, Survey Analysis, and Summary of the Practice of Chiropractic Within the United States. NATIONAL BOARD OF CHIROPRACTIC EXAMINERS; 2005.
by: Adrian Isaza, DC, DACBN, CCAP
TABLE 1 Reviews on Chiropractic Subjective Scores for Overall Quality of Life Improvement Using the Asthma Quality of Life Questionnaire Year Inclusion Hondras, et al, 2008 (7) Randomized controlled trials Average Year # of Studies # of Patients Result Hondras, et al, 2008 (7) 1 Balon, et al, 1998 38 0.31 Average 0.31 TABLE 2 Reviews on Long Acting Beta Agonists for Subjective Scores on the Overall Quality of Life Improvement using the Asthma Quality of Life Questionnaire Year Inclusion # of Studies Walters, et al, 2003 (8) Randomized controlled trials 3 Ducharme, et al, 2010 (14) Randomized controlled trials 4 Average Year # of Patients Result Walters, et al, 2003 (8) 1,350 0.59 Ducharme, et al, 2010 (14) 341 0.10 Average 0.34 TABLE 3 Reviews on Chiropractic Change in Rescue Bronchodilator Medication use Year Inclusion # of Studies Hondras, et al, 2008 (7) Randomized controlled 1 Nielsen, et al, 1995 trials Average Year # of Patients Result Hondras, et al, 2008 (7) 31 0.61 Average 0.61 TABLE 4 Reviews on Long Acting Beta Agonist Change in Rescue Bronchodilator Medication Use at End Point Year Inclusion # of tudies Walters, et al, 2002 (15) Randomized controlled trials 3 Appleton, et al, 2006 (16) Randomized controlled trials 5 Ni Chroinin, et al, 2009 (17) Randomized controlled trials 8 Ducharme, et al, 2010 (14) Randomized controlled trials 12 Average Year # of Patients Result Walters, et al, 2002 (15) 606 0.69 Appleton, et al, 2006 (16) 877 0.78 Ni Chroinin, et al, 2009 (17) 2,172 0.41 Ducharme, et al, 2010 (14) 4,631 0.20 Average 0.52
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|Date:||Mar 1, 2017|
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