J Manipulative Physiol Ther. 2012 (Mar); 35 (3): 227234 ~ FULL TEXT
Kelly R. Holt, BSc (Chiro), PGDipHSc, Heidi Haavik, BSc (Chiro), PhD, C.
Raina Elley, MBChB, PhD
New Zealand College of Chiropractic,
Auckland, New Zealand.
OBJECTIVE: The purpose of this study was to review the scientific literature on the effects of manual therapy interventions on falls and balance.
METHODS: This systematic review included randomized and quasi-randomized controlled trials that investigated the effects of manual therapy interventions on falls or balance. Outcomes of interest were rate of falls, number of fallers reported, and measures of postural stability. Data sources included searches through June 2011 of Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, MEDLINE, EMBASE, CINAHL, PsycINFO, Allied and Complimentary Medicine, Current Controlled Trials, Manual Alternative and Natural Therapy Index System, Index to the Chiropractic Literature, National Institutes of Health (USA), and Google Scholar.
RESULTS: Eleven trials were identified that met the inclusion criteria. Most trials had poor to fair methodological quality. All included trials reported outcomes of functional balance tests or tests that used a computerized balance platform. Nine of the 11 trials reported some statistically significant improvements relating to balance after an intervention that included a manual therapy component. The ability to draw conclusions from a number of the studies was limited by poor methodological quality or very low participant numbers. A meta-analysis was not performed due to heterogeneity of interventions and outcomes. Only 2 small trials included falls as an outcome measure, but as a feasibility study and a pilot study, no meaningful conclusions could be drawn about the effects of the intervention on falls.
CONCLUSION: A limited amount of research has been published that supports a role for manual therapy in improving postural stability and balance. More well-designed controlled trials with sufficient participant numbers are required to draw meaningful clinical conclusions about the role that manual therapies may play in preventing falls or improving postural stability and balance.
Key Indexing Terms: Accidental Falls, Postural Balance, Manual Therapy, Systematic Review, Chiropractic
From the FULL TEXT Article
Falls are the leading cause of injury-related hospital admissions and death in older adults. [1, 2] Every year, approximately one third of community-dwelling older adults experience 1 or more falls.  Falls occur when the individual is unable to maintain their center of gravity within the base of support provided by their feet. A number of risk factors have been identified that increase the risk of falling including increasing age, lower limb disorders, and balance disorders, among others. When a combination of these risk factors exists, the chance of falling may increase to close to 80% per year. 
Up to 30% of all reported falls result in a serious injury or death,  with crude injury rates associated with falls rising sharply as the population ages.  Worldwide, this is placing an enormous burden on health care providers and caregivers with direct health care costs associated with falls approaching US $30 billion per annum in the United States. 
Besides the economic burden, falls result in a significant social impact. Even if significant injury is avoided, the psychosocial distress associated with having a fall can result in a sense of powerlessness and a less active lifestyle, which results in an increased reliance on the family and community for support and assistance.  This can then lead to depression and a reduced quality of life. 
All health care providers are encouraged to support and encourage patients to make positive behavioral changes where appropriate.  This is particularly true in the area of fall prevention where a number of fall risk factors are modifiable.  Manual therapists have been urged to incorporate the principles of health promotion when providing care to their patients who are at risk for falling. [10, 11] Several resources are available to manual therapists to assist them in this role. [11, 12]
Besides a general public health role, manual therapists may be in a position to assist older patients to prevent falls because of the therapeutic interventions that they use. Manual therapy may include a variety of hands-on techniques used by practitioners such as chiropractors, osteopaths, and physical therapists.  Manual therapists routinely treat patients with lower limb dysfunction, muscle weakness, neck pain, back pain, and other conditions that may affect balance and lead to an increased risk of falling. [4, 14-17] If manual therapy results in successful treatment of conditions that increase fall risk, then it may be possible that manual therapists can play a positive role in fall prevention programs.
Manual therapy may also have a positive influence on fall risk if it results in an improvement in 1 or more of the various components of the nervous system that are important for the maintenance of balance.  These components include the cerebellum, the vestibular system, and the somatosensory system among others. This has led to an area of interest to manual therapists because a number of studies have demonstrated that manual therapy interventions influence the function of the central nervous system. [19-23]
This link may be due to important connections between receptors in the cervical spine in particular, as well as other joints, with the vestibular system, visual system, and other neural systems that are important for maintaining postural stability.  If articular or other lesions interfere with mechanoreceptors within the joints or associated muscle spindles, they may result in reduced postural control and balance.  If manual therapy results in correction or improvement of these lesions, it may lead to improved integration of neurologic information in the central nervous system that is important for the maintenance of balance and, therefore, the prevention of falls. [19, 25] The objective of this study was to review the scientific literature on the effects of manual therapy interventions on falls and balance.
This systematic review summarizes the current evidence that relates to the effects of manual therapies on balance and falls. It is the first systematic review to do so. This study revealed that there is no published research that adequately investigates the role that manual therapy may play in preventing falls. There is, however, a limited amount of research that supports a role for manual therapy in improving postural stability and balance.
Although a number of the included trials reported positive findings associated with balance measures after manual therapy interventions, poor methodological quality, low participant numbers, or inadequate follow-up times mean that these results must be interpreted with caution when attempting to assess whether they represent clinically significant findings.
The manual therapy interventions that were associated with positive results included
talocrural joint manipulation [29, 35]
thoracic spine mobilization with soft tissue massage 
physiotherapy treatment including massage, soft tissue treatment, or mobilization [31, 34]
chiropractic care including spinal manipulative therapy and extravertebral manipulation [32, 36]
osteopathic manipulative therapy 
sustained natural apophyseal glides , and
massage and mobilization of the feet and ankles. 
The positive results that were reported after these interventions included improved postural sway, [27, 29, 31, 34, 35, 37] improvement in functional balance tests, [30, 33, 36] and improvement in measures of dizziness. [27, 32, 34] Only 1 trial of sound methodological quality and with acceptable participant numbers reported favorable clinically significant balance outcomes after a manual therapy intervention.  The intervention in this trial was treatment over a 4-week period using sustained natural apophyseal glides and the outcomes that improved included measures of dizziness and balance. The improvements reported persisted over the 12-week posttreatment follow-up period.
When considering the methodological quality of included studies, it should be acknowledged that this review judged studies using an assessment tool that is designed to assess the risk of bias in intervention studies. The authors would like to acknowledge that a basic science study or feasibility study may be well designed to answer the questions it poses but score poorly on an assessment of its risk of bias when considered as a clinical intervention study.
A number of systematic reviews and meta-analyses have reported the role of various other intervention strategies on balance and falls. A considerable amount of evidence supports the role of exercise for modifying fall risk, improving balance, and preventing falls (pooled rate ratio, 0.84; 95% confidence interval [CI], 0.77-0.91).  Tai chi has been reported to have similar benefits as other exercise interventions for improving balance and the prevention of falls (pooled rate ratio, 0.63; 95% CI, 0.52-0.78) ; however, there has been a call for further research on the role of tai chi for fall prevention because a subsequent meta-analysis reported results that did not reach statistical significance (pooled rate ratio, 0.79; 95% CI, 0.60-1.03).  Other interventions such as vitamin D supplementation, home safety interventions, medication withdrawal or modification, use of pacemakers, and cataract surgery have been shown to be beneficial for reducing the rate of falls in certain at-risk groups. 
Limitations and Future Research
The conclusions that can be drawn from this review are limited by a lack of quality trials available for inclusion. Bias due to study design and quality exists because a number of the included trials were basic science studies or pilot or feasibility studies. Many of the trials included low participant numbers or healthy subjects as participants, or investigated outcomes before and after a single intervention with no long-term follow-up or control group. The conclusions that can be made from this review are also limited due to a considerable amount of heterogeneity existing between interventions and outcomes, which meant that no meta-analysis was possible.
Selection bias may have occurred in this review as only 1 person conducted the literature search and article selection phase of the review. However, the search was robust, and the list of studies identified by the literature review was analyzed on 2 separate occasions to ensure that all eligible studies were included in the data extraction phase of the review. In addition, quality assessment was undertaken by 2 authors, separately. Although the literature search was robust, the exclusion criteria for this review meant that trials lacking a control group were not included due to the greater chance of bias associated with their study design. This resulted in the omission of some relevant single-group studies that assessed manual therapy interventions for balance and falls. [41, 42]
The key finding from this review is that more well-designed controlled trials with sufficient participant numbers are required to draw meaningful clinical conclusions about the role that manual therapies may play in preventing falls or improving postural stability and balance. This review also highlights the need for future trials to include participants who are at risk for falling or have reduced postural stability, as opposed to healthy volunteers in order for the results to be valid for the population at most risk.
No published research was identified that adequately investigates the role that manual therapy may play in preventing falls. A limited amount of research has been published that supports a role for manual therapy in improving postural stability and balance. Further research incorporating more rigorous study design and appropriate participant selection and outcome measures is required to adequately investigate the role manual therapy may play in preventing falls and improving postural stability and balance in older people.
A limited amount of research has been published that supports a role for manual therapy in improving postural stability and balance.
No published research was identified that adequately investigates the role that manual therapy may play in preventing falls.
Further well-designed controlled trials with sufficient participant numbers are required to investigate whether manual therapy may play a role in preventing falls or improving postural stability and balance.
Stephenson, S, Langley, J, and Trotter, M.
Impact of injury in New Zealand. 2nd ed.
Injury Prevention Research Unit, Dunedin; 2005
Kannus, P, Khan, KM, and Lord, SR.
Preventing falls among elderly people in the hospital environment.
Med J Aust. 2006; 184: 372373
Gill, T, Taylor, AW, and Pengelly, A.
A population-based survey of factors relating to the prevalence of falls in older people.
Gerontology. 2005; 51: 340345
Prevention of falls in older patients.
Am Fam Physician. 2005; 72: 8188
Chang, JT, Morton, SC, Rubenstein, LZ,
Mojica, WA, Maglione, M, Suttorp, MJ et al.
Interventions for the prevention of falls in older adults:
systematic review and meta-analysis of randomised clinical trials.
Br Med J. 2004; 328: 680
Taylor, D and Stretton, C.
The Otago exercise programme: an evidence-based approach to falls prevention
for older adults living in the community.
N Z Fam Physician. 2004; 31: 391394
Kong, KS, Lee, FK, Mackenzie, AE, and Lee, DT.
Psychosocial consequences of falling: the perspective of older Hong Kong Chinese
who had experienced recent falls.
J Adv Nurs. 2002; 37: 234242
Hawk, C, Rupert, RL, Hyland, JK, and Odhwani, A.
Implementation of a course on wellness concepts into a chiropractic college curriculum.
J Manipulative Physiol Ther. 2005; 28: 423428
Nachreiner, NM, Findorff, MJ, Wyman, JF, and McCarthy, TC.
Circumstances and consequences of falls in community-dwelling older women.
J Womens Health (Larchmt). 2007; 16: 14371446
Holt, KR, Noone, PL, Short, K, Elley, CR, and Haavik, H.
Fall risk profile and quality-of-life status of older chiropractic patients.
J Manipulative Physiol Ther. 2011; 34: 7887
Geriatric chiropractic care as a health promotion and disease prevention
initiative: focus on fall prevention.
Top Integr Health Care. 2010; 1: 15
Larson, L and Bergmann, T.
Taking on the fall: the etiology and prevention of falls in the elderly.
Clin Chiropr. 2008; 11: 148154
Hondras, MA, Linde, K, and Jones, AP.
Manual therapy for asthma.
Cochrane Database Syst Rev. 2005; : CD001002
American Geriatrics Society.
Guideline for the prevention of falls in older persons.
American Geriatrics Society, British Geriatrics Society,
and American Academy of Orthopaedic Surgeons Panel on Falls Prevention.
J Am Geriatr Soc. 2001; 49: 664672
Bryant, S, Atkins, BW, and Bull, PW.
Demographics and diagnostic profile of patients presenting to a
university chiropractic outpatient clinic.
Chiropr J Aust. 2003; 33: 8992
Holt, KR and Beck, RW.
Chiropractic patients presenting to the New Zealand College of Chiropractic
teaching clinic: a short description of patients and patient complaints.
Chiropr J Aust. 2005; 35: 122124
Rubenstein, LZ and Josephson, KR.
Falls and their prevention in elderly people: what does the evidence show?.
Med Clin North Am. 2006; 90: 807824
Della Volpe, R, Popa, T, Ginanneschi, F,
Spidalieri, R, Mazzocchio, R, and Rossi, A.
Changes in coordination of postural control during dynamic stance
in chronic low back pain patients.
Gait Posture. 2005; 24: 24
Haavik Taylor, H, Holt, K, and Murphy, B.
Exploring the Neuromodulatory Effects of
the Vertebral Subluxation and Chiropractic Care
Chiropractic Journal of Australia 2010 (Mar); 40 (1): 3744
Haavik, H and Murphy, B.
Subclinical Neck Pain and the Effects of Cervical Manipulation on Elbow Joint Position Sense
J Manipulative Physiol Ther. 2011 (Feb); 34 (2): 8897
Haavik Taylor, H and Murphy, B.
Altered Central Integration of Dual Somatosensory
After Cervical Spine Manipulation
J Manipulative Physiol Ther. 2010 (Mar); 33 (3): 178188
Haavik-Taylor, H and Murphy, B.
Transient modulation of intracortical inhibition following spinal manipulation.
Chiropr J Aust. 2007; 37: 106116
Haavik-Taylor, H and Murphy, B.
Cervical Spine Manipulation
Alters Sensorimotor Integration:
A Somatosensory Evoked Potential Study
Clin Neurophysiol. 2007 (Feb); 118 (2): 391402
Sensorimotor disturbances in neck disorders affecting postural stability,
head and eye movement control.
Man Ther. 2008; 13: 211
Walsh, MJ, Polus, BI, and Webb, MN.
The role of the cervical spine in balance and risk of falling in the elderly.
Chiropr J Aust. 2004; 34: 1922
Poolman, RW, Struijs, PA, Krips, R, Sierevelt, IN, Lutz, KH, and Bhandari, M.
Does a Level I Evidence rating imply high quality of reporting in
orthopaedic randomised controlled trials?.
BMC Med Res Methodol. 2006; 6: 44
Reid, SA, Rivett, DA, Katekar, MG, and Callister, R.
Sustained natural apophyseal glides (SNAGs) are an effective treatment
for cervicogenic dizziness.
Man Ther. 2008; 13: 357366
Palmgren, PJ, Lindeberg, A, Nath, S, and Heikkila, H.
Head repositioning accuracy and posturography related to cervical facet
nerve blockade and spinal manipulative therapy in healthy volunteers: a time series study.
J Manipulative Physiol Ther. 2009; 32: 193202
Alburquerque-Sendin, F, Fernandez-de-las-Penas, C,
Santos-del-Rey, M, and Martin-Vallejo, FJ.
Immediate effects of bilateral manipulation of talocrural joints
on standing stability in healthy subjects.
Man Ther. 2009; 14: 7580
Bennell, KL, Hinman, RS, Metcalf, BR, Buchbinder, R,
McConnell, J, McColl, G et al.
Efficacy of physiotherapy management of knee joint osteoarthritis:
a randomised, double blind, placebo controlled trial.
Ann Rheum Dis. 2005; 64: 906912
Giemza, C, Ostrowska, B, and Matczak-Giemza, M.
The effect of physiotherapy training programme on postural stability in men
with hip osteoarthritis.
Aging Male. 2007; 10: 6770
Hawk, C, Cambron, JA, and Pfefer, MT.
Pilot Study of the Effect of a Limited and Extended Course
of Chiropractic Care on Balance, Chronic Pain, and
Dizziness in Older Adults
J Manipulative Physiol Ther. 2009 (Jul); 32(6): 438447
Vaillant, J, Rouland, A, Martigne, P,
Braujou, R, Nissen, MJ, Caillat-Miousse, JL et al.
Massage and mobilization of the feet and ankles in elderly adults:
effect on clinical balance performance.
Man Ther. 2009; 14: 661664
Karlberg, M, Magnusson, M, Malmstrom, EM, Melander, A, and Moritz, U.
Postural and symptomatic improvement after physiotherapy in patients with dizziness
of suspected cervical origin.
Arch Phys Med Rehabil. 1996; 77: 874882
Hoch, MC and McKeon, PO.
Joint mobilization improves spatiotemporal postural control and range of motion
in those with chronic ankle instability.
J Orthop Res. 2011; 29: 326332
Hawk, C, Pfefer, MT, Strunk, R, Ramcharan, M, and Uhl, N.
Feasibility Study of Short-term Effects of Chiropractic
on Older Adults With Impaired Balance
J Chiropr Med. 2007 (Dec); 6 (4): 121131
Jones D, Fryer G, Vaughan B, McLaughlin P.
The effect of osteopathic manipulative therapy applied to the lumbar spine
on postural stability: a pilot study [masters thesis].
Victoria University, 2004
Sherrington, C, Tiedemann, A, Fairhall, N, Close, JC, and Lord, SR.
Exercise to prevent falls in older adults: an updated meta-analysis and
best practice recommendations.
N S W Public Health Bull. 2011; 22: 7883
Gillespie, LD, Robertson, MC, Gillespie, WJ,
Lamb, SE, Gates, S, Cumming, RG et al.
Interventions for preventing falls in older people living in the community.
Cochrane Database Syst Rev. 2009; : CD007146
Logghe, IH, Verhagen, AP, Rademaker, AC, Bierma-Zeinstra, SM,
van Rossum, E, Faber, MJ et al.
The effects of tai chi on fall prevention, fear of falling and balance in older people:
Prev Med. 2010; 51: 222227
Hawk, C and Cambron, J.
Chiropractic Care for Older Adults:
Effects on Balance, Dizziness, and Chronic Pain
J Manipulative Physiol Ther. 2009 (Jul); 32 (6): 431437
Strunk, RG and Hawk, C.
Effects of Chiropractic Care on Dizziness,
Neck Pain, and Balance:
A Single-group, Preexperimental, Feasibility Study
J Chiropr Med. 2009 (Dec); 8 (4): 156164
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