Manipulative Therapy for Lower Extremity Conditions: Expansion of Literature Review

Objective: The purpose of this study was to conduct a systematic review on manipulative therapy for lower extremity conditions and expand on a previously published literature review. Methods: The Scientific Commission of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) was charged with developing literature syntheses, organized by anatomical region, to evaluate and report on the evidence base for chiropractic care. This article is the outcome of this charge. As part of the CCGPP process, preliminary drafts of these articles were posted on the CCGPP Web site www.ccgpp.org (2006-8) to allow for an open process and the broadest possible mechanism for stakeholder input. The Cumulative Index to Nursing and Allied Health Literature; PubMed; Manual, Alternative, and Natural Therapy Index System; Science Direct; and Index to Chiropractic Literature were searched from December 2006 to February 2008. Search terms included chiropractic, osteopathic, orthopedic, or physical therapy and MeSH terms for each region. Inclusion criteria required a diagnosis and manipulative therapy (mobilization and manipulation grades I-V) with or without adjunctive care. Exclusion criteria were pain referred from spinal sites (without diagnosis), referral for surgery, and conditions contraindicated for manipulative therapy. Clinical trials were assessed using a modified Scottish Intercollegiate Guidelines Network ranking system. Results: Of the total 389 citations captured, 39 were determined to be relevant. There is a level of C or limited evidence for manipulative therapy combined with multimodal or exercise therapy for hip osteoarthritis. There is a level of B or fair evidence for manipulative therapy of the knee and/or full kinetic chain, and of the ankle and/or foot, combined with multimodal or exercise therapy for knee osteoarthritis, patellofemoral pain syndrome, and ankle inversion sprain. There is also a level of C or limited evidence for manipulative therapy of the ankle and/or foot combined with multimodal or exercise therapy for plantar fasciitis, metatarsalgia, and hallux limitus/rigidus. There is also a level of I or insufficient evidence for manipulative therapy of the ankle and/or foot combined with multimodal or exercise therapy for hallux abducto valgus. Conclusions: There are a growing number of peer-reviewed studies of manipulative therapy for lower extremity disorders.19 page(s

A structured protocol of evidence-based conservative care compared with usual care for acute nonspecific low back pain:a randomized clinical trial

Objective: To compare a protocol of evidence-based conservative care with usual care for acute nonspecific low back pain (LBP) of less than 6 weeks' duration. Design: Parallel-group randomized trial. Setting: Three practices in the United Kingdom. Participants: Convenience sample of 149 eligible patients were invited to participate in the study, with 118 volunteers being consented and randomly allocated to a treatment group. Interventions: The experimental group received evidence-based treatments for acute nonspecific LBP as prescribed in a structured protocol of care developed for this study. The control group received usual conservative care. Participants in both groups could receive up to 7 treatments over a 4-week period. Main Outcome Measures: Oswestry Low Back Disability Index (ODD, visual analog scale (VAS), and Patient Satisfaction Questionnaire, alongside estimation of clinically meaningful outcomes. Results: Total dropout rate was 14% (n=16), with 13% of data missing. Missing data were replaced using a multiple imputation method. Participants in both groups received an average of 6 treatments. There was no statistically significant difference in disability ODI scores at the end of week 4 (P=.33), but there was for pain (VAS) scores (P <.001). Interestingly, there were statistically significant differences between the 2 groups for both disability and pain measures at the midpoint of the treatment period (P <.001). Patient satisfaction with care was equally high (85%) in both groups. Minimally clinically important differences in scores and number needed to treat scores (NNT < 6) indicated that the experimental treatment (protocol of care) offered a clinically meaningful benefit over the control treatment (usual care), particularly at the midpoint of the treatment period. Conclusions: Overall, the 2 treatment groups were similar based on primary or secondary outcome measure scores for the full treatment period (4 weeks, with up to 7 treatments). However, there were statistically significant and clinically meaningful differences in both disability and pain scores at week 2 (midpoint) with 4 treatments, suggesting that the protocol of care had a more rapid effect than usual care

A Single-group pretest posttest design using full kinetic chain manipulative therapy with rehabilitation in the treatment of 18 patients with hip osteoarthritis

Objective: Hip osteoarthritis (HOA) affects 30 million Americans or more, and is a leading cause of disability, suffering, and pain. Standard treatments are minimally effective and carry significant risk and expense. This study assessed treatment effects of a chiropractic protocol for HOA. Methods: Eighteen individuals, who did not qualify due to low baseline Western Ontario and McMaster Osteoarthritis Index scores (WOMAC) for other ongoing HOA randomized control trials, were selected. A prospectively planned protocol, consisting of axial manipulation to the affected hip with modified Thomas and active assisted stretch, was combined with full kinetic chain treatment or manipulative therapy to the spine, knee, ankle, or foot and assessed with use of valid and reliable outcome measures. Results: The primary outcome measure, the Overall Therapy Effectiveness Tool, was assessed with χ2 and demonstrated that 83.33% of participants were improved after the ninth visit, P = .005, and 78% improved at the 3-month follow-up, P = .018. Using the paired t test, WOMAC was improved 64% at the ninth visit, P = .000, and 47% at follow-up, P = .016. Conclusion: In HOA patients with lower WOMAC scores, a highly organized HOA treatment appears to have resulted in statistically and clinically meaningful intragroup changes in the Overall Effectiveness Therapy Tool, WOMAC, Harris Hip Scale, and range of motion, all with P ≤ .05. Although the directionality and strength of the findings are encouraging, fully powered clinical trials are necessary to report generalizable findings.13 page(s