Research Review By Dr. Michael Haneline©

Date Posted:

Apr. 2008

Study Title:

Manipulative therapy for lower extremity conditions: Expansion of literature review

Authors:

Brantingham et al.

Author's Affiliations:

Cleveland Chiropractic College, Los Angeles, California, USA

Publication Information:

Journal of Manipulative & Physiological Therapeutics 2009; 32:53-71.

Background Information:

It is very common for chiropractors to diagnose and treat lower extremity conditions. On the other hand, the public primarily views the chiropractic profession as dealing with the spine only. Extremity conditions have been reported to account for up to 20% of all of all chiropractic care that is provided, with about 10% being related to the care of lower extremity conditions.

Christensen et al. (1) reported that 76.1% of chiropractors who responded to their survey reported using spinal and extremity procedures, in contrast to only 18.7% who limited their practice only to the spine. The authors of this review pointed out that chiropractors are well-prepared in their training to manage patients with lower extremity problems.

Because so many chiropractic patients receive treatment for lower extremity conditions, the purpose of this study was to conduct a literature review of the quantity, quality, and types of research that examined lower extremity manipulative therapy; also, to rank, grade, and present the characteristics of these studies.

A review on this topic was published in 2006 by Hoskins et al. (2), though the current review was more general, complete, and up to date. The Hoskins et al. review was the first comprehensive review of the treatment of lower extremity conditions by chiropractic methods.

Pertinent Results:

The authors retrieved 389 citations as a result of their search efforts. Out of these citations, 39 studies were relevant and supplementary to the clinical or controlled trials previously found by Hoskins et al.

Of the 39 selected studies, the regions of involvement and numbers of studies that were included were as follows:
  • knee – 8 studies
  • hip – 1 study
  • ankle – 7 studies
  • foot – 2 studies
A number of case reports and case series that were not included in the previous review were included. The regions of involvement and numbers of studies that were included were as follows:
  • knee – 2 studies
  • hip – 3 study
  • ankle – 2 studies
  • foot – 6 studies
The reported levels of evidence for manipulation combined with exercise therapy of the various regions and for the listed conditions are as follows (see the Methods section below for the meaning of the rating system):
  • manipulative therapy combined with multimodal or exercise therapy of the hip for hip osteoarthritis – C or limited evidence;
  • manipulative therapy of the knee and/or full kinetic chain combined with multimodal or exercise therapy for knee osteoarthritis – B or fair evidence;
  • manipulative therapy of the knee and/or full kinetic chain combined with multimodal or exercise therapy for patellofemoral pain syndrome – B or fair evidence;
  • manipulative therapy of the ankle and/or foot combined with multimodal or exercise therapy for ankle inversion sprain – B or fair evidence;
  • manipulative therapy of the ankle and/or foot combined with multimodal or exercise therapy for plantar fasciitis – C or limited evidence;
  • manipulative therapy of the ankle and/or foot combined with multimodal or exercise therapy for metatarsalgia – C or limited evidence;
  • manipulative therapy of the ankle and/or foot combined with multimodal or exercise therapy for hallux limitus/rigidus – C or limited evidence;
  • manipulative therapy of the ankle and/or foot combined with multimodal or exercise therapy for hallux abducto valgus/bunion – I or insufficient evidence.

Clinical Application & Conclusions:

It was apparent in this review that manipulative therapy for lower extremity disorders is typically multimodal, including exercise, soft tissue treatment, physical therapy modalities, and/or manipulation of the spine or other extremity joints. Using such combinations of therapies, there is fair evidence supporting the treatment of osteoarthritis of the knee, patellofemoral pain syndrome, and ankle inversion sprain. Similarly, there is limited evidence for this type of treatment in patients with osteoarthritis of the hip.

The authors pointed out that the quantity of studies published in the peer-reviewed literature regarding manipulative therapy for lower extremity disorders is a growing. However, further research is needed; especially larger, methodologically improved randomized controlled and clinical trials.

All things considered, based on the evidence presented in this review, practitioners can confidently use manipulative therapy along with ancillary modalities in the treatment of a number of lower extremity conditions.

Study Methods:

This review was carried out during the preparation of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) Best Practices documents using a standardized methodology. The CCGPP has prepared a register of literature syntheses that have considered the evidence base for chiropractic care applicable to each anatomical region. All of the completed documents, including this one on lower extremity conditions, are available on the CCGPP website: http://www.ccgpp.org/view.htm

In developing the search criteria for this review, the term “manipulative therapy” was used rather than “chiropractic treatment”, which was the term used in the earlier review on this topic by Hoskins et al. The authors thought that the use of “manipulative therapy” would facilitate the inclusion of as much literature on manipulative therapy for lower extremity conditions as was possible. Manipulative therapy was defined as mobilization and manipulation grades I-V, with or without adjunctive care.

The specific search terms were as follows:
  1. chiropractic, osteopathic, orthopedic, and physical therapies
  2. manipulation or mobilization
  3. hip, hip injuries, hip dislocation, and hip joint
  4. knee, knee dislocation, knee injuries, knee joint, collateral, meniscus, and patellofemoral
  5. ankle, ankle injuries, tarsal bones, and ankle joint lateral ligament
  6. foot, foot bones, foot injuries, foot joint, and interphalangeal
Five health care related databases were searched for articles published between December 2006 and February 2008 using the just listed search terms.

The abstracts of 389 papers were reviewed and were segregated into three categories; Category 1 included studies that were randomized controlled or clinical trials, Category 2 included case series that involved 3 or more patients, and Category 3 included case studies that involved only 1 or 2 patients.

Articles were excluded for the following reasons:
  1. pain was referred from spinal sites,
  2. there was referral for surgical intervention (unless there was documented full post-surgical healing with or without rehabilitation),
  3. the condition was not amendable to manipulative therapy (e.g., rheumatoid arthritis, fracture, ligament tear with instability),
  4. a red-flag diagnosis was identified, or
  5. there was a diagnosis absent a description of management or intervention.
Three of the authors independently reviewed the papers using predetermined criteria. The quality of the studies was assessed using the Scottish Intercollegiate Guidelines Network (SIGN) ranking system. More specifically, they used a modified Liddle et al. (3) revision of the SIGN scale.

Evidence for manipulation as a treatment for lower extremity conditions was assigned grades of “A, B, C, and I” which was based on the following scheme:

Grade A: good evidence from relevant studies
  • Studies with appropriate designs and sufficient strength to answer the questions.
  • Results are both clinically important and consistent with minor exceptions at most.
  • Results are free of significant doubts about generalizability, bias, and design flaws.
  • Negative studies have sufficiently large sample sizes to have adequate statistical power.
Grade B: fair evidence from relevant studies.
  • Studies of appropriate designs of sufficient strength, but inconsistencies or minor doubts about generalizability, bias, and design flaws, or adequacy of sample size.
  • Evidence solely from weaker designs, but confirmed in separate studies.
Grade C: limited evidence from studies/reviews.
  • Studies with substantial uncertainty due to design flaws or adequacy of sample size.
  • Limited number of studies; weak design for answering the question addressed.
  • No evidence that directly pertains to the addressed question because studies either have not been performed or published, or are not relevant.
Grade I: no recommendation can be made because of insufficient or non-relevant evidence.

Study Strengths / Weaknesses:

This was a sound review of the literature that searched multiple databases, followed rigorous procedures to sort out the studies for inclusion/exclusion, and utilized accepted instruments to evaluate the quality and strength of the included evidence. As a result, new, recent, and previously non-cited publications were discovered and incorporated.

The authors mentioned that they might have missed certain studies because of searching problems or their inclusion criteria being too restrictive. Nonetheless, the strengths far outweigh the weaknesses in this study.

Additional References:

  1. Christensen M, Kollasch M, Ward R, Kelly R, Day A, zumBrunnen J. Job analysis of chiropractic 2005. Greeley, Colorado: National Board of Chiropractic Examiners; 2005. p. 67-100.
  2. Hoskins W, McHardy A, Pollard H, Windsham R, Onley R. Chiropractic treatment of lower extremity conditions; a literature review. J Manipulative Physiol Ther 2006; 29:658-71.
  3. Liddle J, Williamson M, Irwig L. Method for evaluating research and guideline evidence (MERGE). Sydney: New South Wales Department of Health; 1996.