Content uploaded by Rainer Thiele
Author content
All content in this area was uploaded by Rainer Thiele on Jan 06, 2021
Content may be subject to copyright.
International Journal of Clinical Medicine Research
2019; 6(2): 6-12
http://www.aascit.org/journal/ijcmr
ISSN: 2375-3838
Chiropractic Treatment in Sports: Systematic
Review of Randomized Controlled Trials
Rainer Thiele
Department of Medical Science, Private University of Liechtenstein, Triesen, Principality of Liechtenstein
Email address
rainer.thiele@gmx.com
Citation
Rainer Thiele. Chiropractic Treatment in Sports: Systematic Review of Randomized Controlled Trials. International Journal of Clinical
Medicine Research. Vol. 6, No. 2, 2019, pp. 6-12.
Received: February 13, 2019; Accepted: March 28, 2019; Published: May 10, 2019
Abstract: Background: Since 1980, chiropractic has been used at the Olympic Games to accompany the USA's top athletes
therapeutically. The rapidly developing professional sports sector offers great scope for new therapeutic support for athletes in the
areas of prevention, performance improvement, injury treatment and medical rehabilitation. The aim of this systematic review is
to analyse the latest scientific findings, which can be evaluated on the basis of existing clinical controlled studies. The present
article deals with the question: How efficient is the use of chiropractic in sports in the above-mentioned areas? Methods: The
research is carried out in the PubMed database. The evidence level of the individual studies is determined using the PEDro scale.
The studies with evidence class I are evaluated in tabular form according to the PICO model. Endpoints assessed are grip strength
in judo athletes, ankle injuries, medical rehabilitation with recurrent ankle sprains, jet lag symptoms. Results: The literature review
include 232 researched articles 8 on the subject, including 3 systematic reviews and 5 randomized clinical trials, of which 4
include evaluable results. Overall, in 3 studies, outcomes in the intervention group for performance enhancement, injury treatment
and medical rehabilitation are significantly improved by the use of chiropractic care. The jet lag treatment show no differences
compared to the control group. Conclusion: In 3 out of 4 studies, there are significant improvements with the use of chiropractic in
therapy. Thus, it can be concluded, that the use of chiropractic in sports can improve performance and reduce injury times in
medical rehabilitation. Chiropractic in sports is therefore quite efficient.
Keywords: Sports, Chiropractic, Manipulation, Review, Rehabilitation, Athletes
1. Introduction
Since 1980 the USA has used chiropractic for its athletes at the
Olympic Games. The Brazilians have been at the Olympic Games
and Pan-American Games since 2000. In 1995 at the All African
Games, 1135 athletes from 6000 athletes received a total of 1957
chiropractic treatments. Light athletes (38%) and martial artists
(14.7%) received these treatments. In 2007 in Rio de Janeiro at the
Pan-American Games, 209 chiropractic treatments were
performed for 95 athletes by a total of 660 Brazilian athletes
(14.40%). Another study found that 77% of the American
Football League athletes used a chiropractor. Another 31% of
athletes had chiropractors who were part of their medical team.
The rapidly evolving professional sports sector creates a
wide field in which new therapeutic techniques have great
potential for growth and development, provided their
effectiveness on sports performance has been proven. [1] In
western medicine, there has been a specialization of general
practitioners in sports in recent years.
In addition, medical professionals, such as physiotherapists,
have emerged as well as a number of alternative and
complementary health professionals. Chiropractic is one of them.
Similar to conventional medicine, a separate "special group" has
developed, the sports chiro practice. This is not only about
manipulation. Sports chiropractors are often regarded as
unimodal practitioners with limited consideration of
conventional medical approaches. This "modern" multimodal
sports chiropractic management, should contain components of
the passive and active supply. Both the acute, inflammatory pain
phase and the chronic injury, rehabilitation and prevention phase
should be treated. The typical approach is to diagnose, rule out
exacerbations, diagnose and treat symptomatic tissues, and
identify and evaluate functional deficits, and etiologic factors
responsible for sports injuries. Traditional orthopedic and
neurological testing, chiropractic assessments, structural analysis,
palpation (movement and statics), referral for radiological
analysis and other specialized services may be required. [2]
7 Rainer Thiele: Chiropractic Treatment in Sports: Systematic Review of Randomized Controlled Trials
Chiropractic has been used at various national and international
sporting events, and previous studies have shown that chiropractic
is an accepted, well-used treatment option for athletes. [3]
In this review, an overview of the scientific status of
chiropractic in the field of sports will be given, on the basis
of the researched clinical studies
2. Methods
2.1. Literature Research
A systematic search in the PubMed database was carried out
in August 2018 to identify the literature. The search was limited
to English-language literature. The search was limited to articles
with keywords such as "chiropractic", "manual therapy", "spinal
manipulation", "chiropractic care", "manipulative therapy",
"chiropractic treatment" and "chiropractic intervention"
combined with the words "athletes", "sports", "rehabilitation".
Google Scholar also searched for additional English-language
and German-language literature (see figure 1 in the appendix).
2.2. Rating According to PEDro Scale
Eleven evaluation criteria can be used to divide studies into
different levels of evidence. The PEDro-scale is based on the
Delphi list. This was developed at the University of Maastricht,
Department of Epidemiology, by Verhagen and colleagues.
This is a set of criteria for evaluating the quality of the studies.
The Delphi list and the PEDro scale are not based on empirical
data, but on expert consensus. Criteria 2 to 9 check the internal
validity in order to interpret the results in criteria 10 to 11 via
statistical information. Criterion 1 aims at external validity, but
is not included in the evaluation (see Table 5 the appendix). [4]
The following points of a study were evaluated:
1. Inclusion and exclusion criteria were specified (external
validity, no evaluation point).
2. Subjects were randomized.
3. Assignment to the groups was hidden.
4. Groups were similar for prognostic indicators.
5. Subjects were blinded.
6. Therapists were blinded.
7. Investigators were blinded.
8. A central result was measured in more than 85% of the
assigned volunteers.
9. All volunteers who were available for result measurements
received the treatment after allocation. If not, at least one central
result was analyzed by an "intention to treat" method.
10. For a central result, a statistical group comparison was
proven.
11. For a central result, point measurements and measures
of dispersion were reported (standard deviation, standard
error, confidence interval).
If one of the criteria, with the exception of the first, is
fulfilled, a point was awarded. A total of ten points can,
therefore, be scored. The evidence level was derived from the
total number of points (see table 6 in the appendix).
The core data of the evidence class I studies were compiled
according to the PICO model (see Table 5 in the appendix).
In this table, the studies are evaluated according to the
PICO model.
In detail, the points are:
a.) Study,
b.) Population,
c.) intervention group,
d.) Control group,
e.) Results intervention group,
d.) Results control group, compared.
3. Results
3.1. Literature Research
Literature research resulted in 8 articles on the subject ofit 3
systematic reviews [5 - 7] and 5 randomized clinical trials [1, 8 -
10]. One study was withdrawn [1]. Four studies were finally used
to analyse the topic [1, 8 - 10] (see Figure 1 in the Appendix).
3.2. Results PEDro Scale
The methodological quality of the researched studies was
evaluated using the PEDro scale (PEDro = Physiotherapy
Evidence Database) (see Table 5 in the appendix). Here, each
study was subjected to a question scheme. If a criterion is met,
one point was awarded. A total of ten points were scored.
From the total number of points the evidence level was
determined: The studies have a high methodological quality of
seven or more points, an average methodological quality of
four to six and a low quality of up to three points [11].
Evidence level I was awarded to four studies:
a.) Botelho and Andrade 2012 [1]
b.) Lubbe et al. 2015 [8]
c.) Pellow and Brantingham 2001 [9]
d.) Straub et al. 2001 [10]
3.3. Results PICO Model
3.3.1. Botelho and Andrade 2012 [1]
Grip strength for judo athletes
Primary Endpoint: Grip Strength
In the intervention group with three times spinal
manipulation treatment the following results were achieved:
1. after 1st intervention: mean increase of 6.95% right
hand and 12.61% left hand
2. after 3rd intervention: mean increase of 10.53% right
hand and 16.82% left hand
In the control group with three times apparent spinal
manipulation treatment, no statistically significant differences
between the grip strength measurements were measured. This
clearly shows that cervical spinal manipulation treatment
significantly increased the grip strength of judo athletes.
3.3.2. Lubbe et al. 2015 [8]
Recurrent ankle sprain with functional instability
In the intervention group five weeks to seven days and six
rest days 29 training units for rehabilitation plus six
"manipulations treatment" were carried out. Primary
International Journal of Clinical Medicine Research 2019; 6(2): 6-12 8
endpoint: pain with FADI
1
and VAS
2
Table 1. Results intervention group.
FADI VAS
Baseline 80.4 47.3
Final 98.9 6.2
18.5 Improvement 41.1 Improvement
In the control group there were the pure rehabilitation
training sessions without "manipulations treatment", with the
following results. Primary endpoint: pain with FADI and VAS.
Table 2. Results control group.
FADI VAS
Baseline 75.9 40
Final 91.3 22.1
15.4 Improvement 17.9 Improvement
Clear improvement values can be seen here in the course
of treatment using rehabilitation training units combined with
chiropractic treatment.
3.3.3. Pellow and Brantingham 2001 [9]
Treatment of subacute and chronic ankle inversion sprains
of grades I and II
Primary endpoints: Pain & Functionality
Measurement methods: Mc Gill questionnaire
3
, Numeric
Pain rating scale
4
, Gonometer
5
, Algometer
6
Mean values were measured in both groups after four
weeks of treatment and one month of "follow up", the
following results were observed in the intervention group
with chiropractic treatment alone.
Table 3. Results intervention group.
after 1st treatment:
after one month follow up:
Mc Gill scores 0.2 0.03
NPRS 28% 8%
Goniometer 5 grd. 13 grd.
Algometer 2.4 kg/qcm 4.2 kg/qcm
The following results were achieved in the control group
with ultrasound treatments.
Table 4. Results control group.
after 1st treatment:
after one month follow up:
Mc Gill Scores 0.24 0.13
NPRS 31% 17%
Goniometer 6.5 grd. 8 grd.
Algometer 2.9 kg/qcm 3.8 kg/qcm
Also, here the better results after the treatments and
"follow up" times in the chiropractic intervention group can
1 Foot and Ankle Disability Index, 26 points questionnaire, (4 pain related questions,
22 activity related questions) in which each question is answered (on a scale of 0 – 4,
total score 104), then converted into percent. clinically significant difference at 8 points.
2 Visual Analog Scale, 0 – 100 mm Scale 0 = painless, 100 max. pain, clinically
significant difference 20 – 30 mm.
3 Questionnaire on pain perception 0 – 3, 0 = pain-free.
4 Pain scale from 0 – 10, 10 = max. pain.
5 Measuring instrument for the determination of angles.
6 Device for measuring the pressure pain threshold.
be clearly seen.
3.3.4. Straub et al. 2001 [10]
Effect of Chiropractic on Jetlag in Finnish Junior Elite Athletes
There were 19 days of chiropractic treatments in the
intervention group and 19 days of sham chiropractic
treatments in the control group. To assess the jetlag effect in
the athletes, the following measurements were performed.
Primary Endpoint: Jetlag Symptom Improvement
Measurement methods: “Profile of Mood States“(POMS)
7
,
Heart rate measurements
8
, Sleep disorders
9
, Jetlag scale
10
There were no significant differences in the groups.
4. Summary
Four evaluable RCT studies were available to evaluate the
topic of chiropractic in sports. One study on performance
enhancement [1, 2] on injury and rehabilitation [8, 9] and
another study on evaluation of performance reduction through
jetlag or jetlag improvement [10] through chiropractic treatment.
In the area of performance improvement by increasing the grip
strength in judo athletes [1] as well as in injuries and
rehabilitation measures [8, 9], the results could be significantly
improved by the use of chiropractic treatments. The study to
prove that chiropractic reduces the jetlag effect could not
provide any evidence in this respect. Although the quantity of
evaluation is low due to the number of studies, it is clearly
evident, that chiropractic treatment already has a positive effect
on performance enhancement, injury and rehabilitation measures.
5. Discussion
The results of the considered studies [1, 8, 9,] show clear
improvements for the intervention groups. The endpoints
investigated to demonstrate the use of chiropractic in the
sports fields of performance enhancement [1] injury
treatment [9] and medical rehabilitation [8]. The study on the
improvement of jetlag symptoms [10] by chiropractic
intervention show no differences in the groups.
The review by Ernst and Posadzki [5] from 2012 comes to
similar results, but the study by Hoskin and Pollard [13] on
the topic: prevention of back pain, knee pain and injuries of
the lower limbs in elite Australian regular footballers was
withdrawn and is therefore not included in the evaluation.
Altogether in the majority of the 6 examined studies, better
results for the employment of the chiropractic can be proven.
For example, in the study by Petersen [14] and
Brantingham [15] on the treatment of metatarsal pain.
The Brantingham study [15] from 2005 investigated the
treatment of hallux valgus
11
better results by chiropractic,
7 Questionnaire with 65 questions on the state of health in certain clinical and
non-clinical areas of the patient.
8 Polar Advantage NV heart rate monitor (Polar Electro Kempele Finland).
9 Measured via Actiwatch (16 AW, Mini Mitter, Bend, Ore).
10 Ten points scale, 10 points max. jet lag, measured 4 days after arrival from
Helsinki in Marietta and 4 days after return flight.
11 Medical term for the obliquity of the big toe.
9 Rainer Thiele: Chiropractic Treatment in Sports: Systematic Review of Randomized Controlled Trials
although hallux valgus does not represent a typical sports
injury, it is obstructive to the practice of sports.
Conway’s [6] summary focuses primarily on
understanding anatomy, biomechanics, movement patterns
and kinetic chains of the lower limb, including the pelvis. On
this point, the supervisors and trainers are primarily
responsible. Even the smallest changes in the athlete are
detected early and can prevent injuries and loss of
performance. The pelvic obliquity plays a significant role
here. In such cases, chiropractic is an excellent therapy.
Liebenson [7] notes that provocative maneuvers such as
McKenzie or orthopedic tests can be carried out on a "small
scale" to prevent further injuries or performance losses in
athletes. These initial measures could well be controlled by
coaches or supervisors.
In the majority of cases, the results of the studies examined
speak in favor of treatment with chiropractic in sports.
However, previous studies in this direction are very small.
The number of participants in these studies is also
quantitatively weak. It is necessary to uncover a large
discrepancy between the use of chiropractic in sports in all
segments such as prevention, performance improvement,
injury treatment and medical rehabilitation and the necessary
scientific evidence. Only through the clinically scientific
implication can sport chiropractic find far-reaching
recognition.
For this reason, further studies with a higher number of
participants in the field of sports are needed. The material to
be evaluated in randomized controlled trials (RCT) is very
limited. Research in this field is still in its infancy. Sport
chiropractic could be a useful innovation for the entire field
of sport.
6. Conclusion
Sport chiropractic, although already used since 1980 by
the American Olympic athletes, struggles with the deficit of
daily use by athletes and proving its scientific nature.
Therefore, it is necessary to continue to present studies in this
field with high numbers of participants, including prevention,
performance improvement, injury treatment and medical
rehabilitation. On the basis of the studies carried out so far in
this field, manual medical treatment could represent a
therapeutic innovation for the coming years. For this purpose,
it is necessary to publish further studies in this field and to
provide scientific evidence for the application of chiropractic
treatments in the field of prevention, performance
enhancement and rehabilitation in an appropriate broad
cross-section of sports. With the studies currently available, a
trend towards manual therapy in the form of chiropractic
treatment can be clearly seen.
Appendix
Table 5. PEDro Scala.
Studys PEDro criteria Botelho and Andrade
2012 Brazil [1]
Lubbe et al. 2015
South Africa [8]
Pellow and Brantingham
2001 South Africa [9]
Straub et al. 2001
America [10]
Inclusion and exclusion criteria were specified
Randomisation of test persons
Allocation to the groups hidden
The most important prognostic indicators in the
groups were similar to each other
Test subjects were blinded
Therapists were blinded
Investigators were blinded
more than 85% of the test persons assigned to the
groups completed the study
"Intention to treat" method followed
Group comparison of at least one central outcome
Report about point, as well as scatter measures of at
least one central outcome
total score 8/10 8/10 9/10 8/10
level of evidence I I I I
International Journal of Clinical Medicine Research 2019; 6(2): 6-12 10
Figure 1. Flowchart of the research.
(1) Database for literature research of RCTs and SR updated until 28.07.2018
(2) Search criteria
(3) Total hits n = 232
(4) of which studies and reviews
(5) Inclusion criteria
(6) Relevant literature n = 8 articles on the subject
(7) Breakdown by study design
(8) Exclusion criteria: n = 3 SR and n = 1 RCT, total n = 4
(9) usable RCTs on the subject n = 4 RCTs
SR systematic reviews
RCT randomized controlled trials
11 Rainer Thiele: Chiropractic Treatment in Sports: Systematic Review of Randomized Controlled Trials
Table 6. Evidence classification according to achieved PEDro scale points.
PEDro values max. 10 score Grad
10 – 7 of high quality I
6 – 4 median II
1 – 3 faint III
Table 7. Core statements of the studies according to the PICO model.
Study Population
TN
Interventional
group Control group Result: Intervention group Result: Control group
Botelho and
Andrade
2012 Brazil
[1]
n = 18
Group 1: n = 9
SMT in 3 Weeks
3 x cervical SMT
NW: 3 – 6 h after
BH light head
and neck pain
Group 2: n = 9
SSMT in 3
weeks 3 x
cervical
SSMT without
NW
Primary endpoint: grip strength
measured with a dynamometer in
kg/force after the first intervention:
average increase of 6.95% right hand
and 12.61% left hand after the third
intervention:
mean increase from 10.53% right
hand and 16.82% left hand
Primary endpoint:
grip strength
measured with a dynamometer in
kg/force
no statistically significant differences
between the grip thickness
measurements
Lubbe et al.
2015 South
Africa [8]
n = 33
Group 2: n = 15
rehab + MT 5
weeks x 7 days, 6
RT → 29 TE + 6
MT
Group 1: n = 18
rehab
5 weeks x 7
days,
6 RT → 29 TE
Primary Endpoint: Pain with FADI
12
and VAS
13
FADI
Baseline 80.4
Final 98.9
18.5 enhancement
VAS
Baseline 47.3
Final 6.2
41.1 enhancement
Primary Endpoint: Pain
with FADI and VAS
FADI
Baseline 75.9
Final 91.3
15.4 enhancement
VAS
Baseline 40
Final 22.1
17.9 enhancement
Pellow and
Brantingham
2001 South
Africa [9]
n = 30
Group 1: n = 15
MT BH to
symptom-free or
4 weeks max. 8
BH
Group 2: n = 15
ultrasound
BH to
symptom-free
or 4 weeks max.
8 BH
Primary endpoints: Pain and
Functionality
Measurement methods:
Mc Gill questionnaire
Numeric pain rating scale
gonometer
algometers
averages
after 1st treatment:
Mc Gill scores 0.2
NPRS 28%
Goniometer 5 grd.
Algometer 2.4 kg/qcm
after one month follow up:
Mc Gill Scores 0.03
NPRS 8%
Goniometer 13 grd.
Algometer 4.2 kg/qcm
Primary endpoints: Pain and
Functionality
Measurement methods:
Mc Gill questionnaire
Numeric pain rating scale
gonometer
algometers
averages
after 1st treatment:
Mc Gill scores 0.24
NPRS 31%
Goniometer 6.5 grd.
Algometer 2.9 kg/qcm
after one month follow up:
Mc Gill scores 0.13
NPRS 17%
Goniometer 8 grd.
Algometer 3.8 kg/qcm
Straub et al.
2001 Amerika
[10]
n = 15
Group 1: n = 5
CA BH 19 days
Ø 9 AJ / TN
Group 2: n = 5
SCA
BH 19 days
Ø 8,8 AJ / TN
Group 3: n = 5
Control without
BH
Primary endpoint: Jetlag symptom
improvement
Measurement methods:
"Profile of Mood States" (POMS)
Heart rate measurements
insomnia
Jetlag scale
There were no significant differences
in the groups
Primary endpoint: Jetlag symptom
improvement
Measurement methods:
"Profile of Mood States" (POMS)
Heart rate measurements
insomnia
Jetlag scale
There were no significant differences
in the groups
n number of participants
MT manipulation therapy
RASFI recurrent ankle sprain with functional instability
FADI Foot and Ankle Disability Index
VAS visual analog Scala
TE training sessions
SMT spinal manipulation treatment
12 Foot and Ankle Disability Index, 26 points questionnaire, 4 pain-related questions, 22 activity-related questions, each question answered on a scale of 0-4, total score
104, is then converted into percent, clinically significant difference of 8 points
13 Visual Analog Scala, 0 – 100 mm Scala 0 = painless, 100 max. pain, clinically significant difference 20 – 30 m
International Journal of Clinical Medicine Research 2019; 6(2): 6-12 12
SSMT sham spinal manipulation treatment
NW side effects
BH treatment
max. maximum
RT closing day
CA chiropractic adjustment
SCA sham chiropractic adjustment
o. without
Ø average
AJ adjustment
TN participant
re. right
li. left
References
[1] Botelho, M. B. and Andrade, B. B. (2012) Effect of cervical
spine manipulative therapy on judo athletes' grip strength. J
Manipulative Physiol Ther 35 (1): 38–44.
[2] Pollard, H., et al. (2007) Australian chiropractic sports
medicine. Chiropr Osteopat 15: 14.
[3] Nook, D., et al. (2016) Utilization of Chiropractic Care at the
World Games 2013. J Manipulative Physiol Ther 39 (9): 693–
704.
[4] Hegenscheidt, S., et al. (2010) PEDro scala-german: 1–2.
[5] Ernst, E. and Posadzki, P. (2012) Chiropractic for the
prevention and/or treatment of sports injuries. Focus on
Alternative and Complementary Therapies 17 (1): 9–14.
[6] Conway, P. J. (2001) Chiropractic approach to running
injuries. Clin Podiatr Med Surg 18 (2): 351–362.
[7] Liebenson, C. (1996) Rehabilitation and chiropractic practice.
J Manipulative Physiol Ther 19 (2): 134–140.
[8] Lubbe, D., et al. (2015) Manipulative therapy and
rehabilitation for recurrent ankle sprain with functional
instability. J Manipulative Physiol Ther 38 (1): 22–34.
[9] Pellow, J. E. and Brantingham, J. W. (2001) The efficacy of
adjusting the ankle in the treatment of subacute and chronic
grade I and grade II ankle inversion sprains. J Manipulative
Physiol Ther 24 (1): 17–24.
[10] Straub, W., et al. (2001) The effect of chiropractic care on jet
lag of finish junior elite athletes. J Manipulative Physiol Ther
24 (3): 191–198.
[11] Felsenberg, D., et al. (2008) Guideline physiotherapy and
exercise therapy for osteoporosis. Guideline: 1-87.
[12] Miners, A. L. (2010) Chiropractic treatment and the
enhancement of sport performance. J Can Chiropr Assoc 54
(4): 210–221.
[13] Hoskins, W., and Pollard H. (2010) The effect of a sports
chiropractic manual therapy intervention on the prevention of
back pain, hamstring and lower limb injuries in semi-elite
Australian Rules footballers: a randomized con-trolled trial.
BMC Musculoskelet Disord; 11 (64): 1-11.
[14] Petersen, S, et al. (2003) The efficacy of chiropractic
adjustment in the treatment of primary metatarsalgia. Eur J
Chiropract; 49: 267–279.
[15] Brantingham J. W., et al. (2005) A pilot study of the efficacy
of a conservative chiropractic protocol using graded
mobilization, manipulation and ice in the treatment of
symptomatic hallux abduct valgus bunion. Clin Chiropract; 8
(3): 117–133.
