Journal of Manipulalive alldPhysiolQlicall1,erapeulics 353Volume 12eNumber5eOctober. 1989

0161-4754/89/120500353 SO2.00/0@ 1.989 JMPT.,~

An Evaluati~r'! of. Chir~practic Manipulation as a Tr~atmentof Hyperactivity In Children J-

J. MARTIN GIESEN, Ph.D.,. DAVID B. CENTER, Ph.D.,t AND ROBERT A.IjEACH, D.C.:I:

was highly significant (p = 0.009). Agreement betweentests was also high in this study. For all seven children,three of the four principal tests used to detect improve-ment were in agreement either positively or negatively(parent ratings of activity, motion recorder scores, elec-trodermal measures, and X-rays of spinal distortions).While the behavioral improvement taken alone canonly be considered suggestive, the strong intertest agree-ment can be taken as more impressive evidence thatthe majority of the children in this study did, in fact,improve under specific chiropractic care. The results ofthis study, then, are not conclusive, however, they dosuggest that chiropractic manipulation has the potentialto become an important nondrug intervention for chil-dren with hyperactivity. Further investigation in thisarea is certainly warranted. (J Manipulative PhysiolTher 1989; 12:353-363).

ABSTRACTThe principle aim of this study was to determine the

effectiveness of chiropractic manipulative therapy inthe treatment of children with hyperactivity. Usingblinds between investigators and a single subject re-search design, the investigators evaluated the effective-ness of the treatment for reducing activity levels ofhyperactive children. Data collection included inde-pendent evaluations of behavior using a unique wrist-watch type device to mechanically measure activitywhile the children completed tasks simulating school-work. Further evaluations included electrodermal teststo measure autonomic nervous system activity. Chiro-practic clinical evaluations to measure improvement inspinal biomechanics were also completed. Placebo carewas given prior to chiropractic intervention. Data wereanalyzed visually and using nonparametric Statisticalmethods. Five of seven children showed improvementin mean behavioral scores from placebo care to treat-ment. Four of seven showed improvement in arousallevels, and the improvement in the group as a whole

Key Indexing Tenns: ChiropraCtic, Motor Activity,Galvanic Skin Response.

For years, the fact that stimulant medication had anapparent calming effect on hyperactive children wasreferred to as a "paradoxical effect." In a study bySatterfield and Dawson (6) a hypothesis was formulatedto explain the so-called paradoxical effect. The expla-nation offered by Satterfield and Dawson, based ondata resulting from their study, was that in those caseshaving a positive response to stimulant medication, thehyperactivity was due not to over-arousal, as would belogically expected, but under-arousal. Specifically, theseresearchers hypothesized that reticular activating sys-tem-mediated central nervous system (CNS) arousalwas below normal in their subjects. Thus, they arguedthat hyperactivity was the result of attempts by theirsubjects to increase arousal level through extraneousmotor activity. When administered a stimulant drug,the arousal level was chemically increased thereby re-ducing the need to increase arousal level thr'Ough motor

INTRODUCTIONHyperactivity is a significant problem (1-3) in chil-

dren with behavior and learning disorders. The majorapproach to treatment for this disorder has been treat-ment with stimulant medication (4). One alternative todrug treatment that has been investigated is behaviortherapy (5).

.Professor of Psychology, Mississippi State University. t AssociateProfessor of Special Education, Geo~a State University. * Postgrad-uate Faculty, National College of Chiropractic; private practice ofchiropractic. This research was supported by Grant Number 85-3-4from the Foundation for Chiropractic Education and Research andby Mississippi State University. Opinions expressed in this documentare not necessarily those of the granting agency.

Submit reprint requests to: Dr. Robert A. Leach, P.O. Box 1313,Starkville, MS 39759.

Paper submitted March 8, 1988.

354 Journal of Manipulative and IPhysiologicaJ TherapeuticsVolume 12.NumberS.Qct.:>ber. 1989TREATMENT OF HYPERACTIVITY. GIESEN ET AL

investigators (a clinical psychologist, th~: s\lperintendentof schools and the director of Psychoc~ucational andGuidance Services) monito~ children with learningand behavioral impairments due to brain damageand/or neurological dysfunction and wiith emotionalimpairments. Results of two separate investigationsrevealed that hyperactivity ,nd other impairmentsresponded well to chiropracti1 care and ~:ven exceededresults seen from medication.

Certain anecdotal and case! study evidence has sug-gested a role for chiropractic ~anipulation in treatmentof various mental disorders. ~. J. Palmer established asanitarium in Davenport, lo~ that treated a widevariety of mental disorders o~n with applarent success.Others have reported the eff~ of spinal! disorders onmental impairments and thciJt improvelJtent after chi-ropractic intervention (11).

While these unblinded ~ studies offered initialevidence for a chiropractic effect on autonomic func-tion, Dulgar et al.. (18), Wickes (19), W'iles (20), andothers (21) have offered more contron~:i trials whichsuggest a somatoautonomic etlrect for chi,ropractic ma-nipulation.

Indeed, recent controlled trials docum,ent that CMThas a significant effect on skin tempera1lure (22), andthe CMT causes significant elevation of plasma Beta-Endorphin levels (23). These studies lend further sup-port to the initial uncontrolled case study findings ofimprovement in hyperactivity after chiroJ.nctic manip-ulative therapy, in that chiroltactic manipulative ther-apy has been shown to have Somatoautonomic effectswhic? mi~h~ be expected to ~clude an ~:ffect on auto-nomIc activity. j

activity. The result was an apparent calming effectproduced by a stimulant.

While Satterfield and his associates have continuedresearch along this line (7-11), other research focusingspecifically on the questions of the interrelations be-tween hyperactivity, stimulant medication and meas-ures of electrodermal activity have reported findingswhich indicate that there is considerable complexityinvolved in these relationships. Alternative researchalso indicates that the "paradoxical effect" advanced bySatterfield, and its autonomic assumptions, are notclearly confirmed by other investigators.

The results of Firestone and Douglas (12) are inagreement with those of other researchers (13-15) thathyperactive and normal children do not differ in restingskin conductance levels and show similar increases toincreased task demands. These studies do not lendsupport to the contention that hyperactive children areeither over or underaroused, as proposed by Satterfieldand Dawson (6). Additionally, these studies do supportthe view that hyperactive children show a lower levelof specific responsivity to specific stimuli than normalchildren and this lower responsivity is associated withlonger reaction times for hyperactive compared to nor-mal children.

In this study autonomic data revealed that restingskin conductance was not different in hyperactive com-pared to normal children; hyperactives produced fewerspecific autonomic responses to signal stimuli. Resultsfor the autonomic activity measures indicated no dif-ferences between hyperactives and normals in restingskin conductance level {SCL), with group mean SCLsranging from 24 to 30 }lmhos. While the normals andhyperactives did not differ in phasic skin conductanceresponse (SCR) for amplitude of response to warningor response stimuli, the controls showed a greater fre-quency of skin conductance orienting response (OR)than the hyperactives.

The authors conclude that the skin conductanceresults favor an arousal hypothesis to explain theinc~eased impulsive responding in the reward conditionfor both ~oups. They conclude that tonic skin con-ductance may be viewed as an indicator of overallarousal and a sign that the organism is ready to take inand act on new information.

Chiropractic and Hyperkinetic BehaviorInitial evidence that chiropractic manipulative ther-

apy (CMT) could reduce hyperactivity in children wasproduced by the Psychoeducational and GuidanceServices at College Station, Texas (16). Independent

Rationale and Purpose of StudyHyperactivity has been identified as a major problem

among children with behavidr and leanung disorders.Administration of stimulant Imedication is the majorapproach to treatment for ~ disorder, but the mech-anism of action of such drug treatments in infl.uencingbehavior remains unclear. Also, such drug treatmentscan have undesirable side effects.

There is provocative evidence that chJropractic ma-nipulative therapy can alter Ilevels of I1lervous systemactivity and thus; a) may protide a drug..free treatmentfor hyperactivity, thereby av~iding po~:ible drug side-effects; and b) may represent ~ treatmen1t of hyperactiv-ity that achieves more 10n8-lasting ef1:ects than thatattained by drug treatment.

Given these relationships ~nd pOtential benefits, thepurpose of this research is to establish the efficacy of

Journal of Manipulative and PhysiologiaLI Therapeutics 355Volume 12- Number S -October, 1989

TREATMENT OF HYPERACTIVITY. GIE:SEN ET AL

chiropractic manipulative therapy in the treatment ofchildren with hyperactivity. The viability of chiroprac-tic as a nondrug intervention for hyperactivity couldhave important health implications due to the avoid-ance of the potential side effects of stimulant drugs inchildren, e.g., increased heart rate, arrested growth,insomnia and loss of appetite (3). .

EDA measures are known to vary greatly betweensubjects, a specific cut score for inclusion in the studywas difficult to determine. A further complication wasthat previous research is inconsistent in establishingwhether hyperactive children tend to have relativelyhigh or relatively low EDA levels. Consequently, it wasdecided to use a skin conductance level of approxi-mately 6 Ilmhos as a minimum activity leve:l for inclu-sion in the study. Much lower a level of electrodermalactivity for a subject would present a "floor effect"situation in which improvement, defined aJS reductionin relatively high levels of electrodennal activity, wouldbe increasingly difficult to demonstrate.

METHOD

Subjects and DesignSubject Recruitment and Inclusion Criteria: After

newspaper advertising and referral from a pediatricianand others had produced eight candidates for study,subjects were selected according to several criteria. Allcandidates were of school age (7-13) and had objectiveand subjective clinical findings evidencing a chiroprac-tic intervertebral subluxation complex (spinal lesion).In addition, candidates were selected only if at leastthree of the remaining four criteria were met: a) diag-nosed hyperactive by a qualified professional, b) scoreon a parent rating scale of hyperactivity at or higherthan that for a normal child three years younger thanthe subject, c) mean skin conductance level above 6p.mhos, and d) history of positive response to stimulantmedication for hyperactivity. Finally, only candidatesthat were removed from medication during summerbreak from school were considered for inclusion. Sevenof the eight applicants were accepted for inclusion inthe study. The eighth applicant showed few objectiveclinical signs of spinal lesions and an unusually lowmean skin conductance level (the remainder of theapplicants had high or very high conductance levels),and was dropped from the study.

Use of the Parent Rating Scale for Screening: Theparent rating scale used for screening of the applicantswas that of Werry-Weiss-Pe~ers. Applicants acceptedfor this study had initial scores ranging from 26 to 40with a mean score of 33.2, which for their ages was wellabove norms established for normal children (24). ,Innormal children scores on this. measure decline withincreasing age. For inclusion in this study a subject'sscore had to be at or above that for normal childrenthree years younger than the subject.

Use of Chiropractic Examination for Scn~ening: Chi-ropractic screening examinations were carried out onall eight prospective research applicants. Parents com-pleted a standard case history for their child, includingquestions regarding previous medical, psychological orother treatment for hyperactivity. With parent and childtogether the chiropractor consulted the participants,reviewing the case hiStory and checking for any poten-tial contraindications to manipulation (e.g., prior his-tory of spinal pathology, hiStory of cerebrovascularpathology, etc.). During the interview and (:onsultationthe parent and child were told that there is some caseStudy and anecdotal evidence that chiropractic may beof benefit to children with hyperactivity. Parents wereasked to sign a consent form that outlined the studyand advised that, "There is little or no risk for physicalor psychological harm from anyo( the procedures tobe used. Successful results could result :in drug-freetreatment for hyperactivity." The form and the studywere reviewed and approved by the InStitutional Re-view Board of Mississippi State University which haddetermined that human subjects would OIot be at riskin the study. Parents were advised that the point atwhich intervention begins would vary from child tochild and could not be revealed until the study wascompleted. They were asked to not allow their child tomiss more than 1 week due to vacation, etc. However,all parents were advised that their child cc)uld, for anyreason, drop out of the study at any time.

After consultation, clinical assessment was made,including recording of subjective complaints, objectiveorthopedic and chiropractic structural lexamination,and radiographic examination when indicated by ob-jective clinical criteria. Initial chiropractic screeningrevealed significant subjective, structural, orthopedicand radiologic findings in alt but two of the eightprospective candidates; however, one of the two wasconsidered borderline and wa$ included in the study,

Psychophysiological Screening: The resting skin con-ductance level (SCL) was obtained from each applicantaccording to the procedure described below. Since elec-trodermal activity (EDA) has been used relatively infre-quently in previous hyperactivity research and since

356 JoumalofManipulative and Physiological TherapeutksVolume 12. Number 5. October, 1989TREATMENT OF HYPERACTIVITY. GIESEN ET AL

while the other was dropped. Clinical assessment in-cluded those items listed in Table 1. Additionally, thechildren were screened for clinical signs of vertebro-basilar insufficiency.

August (before school and the question of renewal ofstimulant medication arose) the children began treat-ment by twos instead of singly. Phase changes werethen ordered by interval rather than baS4~d on perform-ance or nonperformance of prior subjects.

Subjects participated as patients at the Leach Chiro-practic Clinic where they received chiropractic evalua-tion and therapy, and the behavioral measures of motoractivity. Appointments were scheduled for three visitsper week. Once per week subjects rece:ived their psy-chophysiological evaluation at the Psychophysiologyand Biofeedback Laboratory in the Department of Psy-chology on the Mississippi State University campus.

Definitions: EDA measured directly a.t; skin resistancelevel (SRL) by the constant current method was thepsychophysiological measure employed in this investi-gation. EDA is primarily the result of physiologicalchanges in the activity of the eccrine sweat gland. Thereis also some evidence (and theoretical debate) regardinga nonsweat gland epidennal component of EDA, par-ticularly for skin potential measures. Since the sweatgland is controlled by the sympathetic branch of theautonomic nervous system, it is geneI'ally thought toreflect changes in the activi., of the sYrn.pathetic nerv-ous system, and secondarily, changes In the centralnervous system. Contemporary research and theory onelectrodermal activity is consistent with this statementbut one of such brevity mary be an oversimplification(29).

Research Design: A single subject research design,the multiple baseline design across subjects, was usedto evaluate the effect of chiropractic manipulative ther-apy on the overt motor behaviors and physiologic meas-ures. Single subject designs are particularly useful withsmall sample sizes and, in this design, external validityis achieved by systematic replication across subjects(25).

While new to the chiropractic profession, single sub-ject research designs have been used for some time inpsychological, educational and physiotherapeutic in-vestigations. Since their introduction to the profession(25, 26), single subject designs have been used in as-sessment of CMT for neck pain (21), and for assessmentof CMT for incontinence (28). Their use here is partic-ularly important in that a small number of subjectswere studied in a clinical setting.

Data collection under non medicated conditions be-gan during summer vacation (when children are takenoff their stimulant medication) after a 2-week wash-outperiod. Baseline was a minimum of 2 weeks of datacollection (six sessions of behavioral and two sessionsof physiological measures), during which measurementindicated minimal variation or a trend away from thatconsidered desirable in a normal subject. During thisphase children received the placebo treatment describedlater. Due to time constraints of completion by mid-

TABLE 1. Chiropractic examination: objective findings

I. Palpation1. Static2. Motion

II. Range of Motion1. Cervical2. Dorsolumbar

III. Compression/Irritation1. Foraminal compression2. Shoulder depression3. Adson's Test4. Kemp's Test5. Soto-Hail6. Extremity Signs

IV. Structural/Postural1. Head tilt2. Shoulder height3. Rib hump/bulge. scoliosis4. Hip height5. Short leg syndrome (measures)

V. Radiography1. Anomaly2. Pathology3. Mechanical variance4. Subluxation

Psychophysiological Evaluation ProcedureSRL measures were taken on a Narco (E&M) Physio-

graph Six with an E&M GSR preamplifier which sup-plied a constant current of 20 IJ.A D.C. Sensitivity wasset at 2.5 Kohms/cm of pen deflection. Electrodes weredisposable Ag/AgCI type (Biotrode Silver Plus) appliedwith Signa Gel (Parker Laboratories, Inc., Orange, NJ)electrode gel. Both were supplied by Biofeedback Inter-,national, Guemeville, CA.

When subjects arrived ati the laboratory for the firsttime, it was explained tha1 each subject was to havehis/her "physiological activity" measure for about 10min. They were to sit quietly without talking duringthis period and were shown that they would be moni-tored on a closed-circuit TV. They were informed thatafter about 8 min of quiet, 'four moderately loud toneswould come on about hall a minute apart, and, afterthat, the session would be pver and the sensors wouldbe removed.

After any questions were answered, the subject wasseated in a reclining chair, the application area was

Journal of Manipulative and PhysiologiCil Therapelitics 357Volume 12. Number 5 .October, 1989

TREATMENT OF HYPERACTIVITY. GIESEN ET AL

cleaned with alcohol, and electrodes were attached tothe medial phalanx area of the second and fourth digitsof the nondominant hand. A nonfunctioning, clothes-pin-clip-style plethysmographic pulse transducer wasalso attached to the third digit to divert specific atten-tion from the electrodes. The child was instructed tokeep the hand in a comfortable position and as still aspossible and not to move the arm since this wouldinterfere with proper recording. A piece of maskingtape was placed loosely over the arm at the wrist toserve as a reminder to the child not to move the handor arm.

SRL measures were taken at 30 sec intervals for 7min. At the 7 min mark, a tape recorder was activated.The tape contained four repetitions of 25 sec of silencefollowed by a 1000 Hz tone of approximately 50 dbplayed through a speaker in the subject room. SRL wasrecorded during the 5 sec just prior to tone onset andthe response to each tone was recorded as the maximumSCL during the tone and for 5 sec following the tone.This recording procedure was repeated for each tone,yielding eight measures.

-Subject Ma"llagemenrand-Procedural Variations: Amajor problem in obtaining physiological measuresfrom children in the age range of those in this study issubjeetmovement and movement artifacts in the datarecordings. This problem was exacerbated by the factthat all children in this study were hyperkinetic and notparticipating in their usual medication regimen. Indi-vidual difTerencesinmovement tendencies during datarecording were considerable. There were rare occur-rences that necessitated interruption of the recordingsequence. These occasions were caused by extrememovement, electrodes becoming unattached, equip-ment malfunction, etc. When these disruptions oc-curred, the research associate followed the procedure ofhalting the recording of data, taking the actions neces-sary to remedy the problem-such as reattaching theelectrodes-and then resuming recording at a point inthe recording sequence approximately I min before thedisruption occurred.

Detection of movement is considered ~m optimalmeasure of overt motor behavior,;applicable to researchon hyperactivity. Some researchers prefer direct obser-vation of motor behavior in a naturalistic setting as thebest behavorial measure of hyperactivity. However, itmay be argued that use of the accelerometer (30) com-bined with physiologic measures of arousal (6) providea satisfactory means of assessing not only current activ-ity levels, but are helpful in mo~ accurately predictingfuture activity levels as well (31). '

During each visit to the practi~oner's office, prior toplacebo or intervention chiropractic manip\uative ther-apy, a graduate student placed the acto meter on thechild's dominant ankle and nondominant wrist (deter-mined by having the child write his nam(~ as well askick a styrofoam footfall. The nondominant wrist wasused because the subjects were asked to work on asimulated school task during data collection that re-quired writing. Since there was no confounding activityinvolving the legs, the ankle of the dominant foot wasused for the second actometer. The actual motion dataused for each session was the average of the data ob-tained for the arm and leg combined in order to obtainan overall motor activity.

Each child was asked to complete a computer gen-erated activity sheet simulating a school task whileYLearing the actometer. The children were seated inchairs high enough off the floor such that their feet werefree to swing and their arms and hands were unre-stricted. The graduate student monitored each childduring the.15 min sessions fro~ a booth (the practi-tioner's X-ray booth with the leaded glas5; covered bytinted material), hidden from the view of the children.

The conditions of the room were comfortablethroughout the study. Children were tested by twos dueto time constraints (having to conduct the study duringthe practitioner's normal lunch hour), but in one casedue to scheduling difficulties and missed appointmentsone of the subjects was tested 9 of 12 1:imes duringpretreatment with another subj~, yet was only tested5 of II times with another subject during the treatmentphase. Due to this inconsistency this subject wasdropped from the statistical analysis after the graduatestudent commented during the study that the childrenacted differently when tested ~one from when testedtogether. I

Overt Motor Behavior MeasurementReliability of the motion recorders (actometer, a

mechanical accelerometer) used in this investigation(Timex, Model 10 I, Karlis & Willis, Middlebury, CT)has been shown to be quite high. Reliability studies byTryon (30) demonstrated that by attaching a device atvarying intervals along a motorized pendulum whichwas oscillating at varied intensities, coefficients of var-iation ranged from 0.90 to 0.99. .

Chiropractic MeasuresChiropractic measures incluqed objective procedures

that are used in the profession (Table I). While mostare fairly reliable including motion palpation for cer-vical joint fixation (32), range of motion testing with ,a

358 Journal of Manipulative and Physiological TherapeuticsVolume IZe Number 5 eOctober, 1989

TREATMENT OF HYPERACTIVITY. GIESEN ET AL

venti on involved the use of light but specific highvelocity, low amplitude thnilsts for the correction ofchiropractic intervertebral subluxation complexes.

goniometric device, structural tests including leg lengthassessment and radiographic evaluation (33, 34) thereis concern about inter- and intraexaminer reliability(35). In this study no attempt was made to use a separateexamining and treating doctor, so some bias in pre- andposttesting might be expected. However, an attempt topredict chiropractic success during initial screening andrate the degree of improvement in chiropractic meas-ures after intervention (psychophysiologic and behav-ioral measures were blinded from the practitioner untilafter chiropractic measures were revealed) offered someprotection against this potential bias. Measurementsijnd all chiropractic evaluations were made in the clinicunder normal operating conditions.

During the baseline data collection phase of theresearch each child received placebo treatment. Non-specific contact points were used and the practitioner"pretended" to be treating the child with a detunedmechanical manipulating device (i.e., Activator instru-ment) adjusted down to zero thrust but with audible"popping" sound (36). During initial use of the device,it became apparent that the hand could not trigger thedevice without some force being distributed to the child.The practitioner then developed a technique wherebyhe held the tip of the instrument between his index andlong finger so that the instrument never actuallytouched the child; even with this delivery some lightforce was distributed to the child; however, nonspecificcontact points were used and specific spinal dysarthriaswere deliberately avoided. In this way the instrumentmade a "noise," and it was the practitioner's perceptionthat the child assumed that there was some benefit tothe procedure. Furthermore, the child received the same"gentle touch" before and after treatment with theplacebo as was received during the actual intervention.The practitioner made every effort to be pleasant andconversational, asking about hobbies and sport interestsand summer vacation plans; during the baseline phasethe children were told often by the practitioner that"different types of treatments are being used, and wewant to see if they help calm you down." Duringbaseline and intervention both the practitioner andscientists were blinded from the other's data collection.

Chiropractic adjustive intervention was varied ac-cording to the spinal needs of the individual child. Allthe children were treated by standard diversified andGonstead techniques. Specific upper cervical correctionfor some children was indicated after analysis (TableI), including one child with a demonstrable kyphosisof the C2-C3 motion segments, while most had inter-vention for juvenile idiopathic scoliosis. In every caseintervention was selective for the specific spinal dysar-thrias detected by examination. The chiropractic inter-

RESULTS

jChiropractic MeasuresPretreatment radiographi findings 'Nere compared

with independent baseline skin conductance level (SCL)for each subject. The rank order correlation was high[r(s) = 0.714] although not quite significant at the 0.05level due to the small sample size. The fact that thecorrelation between independent radiographic findingsand resting SCL was so high is, in itself, a truly remark-able finding of this investigation. Conelations of thismagnitude between electrodermal activity measuresand other measures of ph~iological activity are typi-cally much lower.

Chiropractic data are summarized in Table 2. Therewas not significant symptomatic improvement in thegroup in terms of pain relief(category I findings) essen-tially because there were few muscu:loskeletal com-plaints to begin with. In terms of objective clinicalimprovement such as palpatory, structural, and or-

~ihopedic findings (category II), there was at least someimprovement in all cases, although dramatic in four ofthe seven, in terms of structural assessment of spinaldeviations, notably so in the1-yr-old girl who presentedwith the initial radiographic! finding of a C2-C3 reversalsubluxation. Posttreatment .-adiographic assessment re-vealed correction.

Motor Behavior I

Motion recorder scores ~ subject for each measure-ment session are shown in Figure I. There was somereduction in overt motor be.havior in five of the sevenchildren. One child (subj~ 3) was measured 9 of 12

TABLE 2. Number of positive clinical findings before and afterCMT

Cat I, Category I or subjective findings; Cat II, Category II orobjective clinical findings; Rad, Radiographic filldings (grade 1 is leastsevere).

Journal or Manipulalive and PhysiologiCOl1 Therapeulics 359Volume 12-NumberS-October. 1989

TREATMENT OF HYPERACTIVITY. GIESEN ET AL

limo k1 Mol""'

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~

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times during pretreatment basel ire together with an-other subject in the experiment, bllt was measured only5 of II times together with ano.tijer subject during thetreatment phase. Due to this Jprocedural variationcaused mainly by scheduling co~flicts and the failureof other subjects to keep appoin1ments, subject 3 wasdropped from statistical analysis Qfthis dependent mea-sure. Subject 7 was also exclud~ from this analysisbecause of signficant injuries &ustained at summercamp during his 2 weeks of intervention, which re-quired medical intervention including medication.

While there is some debate ~ncerning the use ofstatistics in single subject researth, some have arguedthat properly applied statistics ca~ aid in analysis of thedata (37). Using the Walsh testj the mean change inmotion recorder scores of the r~maining five subjectswere analyzed for significant ch~nges from baseline tointervention. Results indicated ~hat the reduction inmean motion recorder scores frotn pretest to treatmentperiod was significant for these s~bjects (p .< 0.03).

Results of all subjects were analyzed visually by graphas well, however, visual interpr~tion appl~ars uncon-clusive. J

Electrodermal Activity: Conductance lev'el (SCl)These measures were obtained by repeated sampling

during a 7 min resting period a~ the beginning of eachphysiological assessment sessioq. Due to the fact thatsubjects had different numbers pf physiological assess-ment sessions during the trea~ment, necessitated bytime constraints and design modifications, the threeaveraged skin conductance level (SCL) scores obtainedfrom each subject during each ~ssment session weretreated as a set of observations d~ring pretrleatment anda set of observations during the treatment phase. Thisapproach made possible the usb of statistical analysesin the single-subject design pla* for this investigation.Although somewhat controverSial, the argument hasbeen made in favor of the use pf statistical techniquesin single-subject designs in speclfic situations (38).

Analyzing the SCL observatipns (Figure 2) from allsubjects for the pretreatment hase in comparison tothe observations from the tre tment phase yielded asignificant reduction in means CL (Pretreatment M =11.88 JLmhos; Treatment M = 9.53 JLmhos), 1(187) =2.65, p = 0.009.

The same comparisons for the skin conductanceresponse (SCR) to the first t 0 tones did not attainsignificance for either tone. Fo tone 1, 1(61) = -0.28,p = 0.78; for tone 2, 1(61) = O. 4, p = 0.808.

It should be noted that all a"alyses of the electroder-mal activity data included the klata from all 7 subjects,

SO931ons ...b..nc..

Figure 1. Motion recorder scores by subject.

360 Journal of Manipulative and Physiological TherapeuticsVolume 12.NumberS.October, 1989TREATMENT OF HYPERACTIVITY. GIESEN ET AL

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Figure 2. Electrodennal activity and average resting levels.

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WoWa:~.o""'.0including subjects 3 and 7, who showed spurious

changes in electrodennal activity. Thus the significantreduction in mean skin conductance level noted abovewas a robust effect able to "tolerate" the extraneousvariability associated with subjects 3 and 7. SCL profilesfor all subjects are seen in Figure 3.

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Parental Rating~aleThese results 3re..shown in Figure 4. Four of the seven

subjects showed 'decreases in parental ratings of hyper-kinetic behavior 'in the home environment from thestart of participation to the end of the tr~il1ien:t phase.Subjects 3 and 7, excluded from the analysis of theabove motion recorder analysis, showed no change onthis measure. Excluding th~secsubjects, four of five, or80% showed reductions in pareritalratings of hyperki-netic behavior. :"

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DISCUSSIONExamination of the resultS for each of the main

dependent measures and including all subjects yieldedthe followed results summary:

I. 57% (4 of7) showed improvement in chiropracticradiographic findings.

2. 71.4 % (5 of 7) showed a reduction in overt behav-ioral activity (mean actomotor scores).

3. 57% (4 of 7) showed improvement in level ofautonomic activity (SCL).

4. 57% (4 of 7) showed improvement in parentalratings of hyperactivity.

There was also considerable consistency between out-come measures for each subject. One subject showed

I , ~ ~ a j ~:::: I I I I I I i I I I H-I-I-.J-H-f-I-1-.."

I I I I .I 8 8 81. ..e 8 e e e 8 7 7 7 8 8 .SESSlO-IS

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Figure 3. Skin conductan~ l~elsat rest by session for each subject.

Journal of Manipulative and Physiologic:aJ Therapeutics 361Volume 12e Number SeOctober, 1989

TREATMENT OF HYPERACTIVITY. GIE:SEN ET AL

Figure 4. Parental ratings of hyperkinesity.

under investigation or due to so~ e controllable vari,able

in the data collection procedure. It would be interesting

to know if the motor behavi r of these subjects is

equally variable under more aturalistic conditions,

e.g., in public school classroom

~Ifso, there is probably no way 0 obtain e:Kperimenter

control over this variability wi out introducing new

confounding variables into th~ investigation. If the

motor behavior were not found to be highly variable

under more naturalistic cond~io~s, th~ implicatio~

would be that there was some ~anable In the expen-

mental condition contributing tp it.

In particular, one practice in the experimental con-

dition may have contributed to ~e observed variability.

This was pairing subjects during data collection. There

may well have been an interactive effect between sub-

jects. Under natural conditions, it would be unlikely

that two hyperactive children would be seated together.

It is quite possible that this practice contributed to the

variability. While an attempt was made to always pair

the same subjects, it was not always possible due to

missed appointments and late arrival for appointments.

This too may have contributed to the observed varia-

bility, since it is likely that different childrl~n will affect

one another differently.

Another major design diffiCuity encounl:ered was the

necessity of having to use time ~ther than perfonnance

data to determine phase shifts f~r the subjects. Multiple

baseline designs depend upon data base<i criteria for

phase changes. Without this it is difficult to be certain

that the influence of extrane~us variablles has been

adequately controlled for in the study. Unfortunately,

the time constraints imposed on the study by the length

of the summer vacation made it impossible to fully use

perfonnance data to make phase change decisions. An

attempt was made to base these decisions on perfonn-

ance data, but the decision process was not satisfactory

because of the limited time a t the variability of the

data.

At best, from a behavioral nd design perspective,

this study might be consider~ a pilot investigation.

The results are suggestive of i~provement. The study

was valuable in that it made clqar certain problems that

need to be solved in future studies of hyperactivity in

children using single subject research methodology and

chiropractic intervention. Before such a study is at-

tempted again, investigations (perhaps many) focused

on the nature of the behavio variability observed in

this study need to be conduct and a way to control

this variability found. Also, in any subsequent study of

this type the investigators sho ld plan the study so that

the severe time constraints en untered in this investi-

gation are not present.

improvement on all four of the above dependent meas-ures. Four subjects showed improvement on three ofthe four outcome measures. One subject showed, im-provement or no change on three of the four outcomemeasures. Thus, five of the seven showed improvementon at least three of the four outcome measures. Consid-ering the short duration of chiropractic intervention,and the diverse domains tapped by the four outcomemeasures, these results suggest a clinically significanteffect of chiropractic manipulative therapy on hyper-activity and its autonomic substrate in the hyperactivepatients participating in this investigation.

The greatest problem encountered in attempting touse a multiple baseline design across subjects in thisstudy was the variable data obtained. A single-subjectdesign depends to a great extent on control of measure-ment variability. Traditionally, variability in this typeof design is best handled by an investigation to deter-mine the source of the variability and subsequent con-trol of same. When this is not possible, the baselinephase should be extended and an attempt made toidentify some predictable pattern to the variability. Ifthere is a predictable pattern to the variability then thispattern can be taken into account when analyzing thedata. Finally, if neither of the above is possible, the onlyrecourse left is a statistical analysis of the data. Thislatter recourse is the least satisfactory of the threeapproaches to this problem. Unfortunately, because ofsevere time constraints already discussed, it was notpossible to either take the time to investigate the sourceof the variability or to extend the baseline period. Thus,this investigation had to use the least desirable of theavailable solutions to this problem.

The investigators are uncertain if the variability ob-served in the behavioral data are typical of the disorder

362 Journal or Manipulative and Physiological TherapeuticsVolume IZe Number SeOctober, 1989TREATMENT OF HYPERACTIVITY. GIESEN ET AL

Handling the problem of time constraints is closelyassociated with potential confounding effect of stimu-lant medication on the subjects during the investiga-tion. On the one hand, subject response to medicationis the best available indicator that the hyperactivity isasSociated with an arousal level problem. It is the typeof subject that responds positively to intervention withstimulant medication that is needed for the study. Onthe other hand, the subject needs to be off the medica-tion in order to get the best demonstration of potentialeffect from chiropractic intervention. The only timethat these subjects are typically taken off stimulantmedication is during periods when they are not inschool. Unfortunately, the longest of these periods, i.e.,summer vacation, does not appear to be long enoughto conduct this type of investigation. The only apparentsolution would be to locate subjects who respond posi-tively to stimulant medication but whose parents wantthem off of the medication for reasons unrelated toeffectiveness of the medication.

on the parental rating scale. This was one of two pa-tients that the practitioner predicted would respondbest to chiropractic during i~tial pretre:atment assess-ment (the other patient prediCted to respond best, sub-ject 1, in fact responded best Gf all the children in termsof reduction on the motion recorder average; from71.29 average movements to 52.47). T:be practitionerpredicted improvement base4 solely on findings of thechiropractic examination.

That a partial "whiplash" I could have an effect onneural integrity at the C2-Q3 segmental level is wellknown. However, until this Study there was no docu-mentation that such an injurr with resultant neurolog-ical involvement could affect arousal. We believe thatradiographic demonstration Gf correction of this lesion,combined with psychophysiological evidence of signif-icant improvement in arousal after chiropractic manip-ulative therapy, suggests a somatoautonomic effect ofchiropractic manipulative therapy that 1nay go beyondtreatment of hyperactivity.

For example, there are ~ number of "stress syn-drome" diseases and disorders that, like hyperactivity,have some degree of neurological imbalance as a centraldefect. Classically, the defect'in children with hyperac-tivity is thought to be in aro~ levels. The implicationsfor treatment of other functional disorders of the nerv-ous system by chiropractic ,manipulati:ve therapy areunclear. However, this study' presents an exciting chal-lenge to the profession in ~at regard, and does pointto CMT as a possible nondruB intervention for childrenwith hyperactivity. I

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CONCLUSIONThere was clinical evidence to suggest a beneficial

effect of chiropractic manipulative therapy (CMT) onthis group of children, in terms of specific correction ofspinal disrelationships. This study suggests a beneficialeffect-{)f chiropractic manipulati¥e therapy on variousmeasures of hyperactivity in children. Its p~rpose interms of scope and design was not to demonstrate thatCMT corrected specific vertebral subluxation com-plexes, but rather thatCMT administered by a fieldpractitioner could impact positively on hyperactivity inchildren. In fact, radiographic evidence did not revealremarkable improvement in the group as a whole-partly owing to lack of appropriate length of interven-tion-however, in the case of subject 2 radiographicimprovement was striking considering only one monthof care was administered.

This effect of CMT on specific spinal dysarthrias,combined with physiological, behavioral and parentalassessment of improvement in hyperactivity, is classi-cally demonstrated in the patient (Subject 2) who wasdocumented to have cervical hypolordosis (evidence ofwhiplash) by radiography. Posttreatment assessmentrevealed correction of this significant type of subluxa-tion complex. Motion recorder assessment revealedimprovement from 69.33 to 64.81 (average movementsper recording session). Electrodermal tests revealed areduction in skin conductance. Finally, parental assess-ment of activity from pretest to the final week ofintervention revegl a significant change from 40 to 26

Journal of Manipulative and Physiologi,ca) 'Therapeutics 363Volume 12.Number5.0~tober. 1989

TREATMENT OF HYPERACTIVITY. GIESIEN ET AL

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