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*A literature synthesis is an academically rigorous analysis of all the available scientific literature on a specific topic. Reviewers use internationally accepted tools to rate each article according to specific criteria. These include the type of study (randomized controlled trial, case series, etc), the quality of the study, size of the study and many other factors which influence the credibility and strength of the study's conclusions. Each reviewer independently rates all the available articles, and the ratings are compared among the members of the review team. When there is disagreement among the reviewers regarding the conclusions, a formal consensus process is followed to arrive at an overall conclusion upon which all reviewers can agree. The resulting conclusions do not represent the reviewers’ own beliefs but rather what the literature actually supports. A literature synthesis is a starting point. It indicates only what we can conclude with supportable, scientific evidence. Appropriate therapeutic approaches will consider the literature synthesis as well as clinical experience, coupled with patient preferences in determining the most appropriate course of care for a specific patient. This document is solely a survey of existing studies, and only expresses the opinion of CCGPP. It is not intended to, nor does it establish a standard of care in specific communities, specific cases, or as to the care of any particular individual or condition. Each case must be determined on the basis of a careful clinical examination and diagnosis of the patient, giving due consideration to the specific condition presented and the individual’s informed choice as to care and treatment. No part of this document is intended to support any litigation or proceeding involving the standard of care, medical necessity or reimbursement eligibility.


Team Lead Cheryl Hawk, DC, PhD, CHES Vice President of Research and Scholarship Cleveland Chiropractic College, Kansas City and Los Angeles

Team Members Randy J. Ferrance, DC, MD Private practice, chiropractic Hospitalist, Riverside Tappahannock Hospital, Tappahannock, VA Anthony Lisi, DC Associate Professor of Clinical Sciences University of Bridgeport College of Chiropractic Staff Chiropractor, VA Connecticut Healthcare System, West Haven, CT Marion Willard Evans, Jr, DC, PhD, CHES Director, Health Promotion Degree Programs Cleveland Chiropractic College, Kansas City and Los Angeles Lisa Killinger, DC Professor and Chair, Department of Diagnosis and Radiology Palmer College of Chiropractic, Davenport, IA Jacqueline Bougie, DC Professor, Department of Diagnosis, Los Angeles College of Chiropractic Southern California University of Health Sciences, Whittier, CA


Table of Contents SUMMARY OF RECOMMENDATIONS ..............................................................................3 General literature search methodology ................................................................................4 Chiropractic Care for Non-musculoskeletal Conditions .................................................4 Table 1. Summary of articles related to chiropractic care for patients with non-

musculoskeletal conditions, by type of article and condition ...........................................5 Table 2. Conditions addressed in all case reports and case series, by number of

patients. ..........................................................................................................................6 Table 3. Evidence table for chiropractic care of patients with non-musculoskeletal

conditions........................................................................................................................8 Ratings statement: non-musculoskeletal conditions...........................................................11 Wellness, Health Promotion and Disease Prevention...................................................11 Table 4. Summary of articles related to wellness, prevention and health promotion and

chiropractic care............................................................................................................11 Table 5. Topics addressed in guidelines, systematic reviews and RCTs ...........................11 Table 6. Evidence table for wellness, prevention and health promotion related to

chiropractic care (including health promotion counseling within scope of chiropractic practice).*......................................................................................................................12

Ratings statements: wellness, health promotion and prevention........................................13 Special Populations: Children ........................................................................................15 Table 7. Summary of articles related to chiropractic care for children................................15 Table 8. Evidence table for chiropractic care of children: guidelines..................................16 Ratings statements: children ..............................................................................................16 Special Populations: Pregnant Women .........................................................................17 Table 9. Evidence table for exercise counseling for pregnant women ...............................17 Table 10. Evidence table for spinal mobilization/manipulations for pregnant women.........17 Table 11. Evidence table for diagnostic tests in pregnant women......................................18 Ratings statements: pregnant women................................................................................18 Special Populations: Older Adults..................................................................................20 Table 12. Topics addressed in guidelines, systematic reviews and RCTs for older adults.20 Table 13. Evidence table for older adults ...........................................................................20 Ratings statements: older adults ........................................................................................21 References ........................................................................................................................23


Summary of Recommendations

Topic Conclusion and Strength of Evidence Rating page Non-musculoskeletal conditions 10

Asthma Infantile colic

RATING: C Limited evidence to support chiropractic care, including manual procedures, spinal manipulation/mobilization; benefit may be due to nonspecific factors.

Otitis media RATING: C Limited evidence to support chiropractic care including manual procedures and spinal manipulation.

Cervicogenic vertigo dysmenorrhea

RATING: C Limited evidence to support spinal manipulation/mobilization.

Other non-musculoskeletal

conditions

RATING I: Insufficient evidence to make a recommendation for or against spinal manipulation for patients with other non-musculoskeletal conditions

Wellness, health promotion and disease prevention 13 Spinal manipulation for

health promotion RATING: I Insufficient evidence to make a recommendation for or against spinal manipulation for health promotion and/or disease prevention

Counseling tobacco users to quit

RATING: A Strong evidence that counseling by a provider is effective.

Counseling sedentary patients to engage in

physical activity

RATING: A Strong evidence that counseling by a provider is effective in assisting sedentary patients to become physically active.

Special populations: children 16 Asthma, infantile colic,

otitis media See “non-musculoskeletal conditions” above

Other conditions RATING: I Insufficient evidence to make a recommendation for or against chiropractic care or spinal manipulation for children with other conditions.

Counseling on breast-feeding

RATING: A Strong evidence that counseling by a provider is effective in promoting breast-feeding.

Limiting use of antibiotics for otitis

media

RATIN:G A Strong evidence supporting limitation of use of antibiotics in children with otitis media

Special populations: pregnant women 18 Counseling on exercise RATING: A

Strong evidence that counseling by a provider is effective in promoting exercise.

Low back pain RATING: C Limited evidence to support spinal manipulation/mobilization

Prenatal care with spinal

manipulation/mobilization RATING: C Limited evidence to support spinal manipulation/mobilization for prevention of certain complications of labor and delivery.

Low back pain during labor

RATING: I Insufficient evidence to make a recommendation for or against spinal manipulation/mobilization for LBP during labor.

Diagnostic tests RATING: B Fair evidence for active straight leg raise for measuring disease severity in LBP.

Special populations: older adults 21

Low back pain RATING: C Limited evidence for spinal manipulation for LBP in older adults.

Chronic musculoskeletal

pain RATING: C Limited evidence for spinal manipulation for chronic musculoskeletal pain in older adults

Counseling for physical activity

RATING: A Strong evidence that counseling by a provider is effective in assisting older adults to increase physical activity.


Topics Included in this Section

This section addresses chiropractic care for 1) patients with non-musculoskeletal conditions; 2) prevention, health promotion and wellness; and special populations, including 3) the elderly, 4) children, and 5) pregnant women. Restrictions and search criteria are discussed below. The overall methodology prescribed for all CCGPP teams for evaluation of the literature is described in detail at http://www.ccgpp.org/methodology.pdf.

General Literature Search Procedures

The following procedures apply to all topics included in this section. The initial search was done by a librarian experienced in literature retrieval. Inclusion criteria were: English language, human subjects, and publication through April 2005. Non-peer-reviewed journals were excluded; journals were considered peer-reviewed if they stated as such on their editorial page. Databases searched were Medline, MANTIS, CINAHL and Index to Chiropractic Literature. Hand searches and reference tracking were also performed, and the citation list was assessed for comprehensiveness by the team members and additional content experts, including several chiropractic college faculty and practitioners who were knowledgeable in each topic area. To be consistent with overall guidelines for the CCGPP evaluation process, commentaries or expert opinion articles, descriptive surveys and case reports of 1-2 cases were included in the bibliography but excluded from formal evaluation. Search terms and inclusion and exclusion criteria specific to each topic are discussed under that topic.

Chiropractic Care for Non-musculoskeletal Conditions

Relevant ICD-9 Codes 381.0, 381.01, 381.4 382.0, 382.3,382.4, 382.9 Otitis 780.4 Dizziness and giddiness 789.0 Infantile colic

The procedure of manual spinal manipulation and/or mobilization (including both chiropractic and osteopathic approaches) specifically, and general chiropractic management, which might include other procedures within the scope of chiropractic practice, were included. Articles addressing exclusively non-manual procedures or practices, such as nutritional or herbal management, were excluded. Terms used in the initial search were “chiropractic” AND “visceral” OR “nonmusculoskeletal” OR “non-musculoskeletal;” “manipulation” AND “visceral” OR “nonmusculoskeletal” OR “non-musculoskeletal.” Additional searches were done by specific condition names for any conditions for which randomized trials were identified. Additional citations were identified using the methods described above. These methods yielded a total of 276 articles. There were 21 commentaries or expert opinion articles, 34 descriptive surveys and 93 case reports of 1-2 cases (93) which were included in the bibliography but were excluded from formal evaluation. Table 1 summarizes the literature by condition and type of study; it includes case reports but not expert opinion and descriptive survey articles. Although vision, asthma and vertigo were


the single conditions addressed in the largest number of articles (17 each), asthma and hypertension were addressed in the most RCTs (3 each). Table 1. Summary of articles related to chiropractic care for patients with non-musculoskeletal conditions, by type of article and condition.

Type of article

Condition addressed Randomized controll

ed trial

Sys-tematic Review

Narra-tive

Review

Co-hort

Diag-nostic

Other1 Case Series

Case Report

total

total 20 8 18 5 6 44 27 93 221Vision 1-18 3 1 14 18Asthma19-35 3 1 3 1 1 3 2 4 18Vertigo36-50 1 1 2 6 4 1 15Multiple conditions51-67 1 1 2 1 3 7 15Hypertension68-81 3 1 6 2 2 14Pulmonary disease82-90 1 1 1 3 3 9Otitis media91-99 1 1 1 3 3 9Infantile colic100-108 2 1 1 1 4 9Infertility67, 109-115 7 7ADHD/learning115-122 disabilities

1 1 2 3 7

Chronic pelvic pain123-128 2 1 3 6Nocturnal enuresis129-134 1 1 1 1 2 6Psychological disorders (depression, phobia, anxiety)82, 83, 135-139

2 1 2 1 6

Menstrual disorders140-151 2 2 5 1 2 12Seizures152-156 1 4 5Visceral-related pain/disorders50, 157-161

1 2 2 1 6

Constipation162-166 5 5Dysfunctional nursing167-

172 1 5 6

Immune system173-175 3 3Neurological effects176-179 4 4Arrhythmia/ECG abnormalities180, 181

1 1 2

Autism182, 183 1 1 2Dysphonia184, 185 2 2Eczema/psoriasis186, 187 2 2Encopresis188, 189 2 2Hearing loss/tinnitus190,

191 2 2

Multiple Sclerosis66, 67 1 1 2


Sudden Infant Death Syndrome192, 193

1 1 2

Sleep disorder194, 195 1 1 2Thyroid dysfunction196, 197 1 1 2Urinary incontinence141,

198, 199 1 1 2

Rett syndrome200 1 1Aphasia201 1 1Bowel/bladder dysfunction202

1 1

Cancer pain203 1 1Cerebral palsy204 1 1Crohn’s205 1 1Cystic hygroma165 1 1Diabetes206 1 1Diabetic polyneuropathy207

1 1

Down’s syndrome208 1 1Erb’s palsy209 1 1Jet lag210 1 1Myasthenia gravis211 1 1Parkinson’s212, 213 1 1 2Tourette’s syndrome214 1 1Ulcer215 1 1Urinary tract infection199 1 1Vertebrobasilar ischemia216

1 1

1 includes non-randomized trials, small experimental and pilot studies Case Reports Because of the large number of case reports/series on non-musculoskeletal conditions, Table 2 summarizes the conditions and numbers of patients reported in case reports and case series. However, even though there are a large number of patients described in case reports, these reports can only provide evidence that patients with the conditions described have sought care from chiropractors; case reports cannot provide convincing evidence to support best practices.

Table 2. Conditions addressed in case reports/case series, by number of patients.

Condition addressed Total patients included Visceral-related pain/disorders, including immune system2 651Otitis media 383Vertigo 368


Pulmonary disease 127ADHD/learning disabilities 40Vision 32Asthma 19Chronic pelvic pain 15Cerebral palsy 14Hypertension 13Premenstrual Syndrome 12Infertility 8Arrhythmia/ECG abnormalities 5Constipation 5Infantile colic 5Multiple Sclerosis 5Dysfunctional nursing 4Seizures 4Bowel and bladder dysfunction 3Amenorrhea 2Dysphonia 2Encopresis 2Hearing loss/tinnitus 2Nocturnal enuresis 2Vertebrobasilar ischemia 2Aphasia 1Autism 1Cancer pain 1Cystic hygroma 1Diabetes 1Diabetic polyneuropathy 1Down’s syndrome 1Eczema 1Erb’s palsy 1Glaucoma 1Myasthenia gravis 1Parkinson’s 1Psychological disorders 1Rett syndrome 1Sleep disorder 1Tourette’s syndrome 1Urinary incontinence 1Urinary tract infection 1

1 One case series of 44 MS patients and 37 Parkinson’s is included in the total here.60 2 One case series of 650 patients with “somatic, visceral and immune complaints” is included here61


Table 3. Evidence table for chiropractic care of patients with non-musculoskeletal conditions.*

Citation Study

type condition participants Interventions follow-up Results/outcomes

Notes

Balon 199831

RCT asthma 80 children with mild-moderate asthma

HVLA chiropractic adjustments vs simulated-treatment (soft tissue massage and palpation

2 and 4 mo.

Peak expiratory vol. not significantly changed; symptoms, B-agonist use and QOL improved in both groups

Adequate power

Guiney 200532

RCT asthma 140 children with non-acute asthma

Osteopathic manipulation vs sham (placing hands on different areas of body)

Immediately post-intervention

Peak expiratory vol. significantly improved in treatment group

No power calculation but large sample size; no attempt to assess success of blinding

Goertz 200278

RCT hyper-tension

140 adults with high-normal or Stage 1 hypertension

HVLA (diversified) chiropractic manipulation and diet intervention by DC vs. diet intervention by dietician

After 4 weeks of treatment

No significant between-groups difference; both had small decreases in BP

Adequate power

Hondras 1999148

RCT dys-menorrhea

138 women with primary dys-menorrhea

HVLA vs low-force mimic maneuver

1 hour post-treatment over 3 menstrual cycles

VAS and prostaglandin decreased in both groups and decreased over time. No significant between-groups difference

Adequate power

Nielsen 199533

RCT/ crossover

asthma 31 adults with asthma

HVLA vs sham (gentle manual pressure and drop table with no thrust)

4 weeks then crossover after 2 wk washout

FEV, FVC unchanged; severity and hyperreactivity improved in both groups

Power calculation described; patients served as own controls

Noll 200088

RCT pneumonia Hospitalized patients 60+

OMT vs control w/ light touch

discharge Significantly shorter hospital stay in OMT group (2 days)

No power calculation; outcomes may have been influenced by group assignment

Olafsdottir 2001105

RCT Infantile colic

96 infants Chiropractic manipulation vs being held by nurse 3 treatments over 8 days

8-14 days after treatment

Parent-reported improvement in crying improved in both groups

Parents blinded


Wiberg 1999106

RCT Infantile colic

50 infants Chiropractic manipulation vs inactive medication 3-5 treatments over 2 weeks. Both groups counseled.

End of treatment

Colic diaries interpreted by blinded observer

25/25 in active group stayed in study; 9 dropped out of control group

Mills 200398

RCT Otitis media 57 children 6 mo-6 yrs

Osteopathic manipulation (no HV)

Treatment over 6 mo period

Episodes of AOM, antibiotic use, surgery, tympanometry and audiometry; modest improvements in treatment group

Power calculation done but did not recruit #

Ernst 200164

SR Asthma, dys-menorreha, enuresis, phobia

Sham-controlled trials

SMT no greater than non-specific effects

Ernst 2003159

SR Infantile colic, otitis, dys-menorrhea, chronic pelvic pain

Non-spinal pain

Insufficient evidence

Glazener1

33 SR Nocturnal

enuresis CAM and miscellaneous interventions

Weak evidence for chiropractic SMT

Hondras 200534

SR asthma Manual therapies


Hughes 2002107

SR Infantile colic

Chiropractic care

No evidence of efficacy compared to placebo, but there is pragmatic evidence of effectiveness.

Proctor 2002149

SR Dys-menorrhea

Spinal manipulation

No more effective than sham, but possibly more than no treatment

Reid 200548

SR vertigo Manual therapy

Level 3 evidence

Stevinson 2001150

SR Premen-strual syndrome

CAM therapies (only 1 chiropractic study included)


* All systematic reviews are included. RCTs rated + or n are included.


RATING STATEMENTS: NON-MUSCULOSKELETAL CONDITIONS Total Rated as high Guidelines statements 0 0 Systematic reviews 8 6 RCTs 20 8 Remaining papers on topic (other designs) 248 --

Ratings based on the body of evidence compiled and evaluated

• C for chiropractic care including manual procedures and spinal manipulation/mobilization for patients with asthma and infantile colic, although the clinical benefit may be attributed to nonspecific factors.

• C for chiropractic care including manual procedures and spinal manipulation for patients with otitis media.

• C for spinal manipulation/mobilization for patients with cervicogenic vertigo. • C for spinal manipulation/mobilization for patients with dysmenorrhea • I for spinal manipulation for patients with all other nonmusculoskeletal conditions.


Wellness, Health Promotion and Disease Prevention

Relevant ICD-9 Codes V20.2 Well child exam 99401 Preventive med. Counseling and/or risk factor reduction and

interventions for an individual-15 minutes. 99402 Preventive med. Counseling (30 minutes.) 99403 Preventive med. (45 minutes) 99411 Preventive med. In group. (30 minutes) 99412 Preventive med. In group. (60 minutes)

National guidelines related to counseling on health promotion and prevention, within the scope of chiropractic practice, were included, where available. For the specific topic of chiropractic manipulation/adjustment for the purpose of prevention or health promotion, terms used in the initial search were “chiropractic” AND “health promotion” OR “prevention” OR “wellness.” Additional citations were identified using the methods described above. These methods yielded a total of 95 articles, 29 of which were descriptive surveys and 13 expert opinion. Table 4. Summary of articles related to wellness, prevention and health promotion and chiropractic care. Specifically

addresses manipulation

Specifically includes chiropractic care, not

effect of manipulation

Within scope of chiropractic

practice but not specifically applied

total

Guideline 0 0 10 10Randomized controlled trial 0 0 3 3Systematic review 0 0 5 5Narrative review 1 4 4 9Cohort study 0 1 9 10Economic study 0 0 1 1Diagnostic study 0 2 0 2Other study1 13 1 0 14Case series 0 0 0 0Case report 2 0 0 2Descriptive survey 4 19 5 28Expert opinion 0 10 3 10 1 Includes non-randomized trials, small experimental and pilot studies


Table 5. Topics addressed in guidelines, systematic reviews and RCTs Arthritis prevention 1 guideline Fall prevention for elderly 1 systematic review (Cochrane)

1 guideline Hypertension prevention 2 guideline Multiple interventions 1 guideline

1 RCT (smoking, alcohol, sedentary lifestyle) Osteoporosis prevention 1 guideline Physical activity 1 guideline, 1 systematic review, 1 RCT Prevention of first stroke 1 guideline Smoking 1 cost study, 1 RCT Table 6. Evidence table for wellness, prevention and health promotion related to chiropractic care (including health promotion counseling within scope of chiropractic practice).*

Citation Study type topic Partici-pants

Interventions follow-up Results

Arthritis Foundation, 1999 217

Guideline Arthritis prevention

Health care providers should counsel patients with arthritis on weight control, physical activity, and encourage self-management

Campbell218 Guideline Hypertension prevention

Providers should determine BMI and alcohol consumption for all adults and assess sodium and stress in all hypertensives

CDC219 guideline Cost-effective prevention strategies

Counsel pts on bicycle helmets Mammography Lead screening Colorectal screening Physical activity Reduced fat intake Tobacco use

Cleroux220 guideline Physical activity to prevent hypertension

Counsel 50-60 minutes exercise/day for mild hypertension

Feder221 guideline Fall prevention in elderly

Exercise alone does not reduce fall risk Balance training (specifically t’ai chi) reduces fall risk

Gorelick222 guideline Prevention of first stroke

Reduce smoking, alcohol use, increase physical activity and improve diet

NIH223 guideline Osteoporosis prevention

Calcium, Vit D, physical activity

NIH224 guideline Physical activity and cardiovascular health

At least 30 min. physical activity per day


Burton225 RCT Preventive

visit on smoking, alcohol and sedentary lifestyle

Medicare pts in primary care (1573 intervention;

Counseling vs mailed pamphlet

6 month follow up

No significant improvement

Cummings226 Cost study Physician counseling for smokers

Analysis of RCTs and costs

Physician counseling is at least as cost-effective as other prevention and should be a routine part of health care

Gillespie227 SR (Cochrane)

Fall prevention for elderly

Muscle strengthening and balance retraining, tai chi by trained professionals is effective

Simons-Morten228

SR Physical activity interventions

Multiple contact, supervised behavioral approaches more effective

*The evidence table includes articles to support A or B ratings, as per the guidelines for the CCGPP process. RATING STATEMENTS: WELLNESS, HEALTH PROMOTION AND PREVENTION Spinal manipulation for prevention and/or health promotion Total Rated as high Guidelines statements 0 0 Systematic reviews 0 0 RCTs 0 0 Remaining papers on topic (other designs) 20 -- Ratings based on the body of evidence compiled and evaluated

• I for spinal manipulation for prevention and/or health promotion


Counseling tobacco users to quit Counseling sedentary patients to engage in physical activity Due to the large body of evidence on these topics, the team accepted existing guidelines on counseling tobacco using patients and sedentary patients. Total Rated

as high Guidelines statements 10 10 Ratings based on the body of evidence compiled and evaluated

• A for counseling smokers to quit • A for counseling sedentary patients to engage in physical activity


Special Populations: Children

For this topic, evidence related to the broader topic of chiropractic care, as opposed to the more narrow topic of spinal manipulation/chiropractic adjustments, was evaluated. Thus articles, particularly guidelines, related to the procedures and practices commonly utilized by chiropractors were included. Initial search terms were “chiropractic” AND “pediatric” or “paediatric” or “child” or “infant.” Articles primarily addressing infertility or childbirth were not included under this topic; infertility was included in the nonmusculoskeletal condition search and childbirth was included in the pregnancy search. Additional citations were identified using the methods described above. These methods yielded a total of 233 articles. Commentaries or expert opinion articles (16), descriptive surveys (13) and case reports of 1-2 cases (111) were included in the bibliography but were not formally evaluated. Table 1 summarizes the non-musculoskeletal conditions addressed in children; it includes case reports but not expert opinion and descriptive survey articles. Table 2 summarizes the studies by design and by condition (non-musculoskeletal, musculoskeletal or general). Table 7. Summary of articles related to chiropractic care for children. musculoskeletal

condition non-

musculoskeletal condition

general total

Guideline 0 3 0 3Randomized controlled trial 1 8 0 9Systematic review 0 3 3 6Narrative review 4 12 7 23Cohort study 5 2 2 9Diagnostic study 0 1 0 1Other study1 1 16 0 17Case series 8 11 0 19Case report 55 57 0 112Descriptive survey 1 4 8 13Expert opinion 4 6 6 16 1 Includes non-randomized trials, small experimental and pilot studies


Table 8. Evidence table for chiropractic care of children: guidelines.*

Citation topic Recommendations American Academy of Pediatrics Work Group on Breastfeeding.229

breastfeeding Health care providers should encourage breastfeeding

American College of Emergency Physicians.230

Fever in children up to 3 yrs

Fever in babies < aged <1mo should be presumed to have serious bacterial infection and should receive prompt medical attention

American Academy of Pediatrics231

Acute otitis media in children

Observation without use of antibacterial agents is an option; however pain should be managed

* The evidence table includes articles to support A or B ratings, as per the guidelines for the CCGPP process. RATING STATEMENTS: CHILDREN Total Rated as high Guidelines statements (otitis media; breastfeeding; fever in infants)

3 3

Systematic reviews 6 3 RCTs 9 5 Remaining papers on topic (other designs) 186 --


• C for chiropractic care including spinal manipulation/mobilization for children with

the following conditions, although clinical effects may be nonspecific: o asthma o infantile colic o otitis media,

• I for other conditions in children. • A for counseling parents on value of breastfeeding infants • A for limiting use of antibiotics for otitis media • A for medical comanagement of fever in infants


Special Populations: Pregnant Women Initial search terms were “chiropractic” AND “pregnancy;” “manipulation” AND “pregnancy.” Articles addressing labor and childbirth were included; articles addressing sequellae to pregnancy and childbirth (such as post-partum low back pain) were excluded. Additional citations were identified using the methods described above. These methods yielded a total of 47 articles. Commentaries or expert opinion articles (11), descriptive surveys (9) and case reports of 1-2 cases (5) were included in the bibliography but were not formally evaluated. There were 5 case series, all of which reported positive effects for various types of spinal manipulation for LBP and other pregnancy-related symptoms. Table 9. Evidence table for exercise counseling for pregnant women.*

Citation Study type topic Recommendations ACOG232 guideline Exercise

during pregnancy/ postpartum

• In absence of complications, at least 30 min. of exercise/day most days of the week is recommended.

• Participation in low-risk recreational activities for women with uncomplicated pregnancies is recommended

• Previously inactive women should be evaluated before recommendations for exercise made

Garshasbi 2005233

RCT exercise • Exercise in second half of pregnancy decreased intensity of LBP

Ostgaard234 RCT Exercise and sacroiliac belt

• Individualized exercise program more effective • Non-elastic pelvic support effective for posterior

pelvic pain * The evidence table includes articles to support A or B ratings, as per the guidelines for the CCGPP process. Table 10. Evidence table for spinal mobilization/manipulation for pregnant women.*

Citation Study type topic sample Interventions Results Quality Stuge 235 Systematic

Review LB and pelvic pain

-- Physical Therapy manual procedures and water exercise

Equivocal for manual treatment and water exercise by PTs for LBP of pregnancy

+

King 2003236

Case control

Prenatal care with OMT

160 cases, 161 controls

Spinal Manipulation (osteopathic)

OR greater for pregnancy complications for controls (pregnant women not getting OMT) (meconium-stained amniotic fluid, preterm delivery)

+


* only systematic reviews, RCTs, case control and cohort studies with positive quality scores are included in table. The evidence table includes articles to support A or B ratings, as per the guidelines for the CCGPP process. Table 11. Evidence table for diagnostic tests in pregnant women.*

Citation Study type topic sample Interventions Results

Quality score

Mens 2001237

Diagnostic accuracy

Active straight leg raise in posterior pelvic pain since pregnancy

200 women with PPPP

Measurement of reliability, sensitivity and specificity

ASLR discriminates between PPPP and healthy subjects. Reliability, sensitivity and specificity high.

+

Mens 2002238

Diagnostic accuracy

Active straight leg raise to measure disease severity in posterior pelvic pain since pregnancy

200 women with PPPP

Comparison to pain provocation tests and the Quebec Back Pain Disability Scale

ASLR correlated with Quebec pain scale

+

* The evidence table includes articles to support A or B ratings, as per the guidelines for the CCGPP process. RATING STATEMENTS: PREGNANT WOMEN Total Rated as high Guidelines statements 0 0 Systematic reviews 1 1 RCTs 3 2 Remaining papers on topic (other designs) 22 --

Ratings based on the body of evidence compiled and evaluated Treatment

• A for counseling pregnant women on exercise during pregnancy • C for spinal mobilization/manipulation for LBP of pregnancy • C for spinal mobilization/manipulation as part of prenatal care for prevention of

some complications of labor and delivery • I for spinal mobilization/manipulation for LBP during labor

Diagnostic tests: • B for active straight leg raise for measuring disease severity in LBP in pregnancy



Special Populations: Older Adults

Relevant ICD-9 Codes 721.90 Spondylosis 738.4 Degenerative spondylosis 724.00 Stenosis, spinal 723.00 Stenosis, cervical 724.02 Stenosis, lumbar 724.09 Stenosis, nerve root 724.01 Stenosis, thoracic 733.00 osteoporosis 627.2 Symptomatic menopausal or female climacteric states 729.2 Radiculitis (vertebrogenic) 715.9 Osteoarthritis 721.90 Osteoarthritis, Spine 722.6 Degenerative IVD 722.70 Degenerative IVD with mylepathy 722.4 Degenerative IVD, cervical 722.71 Degenerative IVD, cervical with mylepathy 722.52 Degenerative IVD, lumbar 722.73 Degenerative IVD, lumbar with mylepathy 722.51 Degenerative IVD, thoracic 722.72 Degenerative IVD, thoracic with mylepathy

Initial search terms were “chiropractic” AND “elderly” OR “aged” OR “geriatric;” also “manipulation” AND “elderly” OR “aged” OR “geriatric.” Additional citations were identified using the methods described above. Guidelines concerning the elderly and practices within the scope of chiropractic practice were also included. These methods yielded 94 articles, with 24 of these descriptive surveys and 13 expert opinions. Table 12. Topics addressed in guidelines, systematic reviews and RCTs for older

adults. physical activity counseling 2 guidelines fall prevention for elderly 1 systematic review

3 guidelines chronic pain management, including spinal manipulation 2 guidelines

1 RCT general health/prevention 1 guideline

1 systematic review 1 RCT

screening 1 guideline prevalence of low back pain 1 systematic review spinal manipulation (osteopathic) for functional ability 1 RCT spinal manipulation (osteopathic) for hospitalized elderly with pneumonia

1 RCT


Table 13. Evidence Table for Older Adults Citation Study

type topic Participant

articles Interventions Results

AHRQ and CDC239

Guideline physical activity

16 articles (through 2002)

N/A Recommend moderate exercise (30 min 5x/week) for older patients’ health. Also add strength and flexibility activities 2/week.

AGS240 guideline physical activity

180 articles with 5 RCTs

Exercise counseling

Recommend: Moderate exercise, pt. ed, meds (as needed),

AGS241 guideline fall prevention

83 articles (assessment) 16 (risk)

Fall prevention risk assessment

Recommend 1/yr.assess w/Get up –n-Go, Fall history and physical exam

AGS242 guideline chronic pain

180 articles multiple Recommend multifaceted approaches to health.

Bierman240 guideline improving health

AHRQ guide related to research agenda.

Recommend aging as a priority area for research and connecting with stakeholders to improve research capability

Moreland241 guideline fall prevention

46 articles (risk factors); 37 (RCTs)

Risk assessment and exercise

Strong evidence for multi-factorial risk assess and targeted tx. Incl. exercise and home PT.

Tinetti241 guideline fall prevention

Guidelines based on articles from 1980’s to 2002.

Screening for fall risk factors

Good evidence for screening related to: med use, BP, balance and gait, heart health, and home safety.

USPSTF243 guideline screening schedule

Reviews literature up to 1989

Screening for key risk factors

Recommends regular health screenings, particularly related to leading causes of death/disability in elders

Gillespie227 sys. rev. fall prevention

Review of lit from 1970s to 2002; ~ 400 articles.

exercise Muscle strengthening and balance retraining; tai chi by trained professional are all effective.

Burton225 RCT counseling on smoking, alcohol, sedentary lifestyle

3,097 community dwelling Medicare beneficiaries

Yearly preventive visits for 2 years vs. usual care.

No statistically significant difference between groups

Knebel244 RCT Manipulation and shoulder function

29 pts over 65

Spencer technique manip therapy/ 14 weeks

Significant improvements in function

* All guidelines and systematic reviews are included. RCTs rated + or n are included.


RATING STATEMENTS: OLDER ADULTS Low back pain and musculoskeletal pain in older adults Total Rated as high Guidelines statements 0 0 Systematic reviews 0 0 RCTs 2 0 Remaining papers on topic (other designs) 14 -- Ratings based on the body of evidence compiled and evaluated

• C for spinal manipulation for LBP in older adults • C for spinal manipulation for chronic musculoskeletal pain in older adults

Physical activity counseling in older adults

Total Rated as high Guidelines statements 2 2 Systematic reviews 0 0 RCTs 1 1 Remaining papers on topic (other designs) 3 --


• A for physical activity counseling in the elderly


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