J Manipulative Physiol Ther. 2009 (Jul); 32(6): 438447 ~ FULL TEXT
Cheryl Hawk, DC, PhD, Jerrilyn A. Cambron, DC, PhD, Mark T. Pfefer, RN, MS, DC
Cleveland Chiropractic College,
Kansas City, Mo, USA.
OBJECTIVE: The purpose of this study was to collect preliminary information on the effect of a limited and extended course of chiropractic care on balance, chronic pain, and associated dizziness in a sample of older adults with impaired balance.
METHODS: The authors conducted a randomized pilot study targeting a sample size of 30, comparing 2 schedules of chiropractic care to a no-treatment group. Group 1 (limited schedule) was treated for 8 weeks, group 2 (extended schedule) was treated for 8 weeks and then once per month for 10 months, and group 3 received no treatment. Assessments were made at baseline and 1, 2, 6, and 12 months later. The primary outcome was changed in the Berg Balance Scale (BBS) from baseline to 1 year. Changes in the Pain Disability Index and Dizziness Handicap Index were also measured.
RESULTS: Thirty-four patients were enrolled, 13 in group 1, 15 in group 2, and 6 in group 3. Only 5 had baseline BBS scores less than 45, indicating increased risk for falls. There were no treatment-related adverse events. Nine patients dropped out by 1 year. No significant differences within or between groups in median BBS from baseline to 12 months were observed. Median Pain Disability Index scores improved more from baseline to 1 year in group 2 compared with groups 1 and 3 (P = .06, Kruskal-Wallis test). For the 9 patients with dizziness, a clinically significant improvement in Dizziness Handicap Index scores of groups 1 and 2 was observed at 1 month and remained lower than baseline thereafter; this was not true of group 3.
CONCLUSION: Further investigation of the possible benefit of chiropractic maintenance care (extended schedule) for balance and pain-related disability is feasible and warranted, as well as both limited and extended schedules for patients with idiopathic dizziness.
From the FULL TEXT Article
Falls are one of the chief public health concerns for older adults, being the leading cause of nonfatal injury and comprising two thirds of all unintentional injury deaths in this population.  Direct medical costs of falls are estimated to be $6 to $8 billion per year.  Not only is the number of older adults increasing, but also the fall death rates have increased significantly from 1988 to 2000 for both men and women. 
Falls are the result of interactions of intrinsic and extrinsic risk factors. Fall prevention requires that potentially modifiable risk factors, whether intrinsic or extrinsic, be identified. According to a 2003 evidence-based guideline, impairments in balance and gait are among the most important modifiable risk factors for falls. [4, 5]
Although there is considerable evidence for the effectiveness of chiropractic care, which includes spinal manipulative therapy (SMT) on musculoskeletal conditions of the spine and extremities, [6-8] few studies have investigated its possible impact on balance and fall prevention. [9-11] A possible rationale for such an impact might posit that, because chronic musculoskeletal pain, such as that of osteoarthritis, is one factor affecting gait and balance in older people, chiropractic care may impact fall prevention by treating joint pain and stiffness. Also, the literature suggests a possible positive effect of SMT on certain types of vertigo.  Concerning gait abnormalities, falls may be initiated by muscular weakness of the lower extremity or degenerative diseases affecting the spine, hip, knees, or feet, all of which give rise to subtle deficits.  Evidence exists that there is a relationship between muscle inhibition and joint dysfunction within the lower extremity and the spine. Suter et al  showed decrease in muscle inhibition and increase in knee extensor torques and muscle activation after manipulation of the sacroiliac joints in patients with lower extremity joint dysfunction. Childs et al15 showed immediate improvements in side-to-side weight bearing and iliac crest symmetry after SMT in patients with low back pain. Several studies have shown consistent reflex response associated with SMT. [14, 16, 17, 18] Based upon these studies, it is possible that SMT may have positive effects in older patients with pain, joint dysfunction, and/or vertigo.
Although it is naοve to expect that any single intervention will completely address the multifactorial issue of fall prevention, certainly, it is valuable to add to the current armamentarium of interventions, which may reduce any risk factors. The purpose of this study was to collect preliminary information on the effect of a short and longer course of chiropractic care on balance, chronic pain, and associated dizziness in a sample of older adults with impaired balance.
There are a number of limitations to this study; examining these provides guidance in designing future studies. First, there were limitations related to the sample. This pilot study had a small sample size, precluding inferential statistics. However, we were able to gather information about the overall use of the outcome measures for similar populations. This will be discussed below. Our sample, largely recruited through a fitness center for older adults, may not be generalizable. These patients were relatively healthy and more active than the norm, with only 5 of 34 having an increased risk for falls on the BBS at baseline. A related limitation was a possible ceiling effect for the BBS, which has been suggested by others. 
Second were limitations related to enrollment and attrition. There was a failure of randomization with 9 patients (27%). The unwillingness of our patient population to accept assignment to a group they did not prefer is important to consider for future studies. It is similar to a previous study conducted by the principal investigator in another location but with a similar population of community-dwelling older adults.  Premature adoption of a randomized design may not be the best strategy to gather larger samples for exploratory areas such as ours. The studies we have undertaken while this one was running are single group interventions or observational practice-based research projects, which provide in-depth information of a pragmatic nature, to inform the development of larger controlled studies. Attrition was also high (27%) in this 1-year study. Only 2 dropped out for study-related reasons; the others dropped out for health-related events. With this age group, it may be necessary to plan for greater levels of attrition.
Results of this study were helpful in directing our future research efforts. First, this pilot study showed that the most feasible approach is an observational design. Because large observational studies have been shown to yield similar, yet more generalizable, results than experimental designs, we feel this is a reasonable direction. [46, 47]
Second, the BBS did not appear to have use in identifying balance problems or as a measure of clinical change for our patient population. The patients reported falls at a similar, or even higher, rate than the norm, but their baseline BBS scores did not reflect a risk for falls and did not correlate with their OLST scores. Because of this, added to both the fact that the BBS takes longer than 10 minutes to conduct and that recent evidence published since our study was implemented calls the use of the BBS into question,  we are now using the Timed-Up-and-Go test to assess balance. 
Third, it is possible that with a larger sample followed over a longer period, collecting actual falls data rather than an intermediate measure such as the BBS or timed up to go, subgroup analysis might allow us to identify whether certain groups of patients might benefit from SMT. Our results indicate that patients with dizziness appeared to show improvement in their DHI scores with chiropractic care. A decrease in dizziness might well reduce fall incidence yet not be observed when conducting a balance test, because dizziness is episodic. We are currently directing research efforts toward assessing balance in patients with cervicogenic vertigo. 
Fourth, it appears that incorporating a question about falls into the clinical notes could readily be implemented into chiropractic practice. We are currently using this in a practice-based research study with patients 65 years and older.
An interesting finding was that there was no difference in outcomes between patients treated with HVLA and modified force techniques, and there were no adverse events associated with either treatment approach. This may be because the clinicians were careful to tailor the technique to the individual patient's needs.
Another interesting finding in this study that warrants further investigation is that it appeared that for the group on the extended care schedule, pain and disability decreased and remained at a lower level than for the limited care schedule, for the year we followed patients. This provides preliminary support for chiropractic maintenance care for older adults with chronic pain. This finding adds to the currently extremely sparse literature on this topic.  Less striking, yet still warranting further investigation, was the decrease in dizziness over time with both chiropractic care schedules.
Further investigation of the possible benefit of chiropractic maintenance care (extended schedule) for balance and pain-related disability is feasible and warranted, as well as both limited and extended schedules for patients with idiopathic dizziness.
Further investigation of the possible benefit of chiropractic maintenance care
for balance and pain-related disability is feasible and warranted.
Further investigation of chiropractic care for patients with idiopathic dizziness
is feasible and warranted.
Conflicts of Interest
This study was partially funded by grant 06-10-02 from the Foundation for Chiropractic Education and Research and by Cleveland Chiropractic College, Kansas City, Mo. The authors report no conflicts of interest.
The authors thank Cleveland Chiropractic Research Center, Overland Park, KS, research coordinators Jennifer Bedard and Cathy Evans for their help in managing patient assessment and scheduling. They thank Kenneth R. Blom, president of Stratford Development Corporation, and Debra Wood-Fowler, Director of Fit for Life, Raytown, MO, for providing space for treatment at the Fit for Life facility and facilitating the study. They also thank research faculty clinicians Michael Ramcharan, DC; Richard Strunk, DC, MS; and Nathan Uhl, DC, for their clinical expertise.
Clinical practice. Preventing falls in elderly persons.
N Engl J Med. 2003; 348: 4249
Carroll, NV, Slattum, PW, and Cox, FM.
The cost of falls among the community-dwelling elderly.
J Manag Care Pharm. 2005; 11: 307316
Stevens, JA, Corso, PS, Finkelstein, EA, and Miller, TR.
The costs of fatal and nonfatal falls among older adults.
Inj Prev. 2006; 12: 290295
Englander, F, Hodson, TJ, and Terregrossa, RA.
Economic dimensions of slip and fall injuries.
J Forensic Sci. 1996; 41: 733746
Moreland, J, Richardson, J, Chan, DH et al.
Evidence-based guidelines for the secondary prevention of falls in older adults.
Gerontology. 2003; 49: 93116
Brantingham, JW, Globe, G, Pollard, H,
Hicks, M, Korporaal, C, and Hoskins, W.
Manipulative therapy for lower extremity conditions: expansion of literature review.
J Manipulative Physiol Ther. 2009; 32: 5371
Bronfort, G, Haas, M, Evans, R, Kawchuk, G, and Dagenais, S.
Evidence-informed management of chronic low back pain with spinal manipulation and mobilization.
Spine J. 2008; 8: 213225
Hurwitz, EL, Carragee, EJ, van der Velde, G et al.
Treatment of Neck Pain: Noninvasive Interventions: Results of the Bone and Joint Decade
20002010 Task Force on Neck Pain and Its Associated Disorders
Spine (Phila Pa 1976). 2008 (Feb 15); 33 (4 Suppl): S123152
Hawk, C, Pfefer, M, Strunk, R, Ramcharan, M, and Uhl, N.
Feasibility study of short-term effects of chiropractic manipulation on older adults with impaired balance.
J Chiropr Med. 2007; 6: 121131
Hawk, C, Hyland, J, Rupert, R, Colonvega, M, and Hall, S.
Assessment of balance and risk for falls in a sample of community-dwelling adults aged 65 and older.
Chiropr Osteopat. 2006; 14: 313
Hawk, C, Rupert, R, Colonvega, M, Hall, S, Boyd, J, and Hyland, J.
Chiropractic care for older adults at risk for falls: a preliminary assessment.
J Am Chiropr Assoc. 2005; 42: 1018
Reid, SA and Rivett, DA.
Manual therapy treatment of cervicogenic dizziness: a systematic review.
Man Ther. 2005; 10: 413
Geriatric practice-specific issues.
in: S Haldeman (Ed.) Principles and Practice of Chiropractic. 3rd ed.
McGraw-Hill, New York; 2005: 10791098
Suter, E, McMorland, G, Herzog, W, and Bray, R. Decrease in quadriceps inhibition after sacroiliac joint manipulation in patients with anterior knee pain. J Manipulative Physiol Ther. 1999; 22: 149153
Childs, JD, Piva, SR, and Erhard, RE.
Immediate improvements in side-to-side weight bearing and iliac crest symmetry after manipulation in patients with low back pain.
J Manipulative Physiol Ther. 2004; 27: 306313
Colloca, CJ, Keller, TS, and Gunzburg, R.
Biomechanical and neurophysiological responses to spinal manipulation in patients with lumbar radiculopathy.
J Manipulative Physiol Ther. 2004; 27: 115
Dishman, JD and Bulbulian, R.
Comparison of effects of spinal manipulation and massage on motoneuron excitability.
Electromyogr Clin Neurophysiol. 2001; 41: 97106
Herzog, W, Scheele, D, and Conway, PJ.
Electromyographic responses of back and limb muscles associated with spinal manipulative therapy.
Spine. 1999; 24: 146152 ([discussion 153])
in: M Whaley (Ed.) American College of Sports Medicine's guidelines for exercise testing and prescription. 7th ed.
Lippincott Williams & Wilkins, Philadelphia; 2006: 237247
Green, H, McEntegart, D, Byrom, B, Ghani, S, and Shepherd, S.
Minimization in crossover trials with non-prognostic strata: theory and practical application.
J Clin Pharm Ther. 2001; 26: 121128
Stevens, J and Olson, S.
Check for safety: a home fall prevention checklist for seniors.
in: U.S. Department of Health and Human Services, Centers for Disease Prevention and Control (Ed.)
National Center for Injury Prevention and Control.
Centers for Disease Prevention and Control, Atlanta; 1999
National Institute on Aging. Exercise:
a guide from the National Institute on Aging.
Bethesda: National Institute on Aging. (Available from:)
Christensen, M, Kollasch, M, Ward, R, Webb, K, Day, A, and ZumBrunnen, J.
Job analysis of chiropractic.
National Board of Chiropractic Examiners, Greeley (Colo); 2005
Lamb, SE, Jorstad-Stein, EC, Hauer, K, and Becker, C.
Development of a common outcome data set for fall injury prevention trials: the Prevention of Falls Network Europe consensus.
J Am Geriatr Soc. 2005; 53: 16181622
Bogle-Thorbahn, L and Newton, R.
Use of the Berg balance test to predict falls in elderly persons.
Phy Ther. 1996; 76: 576583
Harada, N, Chiu, V, Damron-Rodriguez, J,
Fowler, E, Siu, A, and Reuben, DB.
Screening for balance and mobility impairment in elderly individuals living in residential care facilities.
Phys Ther. 1995; 75: 462469
Shumway-Cook, A, Baldwin, M, Polissar, NL, and Gruber, W.
Predicting the probability for falls in community-dwelling older adults.
Phys Ther. 1997; 77: 812819
Whitney, SL, Poole, JL, and Cass, SPA.
Review of balance instruments for older adults.
Am J Occup Ther. 1998; 52: 666671
Lajoie, Y and Gallagher, SP.
Predicting falls within the elderly community: comparison of postural sway, reaction time, the Berg Balance Scale and the Activities-specific Balance Confidence (ABC) scale for comparing fallers and non-fallers.
Arch Gerontol Geriatr. 2004; 38: 1126
Steffen, T and Seney, M.
Test-retest reliability and minimal detectable change on balance and ambulation tests, the 36-item short-form health survey, and the unified Parkinson disease rating scale in people with parkinsonism.
Phys Ther. 2008; 88: 733746
Atwater, S, Crowe, T, Deitz, J, and Richardson, P.
Interrater and test-retest reliability of two pediatric balance tests.
Phys Ther. 1990; 70: 7987
Drusini, AG, Eleazer, GP, Caiazzo, M et al.
One-leg standing balance and functional status in an elderly community-dwelling population in northeast Italy.
Aging Clin Exp Res. 2002; 14: 4246
Shimada, H, Uchiyama, Y, and Kakurai, S.
Specific effects of balance and gait exercises on physical function among the frail elderly.
Clin Rehabil. 2003; 17: 472479
Maki, B, Holliday, P, and Topper, A.
A prospective study of postural balance and risk of falling in an ambulatory and independent elderly population.
Gerontology. 1997; : M72M84
Chibnall, JT and Tait, RC.
The Pain Disability Index: factor structure and normative data.
Arch Phys Med Rehabil. 1994; 75: 10821086
Gronblad, M, Jarvinen, E, Hurri, H, Hupli, M, and Karaharju, EO.
Relationship of the Pain Disability Index (PDI) and the Oswestry Disability Questionnaire (ODQ) with three dynamic physical tests in a group of patients with chronic low-back and leg pain.
Clin J Pain. 1994; 10: 197203
Tait, RC, Chibnall, JT, and Krause, S.
The Pain Disability Index: psychometric properties.
Pain. 1990; 40: 171182
Tait, RC, Pollard, CA, Margolis, RB, Duckro, PN, and Krause, SJ.
The Pain Disability Index: psychometric and validity data.
Arch Phys Med Rehabil. 1987; 68: 438441
Hawk, C, Long, C, Reiter, R, Davis, C, Cambron, J, and Evans, R.
Issues in planning a placebo-controlled trial of manual methods: results of a pilot study.
J Alt complementary Med. 2002; 8: 2132
Hawk, C, Long, CR, Rowell, RM, Gudavalli, MR, and Jedlicka, J.
A randomized trial investigating a chiropractic manual placebo: a novel design using standardized forces in the delivery of active and control treatments.
J Altern Complement Med. 2005; 11: 109117
Hawk, C, Rupert, R, Colonvega, M, Boyd, J, and Hall, S.
Comparison of bio-energetic synchronization technique and customary chiropractic care for older adults with chronic musculoskeletal pain.
J Manipulative Physiol Ther. 2006; 29: 540549
Nordstrom, DC, Konttinen, YT, Solovieva, S, Friman, C, and Santavirta, S.
In- and out-patient rehabilitation in rheumatoid arthritis. A controlled, open, longitudinal, cost-effectiveness study.
Scand J Rheumatol. 1996; 25: 200206
Wall, J, Lichtenberg, P, MacNeill, S, Walsh, P, and Deshpande, S.
Depression detection in geriatric rehabilitation: Geriatric Depression Scale short form vs long form.
Clin Gerontol. 1999; 20: 1321
Outcome measures for assessment of treatment of the dizzy and balance disorder patient.
Otolaryngol Clin North Am. 2000; 33: 519533
Jacobson, GP and Newman, CW.
The development of the Dizziness Handicap Inventory.
Arch Otolaryngol Head Neck Surg. 1990; 116: 424427
Concato, J, Shah, N, and Horwitz, RI.
Randomized, controlled trials, observational studies, and the hierarchy of research designs.
N Engl J Med. 2000; 342: 18871892
Evidence summaries and synthesis: necessary but insufficient approach for determining clinical practice of integrated medicine?.
Integrative Cancer Ther. 2006; 5: 15
Muir, S, Berg, K, Chesworth, B, and Speechley, M.
Use of the Berg Balance Scale for predicting multiple falls in community-dwelling elderly people: a prospective study.
Phys Ther. 2008; 88: 449459
Shumway-Cook, A, Brauer, S, and Woollacott, M.
Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test.
Phys Ther. 2000; 80: 896903
Strunk, RG and Hawk, C.
Effects of chiropractic care on dizziness, vertigo and balance: a single group pre-experimental feasibility study.
Proceedings of the World Federation of Chiropractic Biennial Congress;
2009 Apr 30-May 2; Montreal, Quebec, Canada.
World Federation of Chiropractic, Toronto; 2009
Leboeuf-Yde, C and Hestbaek, L.
Maintenance care in chiropracticwhat do we know?.
Chiropr Osteopat. 2008; 16: 3
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