Background
Main text
Conceptual framework for studying the impact of multimodal chiropractic care on falls, postural control, and gait health
Musculoskeletal strength
Musculoskeletal flexibility
Pain
Proprioception
Vestibular function
Polypharmacy
Education
Systematic review of the impact of chiropractic care on falls, postural control, and gait health
Methods
Literature search
Literature Searched | Search Terms |
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PubMed | (chiropractic [Mesh] OR chiro*[Mesh] OR chiropractic [tiab] OR chiro* [tiab] OR “chiro* manipulation”) AND (gait [Mesh] OR gait [tiab] OR fall [Mesh] OR fall [tiab] OR balance [mesh] OR balance [tiab] OR vestibul* OR dizz*) |
Embase | (‘chiropractic’/exp. OR chiropractic OR chiro OR chiropractice OR ‘chiropractice care’ OR (chiropractice AND (‘care’/exp. OR care))) AND (‘gait’/exp. OR gait OR ‘exp gait’ OR (exp AND (‘gait’/exp. OR gait)) OR ‘falling’/exp. OR falling OR ‘balance’/exp. OR balance OR ‘exp balance’ OR (exp AND (‘balance’/exp. OR balance)) OR vestibular OR ‘dizz*or dizzy’ OR (dizz*or AND dizzy)) AND (‘Article’/it OR ‘Article in Press’/it) |
Cochrane Library | (chiropractic or chiro):ti,ab,kw AND (gait or fall or balance or vestibular):ti,ab,kw |
PEDro | 1. chiro* AND gait |
2. chiro* AND fall* | |
3. chiro* AND balance | |
4. chiro* AND vestibular | |
5. chiro* AND dizz* | |
ICL | All Fields:chiro* AND All Fields:gait OR All Fields:fall* OR All Fields:balance OR All Fields:vestibular OR All Fields:dizz*, Publication Type:Clinical Trial OR All Fields:chiro* AND All Fields:gait OR All Fields:fall* OR All Fields:balance OR All Fields:vestibular OR All Fields:dizz*, Publication Type:Randomized Controlled Trial OR All Fields:chiro* AND All Fields:gait OR All Fields:fall* OR All Fields:balance OR All Fields:vestibular OR All Fields:dizz*, Publication Type:Controlled Clinical Trial |
Eligibility criteria and synthesis
Study selection and data extraction
Risk of bias assessment
Results
Participants’ characteristics and study settings
Main Author, Year (country) | Type of study | Sample (mean age) | Study Population | Intervention | Intervention: Frequency /duration | Control group | Control: Frequency/ duration | Measured outcomes | Relevant Findings |
---|---|---|---|---|---|---|---|---|---|
Bracher, 2000 (Brazil) [164] | SACT | 15 (41 median) | Adults (27–82), in otorhinolaryngology practice, dizziness and diagnosis of cervical vertigo | Multimodal chiropractic (spinal manipulation, manual techniques, electrotherapy, medication (sedation), biofeedback, exercise) | Individual, as needed, mean 5 (3–10) | – | – | Vertigo severity, Musculo-skeletal Pain | Descriptive statistics reported from baseline to study completion: • 9 patients (60%) reported complete remission of vertigo symptoms. • 3 patients (20%) reported improved vertigo symptoms. |
Hawk, 2007 (USA) [158] | RCT | 11 (73.0) | Older adults (60+), OLST < 5 sec, ambulatory, no balance exercises | Multimodal (spinal manipulation, soft tissue and myofascial release, heat) | 2x weekly, over 8 weeks (16 sessions total) | 8 balance exercises | 2x weekly, over 8 weeks (16 sessions total) | BBS, OLST, PDI, DHI, self-reported falls | Descriptive statistics reported little detectable change from baseline to study completion in the collected outcomes of intervention group: • Change in DHI scores ranged: − 12 to 32. • Change in BBS scores ranged: − 5 to 16. • Change in OLST scores ranged: − 5 to 0. • No trends observed in collected falls data. |
SACT | 14 (77.0) | Older adults (60+), OLST < 5 sec, ambulatory, no recent SM | Multimodal chiropractic, (HVLA, other manipulations, soft tissue treatment, hot packs) | 2x weekly over 8 weeks (16 sessions total) | – | – | SF-BBS, OLST, PDI, DHI, GDS | Descriptive statistics reported from baseline to study completion: • 3/6 patients with baseline DHI scores indicating dizziness, showed clinically significant reduction (> 18 points). • Little to no trends observed in both SF-BBS and OLST scores. | |
RCT | 34 (80) | Older adults (60+), OLST < 5 sec, ambulatory, no balance exercises | Multimodal chiropractic (spinal manipulation, soft tissue and myofascial release, heat; hip, knee ankle) | GR1: 2x weekly, over 8 weeks (16 sessions total) GR2: 2x weekly, over 8 weeks + 10 monthly visits, over 10 months (26 sessions total) | GR3: Home-based balance exercises | Over the study period, no established frequency | BBS, OLST, PDI, DHI, GDS, self-reported falls (in clinical notes) | Descriptive findings reported from baseline to study completion: • Trend toward increasing BBS scores in GR2. • DHI scores improved in GR1 and GR2. • Reporting of falls was not equal among groups (GR1: 18 visits, 6 reported falls. GR2: 26 visits, 9 reported falls. GR3: 5 visits, 0 reported falls). | |
Herzog, 1988 (Canada) [167] | SACT | 11 (−-) | Adults with unilaterally decreased mobility in sacroiliac joint | Spinal manipulation of sacroiliac joint | 6 sessions over 2 weeks | – | – | Gait Symmetry, aVAS, ODI, palpation-based joint mobility | Reported observations from baseline to study completion: • Improvements in symmetry observed in ML GRF between the involved and noninvolved sides. • No detected differences for vertical or AP GRF. |
Herzog, 1989 (Canada) [168] | SACT | 11 (−-) | Chiropractic patients with sacroiliac problems | Spinal manipulation of sacroiliac joint | Single session | – | – | Gait Symmetry1 | • No changes observed from baseline to study completion in measures of gait symmetry or GRF. |
Herzog, 1991 (Canada) [160] | RCT | 37 (33.5) | Adults (18–50), ambulatory with chronic sacroiliac joint problems, nor obese | Spinal manipulation of sacroiliac joint | 10 sessions over 4 weeks | Back school therapy program by PT (stretching, strengthening exercises, no manipulation) | 10 sessions over 4 weeks | VAS, ODI, Gait Symmetry1 | • SM group showed improvements in gait symmetry (in all GRF components) from baseline to study completion. • Back school therapy did not show improvement in gait measures. |
Holt, 2011 (New Zealand) [34] | Observational | 101 (72.0) | Older adults (65+), ambulatory, active in chiropractic care | Multimodal chiropractic care | Individual, as needed | – | – | History of falls, BBS, ABCs, Posturographyb | Descriptive statistics reported: • 34.6% of the participants reported at least 1 fall in the prior year. • Mean BBS scores of 51.9 (SD 5.9) reported. • 59.4% of participants exhibited posturographic measures categorized as severely or profoundly impaired or were unable to complete posturographic assessment (included in profound category). |
Holt, 2016 (New Zealand) [114] | RCT | 60 (72.2) | Older adults (65+), community dwelling, ambulatory | Multimodal chiropractic care chiropractic (HVLA, table and instruments adjustments) | Individual, as needed (range: 2–33) | Usual care (as prior to the study) | – | Joint position, stepping reaction time, static postural control2, SF-36, multisensory processingc | • Chiropractic treatment group showed improvements in choice stepping reaction time (p < 0.05) and in ankle joint position sense (p < 0.05) compared to usual care group. |
Kendall, 2018 (Australia) [63] | RCT | 22 (73) | Older adults (65–85) with neck pain and concomitant dizziness > 3 months | Activator II instrument assisted manipulation with joint mobilization, massage, ROM neck exercise or heat | 1x weekly, over 4 weeks (4 sessions total) | Sham intervention (Activator II instrument impulses (set at zero) and gentle placement of practitioner’s hands on the cervical and thoracic spine | 1x weekly, over 4 weeks (4 sessions total) | DHI, TUG, NDI, NRS, FES-I | Descriptive statistics reported [mean (SD)] from baseline to study completion: • Improvements in DHI scores for both intervention [40.77 (12.48) to 28.33 (14.37)] and control groups [44.00 (16.97) to 36.40 (20.11)]. • Small improvements seen TUG test score in the intervention group [12.18 (2.07) to 11.87 (3.67)] but not in control group [12.09 (2.87) to 12.36 (411)]. |
Maiers, 2014 (USA) [161] | RCT | 241 (71.7) | Older adults (65+) with neck pain, ambulatory, stable medications, MMSE score > = 20 | GR1: SM with home exercise, GR2: SRE with home exercise | SM: Individualized (range 5–19) Supervised rehabilitative exercise: 20, 1-hour sessions over 12 weeks | GR3: Home exercise | 4x weekly for 45–60 minutes over 12 weeks (48 sessions total) | NRS, NDI, SF-36, satisfaction, global improvement, medication use, ROM, strength, TUG | • Change in TUG test time was reported (Mean [95% CI]) as week 12 score minus baseline score, no significant between group differences reported: • GR1: (−0.3 [− 0.8 to 0.2]). • GR2: (− 0.3 [− 0.7 to 0.1]). • GR3: (− 0.2 [− 0.7 to 0.3]). |
Maiers, 2019 (USA) [174] | RCT | 182 (71.1) | Older adults (65+), ambulatory, community dwelling, self-reported back and neck disability > = 12 weeks | SM (HVLA, soft tissue, thermal therapy, stretching) + SRE | GR1: 12 weeks of SM as needed + 1 hour SRE session 2x in 1st month, then 1x/month GR2: 36 weeks of SM as needed + 1 hour SRE session 2x in 1st month, then 1x/month | – | – | Incidence of falls, ODI, NDI, NRS, EQ-5D, TSK, medication use, perceived improvement, self-efficacy, satisfaction, strength, SPPB, accelerometry | Incidence of falls measured through proportions and limited statistical analysis: • GR1: Proportion of falls ranged from 6 to 13%. • GR2: Proportion of falls ranged from 10 to 13%. • Between group differences at each measurement were reported as: p = 0.4 at 12 weeks, p = 0.4 at 24 weeks, p = 0.7 at 36 weeks, p = 0.8 at 52 weeks, p = 0.3 at 78 weeks. |
Malaya 2020 (USA) [171] | Crossover (RCT) | 24 (29.5) | Healthy adults (21–40), not pregnant, no major injury to the extremities, no previous surgery, no known neurological or systemic disease | GR1: Lower extremity manipulations on day 1 and upper extremity manipulations on day 2 GR2: Upper extremity manipulations on day 1 and lower extremity manipulations on day 2 | Single intervention of nonspecific long-axis distractions to lower extremity (ankle, knee, and hip) or upper extremity (shoulder, elbow, and wrist) | – | – | Static postural assessmentd | • No significant changes in pathlength or range of sway for the floor surface condition at any sensor location after manipulation. • Lower extremity manipulation affected sway dynamics of the trunk for the floor surface condition • Significant results reported for the AP rocker board surface condition after upper extremity manipulation at the trunk sensor (path p < 0.05 main effect; range p < 0.05 interaction effect) and surface sensor (path p < 0.05 main effect) • Significant main effect results reported for the AP rocker board surface condition after lower extremity manipulation at the trunk sensor (SampEn p < 0.05 interaction effect) |
Malaya 2021 (USA) [172] | Crossover (RCT) | 23 (27.4) | Healthy adults (21–35), not pregnant, no known musculoskeletal, neurologic or visual impairment | GR1: Lower extremity manipulations on day 1 and upper extremity manipulations on day 2 GR2: Upper extremity manipulations on day 1 and lower extremity manipulations on day 2 | Single intervention of nonspecific long-axis distractions to lower extremity (ankle, knee, and hip) or upper extremity (shoulder, elbow, and wrist) | – | – | Static postural assessment4, COP | • Reduction in ML COP pathlength (p = 0.005) observed after both upper and lower extremity manipulation. • No significant change observed for range or SampEn in either group. |
Osterbauer, 1993 (USA) [173] | Case series | 10 (38.0) | Adults with chronic, phase 1 SIJ syndrome | Spinal manipulation (mechanical force, manually assisted, short lever adjustments) | 3x weekly, over 5 weeks, 1 year follow up as needed | – | – | Slow-walking gait symmetry1, VAS, ODI | • No changes observed from baseline to study completion in gait symmetry or GRF. |
Palmgren, 2009 (Sweden) [170] | Crossover (Time Series) | 6 (34.67) | Healthy adults (28–45) | GR1: Facet nerve block then late SM to C5/C6 GR2: Early SM to C5/C6 then facet nerve block | Single manipulation/single nerve block | – | – | Posturography2, Head positioning e | • No changes observed between subgroups in measures of posturography with eyes open or closed. |
Robinson, 1987 (USA) [169] | SACT | 9 (−-) | Adults (20–40), chronic LBP, unilateral decreased interarticular mobility of SI joint | Spinal manipulation of the sacroiliac joint | Single manipulation | – | – | Gait symmetry1 | • Gait symmetry data showed trends toward improvement between measures taken at baseline and study completion (χ2 = 13.1). |
Strunk, 2009 (USA) [166] | SACT | 19 (70 median) | Adults (40+) with recurrent dizziness (self-reported) with neck pain | Multimodal chiropractic (SM, flexion distraction, soft tissue therapy, heat) | 2x weekly, over 8 weeks (16 sessions total) | – | – | DHI, SF-BBS, NDI, FABQ | Descriptive statistics reported from baseline to study completion: • Median change in DHI score of 7. 3 participants showed clinically significant improvements in DHI scores from baseline to visit 16. 4 additional participants improved scores. • Mean change in SF-BBS score of 3 recorded from the 15 patients that performed SF-BBS. 7 of these patients showed a 4-point improvement from baseline to week 8. |
Vining 2020 (USA) [46] | RCT | 109 (30) | Active-duty military personnel with LBP | Multimodal chiropractic (clinical evaluation, HVLA SM, education, self-management advice) | Individualized frequency 4 week duration (mean 5.3 visits) | Wait-list control | 4 week duration | Strength, single-leg balance with eyes open and eyes closed, endurance, VAS, RMDQ, PROMIS-29, FABQ | • Significant improvement in single-leg balance with eyes closed in chiropractic group. • No significant improvement seen in single-leg balance with eyes open in chiropractic group (p = 0.43). |
Ward 2013 (USA) [162] | RCT | 11 (28.0) | Healthy adults (18–45), college students, no CMT on the study day | HVLA, superior ilium elongation | Single manipulation | No manipulation, participants with one short leg or no short legs | – | Gait variability, f joint angles, DS time, stance time | • No significant results to report. • Minor trends seen in the treatment group from baseline to study completion with an identified right short leg: increases in step length and stride length, decreases in right hip angle, and changes in double support time. |
Ward 2014 (USA) [163] | RCT | 21 (25.0) | Healthy adults (18–45), college students, no CMT on the study day | HVLA, Bilateral SI join manipulation | Single manipulation | No manipulation, participants with one short leg or no short legs | – | Gait variability6, joint angles, DS time, stance time | • No changes observed from baseline to study completion in intervention group joint angles and gait parameters. |
Intervention and control group characteristics
Outcome measures
Adverse events
Risk of bias assessment
Author | Random sequence generation | Allocation concealment | Blinding of the participants | Blinding of outcome assessment - self-reported outcomes | Blinding of outcomes assessment - objective measures | Incomplete outcome data | Selective reporting | Other bias |
---|---|---|---|---|---|---|---|---|
Hawk-2007 [158] | + | ? | – | – | ? | + | + | + |
? | NA | – | – | ? | ? | + | N/A | |
Herzog-1991 [160] | ? | – | – | – | – | + | + | – |
Holt-2016 [114] | + | + | – | ? | + | + | + | N/A |
Kendall-2018 [63] | + | ? | + | + | + | + | + | + |
Maiers − 2014 [161] | + | + | – | + | + | + | + | ? |
Maiers-2018 [27] | + | + | – | + | + | ? | ? | ? |
Malaya-2020 [171] | + | + | – | N/A | + | + | + | + |
Malaya-2021 [172] | + | ? | – | N/A | + | + | + | + |
Palgrem-2009 | ? | + | – | N/A | + | + | + | N/A |
Vining-2020 [46] | + | + | – | – | + | + | + | + |
Ward-2013 [162] | + | – | – | N/A | + | + | ? | – |
Ward-2014 [133] | + | – | – | N/A | ? | + | + | – |