Chiropraktik-in-hamburg.de

ORIGINAL RESEARCH
An Impairment Rating Analysis Of Asthmatic Robert L. Graham, D.C.; Richard A. Pistolese, B.S.* Abstract — A self-reported asthma-related impairment study was conducted on 81 children under chiropractic care.
The intent of this study was to quantify self-reported changes in impairment experienced by the pediatric asthmatic
subjects, before and after a two month period under chiropractic care. Practitioners, representing a general range of six
different approaches to vertebral subluxation correction, administered a specifically designed asthma impairment ques-
tionnaire at the appropriate intervals. Subjects were categorized into two groups; 1–10 years and 11–17 years.
Parents/guardians completed questionnaires for the younger group, while the older subjects self-reported their percep-
tions of impairment. Significantly lower impairment rating scores (improvement) were reported for 90.1% of subjects
60 days after chiropractic care when compared to the pre-chiropractic scores (p < 0.05) with an effect size of 0.96. As
well, there were no significant differences across the age groups based on parent/guardian versus self rated scores. Girls
reported higher (less improvement) before and after care compared to boys, although significant decreases in impair-
ment ratings were reported for each gender. This suggested a greater clinical effect for boys which was supported by
effect sizes ranging from 1.2 for boys compared to 0.75 for girls. Additionally, 25 of 81 subjects (30.9%) chose to vol-
untarily decrease their dosage of medication by an average of 66.5% while under chiropractic care. Moreover, infor-
mation collected from patients revealed that among 24 patients reporting asthma “attacks” in the 30 day period prior
to the study, the number of “attacks” decreased significantly by an average of 44.9% (p <.05). Based on the data obtained
in this study, it was concluded that chiropractic care, for correction of vertebral subluxation, is a safe nonpharmacolog-
ic health care approach which may also be associated with significant decreases in asthma related impairment as well as
a decreased incidence of asthmatic “attacks.” The findings suggest that chiropractic care should be further investigated
relative to providing the most efficacious care management regimen for pediatric asthmatics.
Key words: asthma, adjustment, children, chiropractic, impairment rating, pediatric, vertebral subluxation. Introduction
marked increase in the inspiratory muscle forces and results in Bronchial asthma is a disorder of increased tissue responsive- varying degrees of dyspnea and fatigue, likely due to the ness of the tracheobronchial tree to various stimuli, resulting in patient’s use of accessory muscles of ventilation (platysma and paroxysmal contraction of bronchial airways.1 The airway S.C.M.3). Sternocleidomastoid muscle contractions have been obstruction in asthma is due to a combination of factors that shown positive correlation with the development of severe air- include spasm and edema of the smooth muscle of the airways, flow obstruction, hyperinflation, and a marked reduction in gas and increased mucus secretion.2 With more severe asthma, the asthmatic is forced to compensate for bronchoconstriction in A positive correlation between chiropractic care administered order to permit gas exchange to take place. This is done by for the correction of vertebral subluxation and the patient’s per- breathing at high lung volumes, which enlarges the total lung ception of decreased respiratory effort, and severity of sympto- capacity, resulting in a mechanical opening of the airways.
matology, has been noted in several studies of patients ranging Unfortunately, breathing in a hyperinflated state requires a from 2 to 63 years of age. 5 6 7 8 9 10 Chiropractic care has been pro-posed to significantly reduce non-specific bronchial hyperactiv-ity (n-BR) as well as patient rated asthma severity.7 Non-specif- *Richard A. Pistolese is a Research Assistant for the International ic bronchial hyperactivity (n-BR) measures the resistance to Chiropractic Pediatric Association. He is currently in his final year of breathing of the bronchial airways after histamine dihydrochlo- study at Life University, School of Chiropractic. ride challenge. Although objective evidence is slow emerging in Address reprint requests to: Robert L. Graham, D.C., 3901 regard to the effect of chiropractic care on respiratory function Chicago Drive, Suite 110, Grandeville, MI 49418.
This study was supported by the Michigan Chiropractic Council, recent report showing improved forced expiratory volume in 4748 Washtenaw Avenue, Ann Arbor, MI 48108. patients following adjustments for upper cervical subluxation.13 Pediatric asthmatic patients and chiropractic care JOURNAL OF VERTEBRAL SUBLUXATION RESEARCH, VOL. 1, NO. 4, 1997 1
Vertebral subluxation is characterized, in part, by vertebral Consequently, the presence of vertebral subluxation, i.e. kine- misalignment (kinesiopathology), neuropathology and myo- siopathology, neuropathology and myopathology, may increase pathology.14 15 16 17 It has been demonstrated that pressures as lit- the asthmatic patients perception of respiratory effort. The pre- tle as 10mm Hg can cause significant neural dysfunction, sent study, therefore, was designed as a preliminary assessment of decreasing the number and amplitude of action potentials by up perceived change in the extent of impairment of pediatric asth- to 60% of initial values.18 19 20 This mechanical pressure on the matic patient’s while under chiropractic care for the correction nerve and surrounding tissues which may cause tissue ischemia is proposed to result in the release of chemical inflammatory The importance of gathering data relative to the pediatric agents such as substance P 21 22, bradykinin, and histamin 22 as a population is apparent considering current statistics. In the result of the osseous misalignment and subsequent neuromuscu- United States, asthma affects an estimated 14-15 million persons, lar pathophysiology. This neuromuscular pathophysiology can including 4.8 million (6.9%) under 18 years.28 In 1993, asthma accounted for an estimated 198,000 hospitalizations and 342 Recent study on the neurogenic mechanisms of asthma has deaths among persons less than 25 years of age. Children were focused on the release of neuropeptides by an axon reflex path- more likely than teens and adults to receive asthma care in the way.These peptides, which include substance P, calcitonin-relat- outpatient settings; adolescents and young adults were more ed peptides, and neurokinin A (a bradykinin), have been shown likely than other age groups to receive emergency care.28 respectively to have vascular permeability and mucus secreta- Although the treatment of asthma by medication is prevalent, gogue activity, bronchial vascular dilation effect, and a bron- and for many life sustaining, the health complications associated choconstrictor activity.2 These are the same neurotransmitters with this approach are well known.29 30 31 32 Since the correction postulated to be released from tissues in the presence of verte- of vertebral subluxation is non-invasive, the documentation of bral subluxation,21 which may initiate and/or complicate the changes in asthma related impairment, which could reduce or eliminate the need for medication, is a necessary step in evolv- As the vertebral subluxation is believed to negatively effect ing the most efficacious care for the millions of children chal- neurological function, 21 the neuroanatomy and physiology of structures associated with respiratory effort could be affected bythis condition. In this regard, the neuroanatomy and physiology related to the cervical area reveals that the respiratory centerconsists of neurons located bilaterally and divided into three major collections. These are the dorsal respiratory group locat- Potential subjects for this study were sought through news- ed in the dorsal portion of the medulla oblongata which main- paper advertisement. All subjects between the ages of one to ly regulates inspiration, the ventral respiratory group which reg- seventeen years of age with a previous medical diagnosis of asth- ulates both inspiration and expiration located in the medulla ma were considered. Informed consent was obtained from the oblongata, and the pneumotaxic center located dorsally in the parents, and/or legal guardian, consistent with the Human superior portion of the pons which helps to regulate rate and Subjects Committee protocol of the Michigan Chiropractic pattern of breathing.24 The medulla oblongata passes inferiorly Council. Qualifying subjects were required to be studied for a through the foramen magnum and the C1 spinal canal.25 It has period of 60 days. A total of 81 subjects participated, all of been theorized 26 that misalignment (a component of vertebral whom completed the study duration of 60 days. The subject subluxation) of C1 can cause stress and subsequent neural dys- population consisted of 37 females and 44 males ranging in age function to the medulla oblongata and spinal cord. Additionally, from one to 17, with a mean age of 10 ± 4.13 years.
the phrenic nerve from the cervical plexus, which innervates thediaphragm, receives fibers from the third, fourth and fifth cervi- A total of 33 chiropractors in various locales of the state of Accessory muscles of breathing such as the platysma and Michigan volunteered to participate in this study. All practi- sternocleidomastiod muscles also receive innervation from tioners were members of the Michigan Chiropractic Council.
nerves of cervical origin. The platysma muscles are innervated Each practitioner followed the same procedures in obtaining by the cervical branch of the facial nerve, and the sternocleido- data for the study. Subjects were evaluated over a period of 60 mastiod muscles are innervated by the spinal branch of the days during which time they were examined for the presence of accessory nerve as well as branches from the anterior rami of the vertebral subluxation in accordance with the protocols of the second and third cervical nerves. These nerves are intimately techniques employed by each participating chiropractor. These associated with the upper cervical area.25 27 techniques included, Activator Methods, Diversified, Gonstead, Misalignment of thoracic vertebra may cause neural dysfunc- Upper Cervical Technique-H.I.O, Network Spinal Analysis, and tion to the nerves which innervate anterior serrati, scaleni, Thompson Terminal Point Technique, all of which have been abdominal recti, and internal and external intercostal muscles described elsewhere.33 When vertebral subluxation was indicat- which function to raise and lower the rib cage during respira- ed to be present, subjects were administered chiropractic adjust- tion. Misalignment of thoracic vertebra may also cause costo- ment(s) followed by an evaluation for the correction of vertebral transverse fixation, which can limit diaphragmatic excursion and subluxation according to the procedures of the methods prac- ticed. No recommendations concerning the use of medication nerves also contribute to the innervation of the diaphragm.27 in the treatment of bronchial asthma were made to subjects by JOURNAL OF VERTEBRAL SUBLUXATION RESEARCH, VOL. 1, NO. 4, 1997 Pediatric asthmatic patients and chiropractic care any of the chiropractors participating in the study.
of 0.2 is taken to mean a small clinical effect, 0.5 is taken tomean a moderate clinical effect, and 0.8 is taken to mean a large Self-Reported outcomes of Asthmatic Impairment It was necessary to develop an instrument appropriate to sur- vey the population of subjects in the present study. The most suitable format was found in the Oswestry Low Back PainDisability Questionnaire. 34 35 This questionnaire was chosen Content and Construct Validity and because its disability orientation closely related to anecdotal Internal Consistency of the MOIRS Questionnaire reports from Michigan Chiropractic Council members regard- As presented in the introduction, content validity was initial- ing the level of impairment observed in patients who had been ly established by having practitioners participating in the study diagnosed with asthma. However, it was necessary to modify the validate the content of the survey relative to its intended pur- instrument to reflect areas of impairment which would specifi- pose. The content, either adopted from the Oswestry Pain cally relate to breathing difficulty instead of low back pain.This Disability questionnaire or originally developed, was approved was accomplished by substituting the phrase “breathing prob- unanimously by these practitioners as reflecting the type of dis- lems” in the place of “low back pain,” and changing the con- abilities reported by their asthmatic patients. Following the tent of the ten broad areas (Appendix). In its final form, the study, practitioners reported that subjects found the question- instrument was composed of ten questions. For each of the ten naire to be clear and complete, both primary attributes of con- questions, participants were asked to choose one of the six replies that best described their impairment. These answers were Since construct validity is a process requiring considerable subsequently scored 0-5, with 5 being the highest level of evidence gathered over a period of time through repeated uses impairment.As with the Oswestry Questionnaire, the final score of the instrument, no gold standard currently exists with regard was a percent of the highest score which could be reported (5 x to the type of questionnaire administered in this study. However, 10 = 50). Since some of the questions were not relevant to the several initial measures of validity did arise from the present age level of participants (such as walking difficulties), these sec- study. First, since the instrument was intended to discriminate tions were not answered. Therefore, the highest score attainable “post intervention” effects, its ability to detect statistical differ- was adjusted accordingly, with the percentage reflecting the ences between pre and post chiropractic care (presented below) change. This instrument, adapted from the Oswestry format is attests to its validity in that regard.40 herein referred to as the Modified Oswestry Impairment Rating Reliability was examined by determining Cronbach’s coeffi- cient alpha41 for the ten questions in the survey instrument In each practice, the questionnaires were completed prior to before (0.70) and after chiropractic care (0.77). These coeffi- the commencement of care, and again 60 days following the ini- cients reveal a substantial level of internal consistency within the tial visit. Subjects 11 years and older completed the question- instrument.This level of reliability also contributes to the initial naires, while parents or legal guardians acted for younger phase of evaluating its construct validity. Further use of this patients. Additionally, subjects or parents/ guardians were asked instrument in similar asthmatic populations will be required to to supply information regarding changes in number of asthma attacks, and medication usage via an informal questionnaire.
MOIRS Ratings Before and After Chiropractic Care Significantly lower MOIRS scores of 20.6 ± 12.1 were reported 60 days after chiropractic care when compared to the Pre and post care scores on the MOIRS were evaluated by a pre-chiropractic scores 32.1 ± 12.0 (p < 0.000). Within the two tailed paired sample t-test assuming equal variances,36 37 and population of 81 patients, there were 73 (90.1%) reports of a two tailed independent t-test assuming unequal variances36 37 decreased impairment. In 4 (4.9%) there was no reported for (1) gender effects, (2) age effects, and (3) response scores change, and in 4 (4.9%) there were reports of increased impair- based on completion by the subject versus parent or guardian.
Significance was determined for all analyses at p < 0.05.
Additional information supplied by patients or Response scores were not evaluated as a function of the practice parent/guardian revealed that among 24 patients reporting asth- from which they were derived since the number of individual ma “attacks” in the 30 day period prior to the study, the num- subjects per practice was too low to achieve statistical power.
ber of “attacks” decreased from an average of 2.96 ± 3.30 inci- Additionally, utilizing scores from the MOIRS as a measure dents per 30 days prior to study, to 1.3 ± 2.60 incidents per 30 of change in impairment, effect sizes38 were determined to assess days during the study. This represented a significant decrease of the clinical significance associated with chiropractic care. Effect 44.9% (p <.05). Additionally 25 of 81 (30.9%) patients chose to size was determined by the following relationship [mean voluntarily decrease their dosage of medication by an average of MOIRS pre care score — mean MOIRS post care score / std.
66.5%, with a range of 20% to 100% per month.
dev. of MOIRS pre care scores].This measurement allowed forexpression of the extent to which a post intervention measure- Subject Categories
ment [post MOIRS rating] varied from normal variationaround the mean of pre intervention measurements [pre Self-Reported versus Parent/Guardian-Reported Responses MOIRS rating]. Following the relationship described, a value Subjects were divided into age ranges according to their Pediatric asthmatic patients and chiropractic care JOURNAL OF VERTEBRAL SUBLUXATION RESEARCH, VOL. 1, NO. 4, 1997 3
Table 1. Impairment Score Changes* in Bronchial Asthma Pediatric Patients Before and After Chiropractic Care.
• Impairment rating scores were obtained from the Modified Oswestry Index Rating Scale (MOIRS, see Methods for protocols).
Higher Scores represent greater impairment.
† Probability values of less than 0.05 were significant.
‡ Effect size (see Methods) is a measure of clinical effect, where 0.2 is a small effect,a moderate effect, and 0.8 a large effect.
– Compared across (between) groups, post care males scored significantly (p = 0.02) lower (improvement) than females. No other comparisons between groups were statistically significant.
apparent ability to complete the questionnaire alone, or requir- the subject population as a whole (0.96), boys demonstrated a ing a parent or guardian to act for them. The division was made higher effect size (1.20) than did girls (0.75), as can be seen in between 1 to 10 years and 11 to 17 years. Although MOIRS Table 1, thus supporting a proposed larger clinical effect for scores were lower in the younger age bracket prior to and after care than the higher age group, there was no significant differ-ence between the age categories. This suggested that guardian Discussion
versus self-reporting elicited the same range of responses.
Moreover, in both age groups, MOIRS scores were significant- ly lower (improvement) following chiropractic care compared to Due to lack of previous use of the MOIRS, its internal con- pre chiropractic MOIRS scores (p < 0.000).
struct validation is in the initial phase.The instrument is admin-istered easily, lending itself to use by parents/guardians as well as self-rating by young adults. It is anticipated that it will continue Girls showed slightly higher impairment scores (34.2 ± to be used by chiropractors and other practitioners interested in 13.5) before chiropractic care than did boys (30.3 ± 10.3).
assessing health outcomes associated with asthmatics. Since the Although both genders reported significantly decreased demonstration of internal and external validity for any ques- impairment after care, scores were significantly higher among tionnaire is a process42 rather than a singular event, it is impor- girls (24.0 ± 12.5) when compared to boys(17.8 ± 11.1), sug- tant that data be gathered from a number of studies for compar- gesting a more profound clinical effect for males.This possibil- ison. As a first step in this process, this paper has introduced data ity was further explored by investigating effect sizes, separate- which provides a base for comparison. Consequently, while the statistical differences and effect sizes reported in this investiga- Effect size, derived from MOIRS scores before and after chi- tion are compelling, they must be interpreted with caution ropractic care, was used as a measure of estimating the extent of while awaiting continued evidence regarding validation of the clinical change. While, overall, the clinical effect was large for JOURNAL OF VERTEBRAL SUBLUXATION RESEARCH, VOL. 1, NO. 4, 1997 Pediatric asthmatic patients and chiropractic care Perceived Changes in Impairment Due to Asthma tions in efficacy. Moreover, it will be of interest to conduct The information collected concerning change in the number additional study regarding the consistency of segmental loca- of asthma “attacks” during this study needs to be viewed in con- tions which are adjusted among the different approaches, con- sideration of the timing of the study (May–September), since comitant with reported changes in asthma impairment. Such some atopic (allergic) asthmatic events may be contributed to by information could offer considerable insight regarding the seasonal factors such as exposure to higher amounts of pollen.
range of possible approaches effective in the correction of ver- Additionally, influences due to the incidence of non-atopic (nonreagenic) events and atopic asthmatic events incited byexposure to environmental antigens which can not be related to Conclusions
seasonality, such as animal hair, cigarette smoke, and variouschemotoxins, were not considered in the present study. To some The authors of this study do not suggest that chiropractic extent, therefore, the number of asthmatic “attacks” could be care is to be considered a substitute for prudent, proper med- related to these factors. However, the significant reduction in ical attention for the asthmatic patient. However, it should be asthmatic “attacks” coupled with the high percentage of respon- noted, that traditional pharmacological approaches to the dents (or their parent/guardian) voluntarily reducing medication management of asthma have been shown to represent a risk levels, suggests a more permanent effect. This is based on the to the patient,29 44 45 with several studies calling into question logical presumption that asthmatic subjects or parents/guardians the efficacy of such treatment in the management of asth- would be expected, through their personal experience, to rec- matic conditions.29 30 31 32 Therefore, when considering phar- ognize “typical” seasonal or occasional environmental influences maceutical agents in the management of asthma in the pedi- atric patient, the expected benefit must be weighed against Although demonstrating significant decreases in scores the inherent risks. As shown in the present study, chiropractic (improvement) pre to post chiropractic care, the 11-17 year old care, a safe nonpharmacologic health care approach, may also subjects of both sexes demonstrated a trend of self-reporting be associated with self-reported decrease in asthma-related higher scores than younger subjects (one–ten years).While these impairment to the patient, including the patient’s percep- differences were not significant, the trend may reflect some level tion of reduced respiratory effort, as well as a decreased of variation in perception between those self-rating, as opposed incidence of asthmatic “attacks.” In view of these findings it to parents/guardians. As pediatric studies will frequently involve is suggested that chiropractic care be further investigated this type of design, this issue should remain an important con- regarding its role in the overall health care management of cern as it impacts on validation of the instrument.
While there were no significant differences in age groups within genders, females reported significantly less post improve- Acknowledgements
ment than males.The implication that a more pronounced clin-ical effect was apparent for males than females, while substanti- The Michigan Chiropractic Council (M.C.C.) would like to ated by statistical significance as well as effect size, currently thank Mrs. Kimberly Klapp for her generous assistance in com- lacks explanation. However, some evidence exists which sug- piling the data collected in this study. The M.C.C. would like to gests that females tend to report their health lower than males thank the following doctors for donating their time and services even though they may not exhibit other indicators of a lower in the performance of this study: Dr. Ronnie Adkins, Dr. Robin state of health.Verbrugge 43 proposes that this could be a reflec- Barricklow, Dr. Jefferey Buller, Dr. Samuel Caruso, Dr. William tion of the more frequent utilization of helath care by females.
Cook, Dr. Guy Dione, Dr. Bruce Dorais, Dr. Kurt Froese, Dr.
As this information is specific to adult populations it may or Salvatore Gennero Jr., Dr. Robert L. Graham, Dr. Amy may not account for the observation regarding gender differ- Gramzow, Dr. Davis Guzzardo, Dr. Robert Heit, Dr. Gregory ences in the present study, especially considering the fact that Hicks, Dr. Raymond Kaminsky Jr., Dr. Thomas Klapp, Dr.
responses from approximately half of both the male and female Thomas Kopinsky, Dr. Daniel LaFramboise, Dr. Larry Libs, Dr.
subjects were reported by parents/guardians. Certainly, a follow David Mason, Dr. Kevin O’Dell, Dr. Richard Oberhew, Dr.
up study investigating more subjects will be needed to attest to Mary Parr-Wlodyga, Dr. Roy Picard, Dr. Linda Rassel, Dr.Arlen the consistency of this finding. Moreover, evaluation of the Rubin, Dr. Keith Sarver, Dr. Daniel Schultz, Dr. Karen Siupik, inference that the significant reduction in impairment was due Dr. Kurt Titze, Dr. Stephen Upchurch, Dr. Dennis Whitford, Dr.
to chiropractic care will require a controlled clinical research design to focus on gathering evidence related to cause and The M.C.C. would additionally like to thank the effect. Relative to this issue, the diversity of techniques International Chiropractic Pediatric Association for their assis- employed by different chiropractors participating in the study tance in the organization and analysis of data collected in this could be broadly grouped into six general approaches.While it study, and the writing of this paper.
is not possible from the data collected in this study to ascertain The I.C.P.A. and Richard A. Pistolese would like to if one technique was more effective than another, it is evident thank Larry Webster, D.C. for his love, guidance and inspi- that, overall, subjects or parent/guardians responded similarly, ration; W. Adrian Yeung, MS, Donald Gutstein D.C., Bruce regardless of the chiropractic approach used for correction of Pfleger, Ph.D., Ed Owens, D.C., Susan Brown, Ph.D., and vertebral subluxation. Further study, among those advocating Life University’s Resource Center Staff for their kind specific approaches will be necessary to elucidate any distinc- Pediatric asthmatic patients and chiropractic care JOURNAL OF VERTEBRAL SUBLUXATION RESEARCH, VOL. 1, NO. 4, 1997 5
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JOURNAL OF VERTEBRAL SUBLUXATION RESEARCH, VOL. 1, NO. 4, 1997 Pediatric asthmatic patients and chiropractic care Appendix
This questionnaire has been designed to give the doctor information as to how breathing difficulty has affected your ability to man-age everyday life. Please answer every section and mark in each section the ONE box which applies to you. We realize you may con-sider that two of the statements in any one section relate to you, but please mark the box which most closely describes your condition Current difficulties
In the past 4 weeks how much time have you
■ I have no breathing problems at this moment.
missed from work, school, or usual activity
■ I have mild breathing problems at this moment.
because of asthma?
■ I have moderate breathing problems at this moment.
■ My breathing problems are fairly severe at this moment.
■ My breathing problems are severe at this moment.
■ My breathing problems are very severe at this moment.
■ One to two weeks.
■ Two to three weeks.
How many times have you ever been
hospitalized for Asthma
■ Never.
How often do asthma attacks awaken you at night?
■ Five or six times a week.
■ Every Night.
When was the last time you had a severe
flare-up or needed treatment for your asthma?
School / Work
■ My breathing never interferes with work activity.
■ My breathing rarely interferes with work activity.
■ My breathing moderately interferes with work activities.
■ My breathing interferes very much with work activities.
■ My breathing prevents me from doing most jobs.
■ My breathing prevents me from doing any work.
Mild Activity
How much does your asthma interfere with your
■ I can walk any distance with no problems.
social activities (family, friends, neighbors or groups)
■ I can walk any distance with occasional problems.
■ I can walk a lot but have frequent breathing problems.
■ I don’t walk much because I have frequent problems ■ I walk rarely because I have frequent and severe ■ I never walk because of severe breathing problems.
10) Medication
Vigorous Activity
■ I never take medication or inhalants.
■ I participate in vigorous activity with no breathing ■ I very rarely take medication or inhalants.
■ I rarely take medication or inhalants.
■ I participate in vigorous activity with mild breathing ■ I sometimes take medication or inhalants.
■ I frequently take medication or inhalants.
■ I participate in vigorous activity with moderate breathing ■ I participate in vigorous activity with severe breathing ■ My activities are rarely vigorous because of severe breathing ■ I am never vigorous because of severe breathing problems.
Pediatric asthmatic patients and chiropractic care JOURNAL OF VERTEBRAL SUBLUXATION RESEARCH, VOL. 1, NO. 4, 1997 7
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8 Reprinted from JOURNAL OF VERTEBRAL SUBLUXATION RESEARCH, VOL. 1, NO. 4, 1997
Pediatric asthmatic patients and chiropractic care

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