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,  few studies have investigated its possible impact on balance and fall prevention.  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.
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