Manipulative Therapy of Lower Extremity Conditions: Summary of Clinical Practice Recommendations
Commission of the Council on Chiropractic Guidelines and Practice Parameters
Process and Methods
The Council on Chiropractic Guidelines and Practice Parameters (CCGPP), was formed in 1995 at the behest of the Congress of Chiropractic State Associations (COCSA) and with assistance from the American Chiropractic Association, Association of Chiropractic Colleges, Council on Chiropractic Education, Federation of Chiropractic Licensing Boards, Foundation for the Advancement of Chiropractic Sciences, Foundation for Chiropractic Education and Research, International Chiropractors Association, National Association of Chiropractic Attorneys and the National Institute for Chiropractic Research.
The CCGPP’s mission is to provide consistent and widely adopted chiropractic practice information, to perpetually distribute and update these data as necessary, so that consumers and others have reliable information on which to base informed health care decisions. CCGPP was also delegated to examine all existing guidelines, parameters, protocols and best practices in the United States and other nations with a chiropractic lens. Participation and process have been as transparent as possible and a major goal is to represent a diverse cross-section of the profession on the projects that CCGPP has been involved in.
Six members were appointed to represent COCSA. Other members were appointed by the other organizations that created CCGPP. The CCGPP is a steering organization comprised of 21 individuals. 16 are chiropractors with one in education, one in research and 14 in full-time private practice. There is a vendor representative, a representative from chiropractic colleges and attorneys representing the National Association of Chiropractic Attorneys, as well as a public member. A Scientific Commission with several dozen members reports to and is supervised by CCGPP.
CCGPP identifies and evaluates evidence, which is compiled in a summary document for the chiropractic profession and other related stakeholders. The information contained in these documents is a literature synthesis. A literature synthesis is an academically rigorous analysis of all the available scientific literature on a specific topic. Reviewers use internationally accepted tools to rate each article according to specific criteria. These include the type of study (randomized controlled trial, case series, etc), the quality of the study, size of the study and many other factors which influence the credibility and strength of the study’s conclusions. Each reviewer independently rates all the available articles, and the ratings are compared among the members of the review team. When there is disagreement among the reviewers regarding the conclusions, a formal consensus process is followed to arrive at an overall conclusion upon which all reviewers can agree. The resulting conclusions do not represent the reviewers’ own beliefs but rather what the literature actually supports.
For this document, team efforts in review, rating, and reporting of literature synthesis were guided, as much as possible, by the widely accepted Appraisal of Guidelines for Research and Evaluation process. The main features included (1) review by a panel of experts; (2) detailed topic selection based on literature of most common conditions and procedures; (3) structured instruments for rating the quality of and results from the literature; (4) consensus process conducted within the team to adjudicate differences in professional opinion; and (5) wide stakeholder review by patients, professionals, policymakers, and third-party payers. As part of the CCGPP process, these articles were posted in draft form for public comment on the CCGPP Website (2006-8) to allow for an open process and the broadest possible mechanism for stakeholder input. For this document, the literature searched included an earlier systematic review and extended through February 2008.
Results
Of the total 389 citations captured, 39 were determined to be relevant. Review of these articles resulted in the following clinical practice recommendations for manipulative therapy of lower extremity conditions. There is a level of C or limited evidence for manipulative therapy combined with multimodal or exercise therapy for hip osteoarthritis. There is a level of B or fair evidence for manipulative therapy of the knee and/or full kinetic chain, and of the ankle and/or foot, combined with multimodal or exercise therapy for knee osteoarthritis, patellofemoral pain syndrome and ankle inversion sprain. There is also a level of C or limited evidence for manipulative therapy of the ankle and/or foot combined with multimodal or exercise therapy for plantar fasciitis, metatarsalgia and hallux limitus/rigidus. There is also a level of I or insufficient evidence for manipulative therapy of the ankle and/or foot combined with multimodal or exercise therapy for hallux abducto valgus.
Summary of Clinical Practice Recommendations
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There is a level of C or limited evidence for manipulative therapy combined with multimodal or exercise therapy of the hip, for hip osteoarthritis. |
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There is a level of B or fair evidence for manipulative therapy of the knee and/or full kinetic chain combined with multimodal or exercise therapy for knee osteoarthritis. |
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There is a level of B or fair evidence for manipulative therapy of the knee and/or full kinetic chain combined with multimodal or exercise therapy for Patellofemoral Pain Syndrome. |
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There is a level of B or fair evidence for manipulative therapy of the ankle and/or foot combined with multimodal or exercise therapy for Ankle Inversion Sprain. |
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There is a level of C or limited evidence for manipulative therapy of the ankle and/or foot combined with multimodal or exercise therapy for Plantar Fasciitis. |
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There is a level of C or limited evidence for manipulative therapy of the ankle and/or foot combined with multimodal or exercise therapy for Metatarsalgia. |
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There is a level of C or limited evidence for manipulative therapy of the ankle and/or foot combined with multimodal or exercise therapy for Hallux Limitus/Rigidus. |
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There is a level of I or insufficient evidence for manipulative therapy of the ankle and/or foot combined with multimodal or exercise therapy for Hallux Abducto Valgus/Bunion. |
While the recommendations in this document are reflective of the current best available evidence regarding chiropractic intervention for the conditions cited, they are not indicative of the full scope of chiropractic care in these areas. Additional research is recommended to improve the base of evidence for which anecdotal evidence indicates chiropractic intervention may be appropriate.
Conclusion
There is a growing number of peer reviewed, published studies of manipulative therapy for lower extremity disorders. Larger, methodologically improved and well funded randomized controlled and clinical trials, as well as observational, clinical and basic science research, case series and studies are both needed and merited. Interdisciplinary collaboration should be encouraged and supported as well. Finally, the basic overarching model of similarity of indications for and beneficial effect/responsiveness of patients to manipulative therapies for joint conditions throughout the human body merits further attention.
Supporting Documentation for Above Recommendations
Brantingham JW, Globe G, Pollard H, Hicks M, Korporaal C, Hoskins W. Manipulative therapy for lower extremity conditions: expansion of literature review. J Manipulative Physiol Ther. 2009 Jan;32(1):53-71.