Chiropractic: a bogus* treatment for bedwetting?
Posted by apgaylard on May 21, 2009
A wide variety of claims are made for chiropractic treatment. One that really surprised me is that it can be used to treat bedwetting (nocturnal enuresis) in children. I really struggle with the basic plausibility of this claim. I mean, how can spinal manipulation control whether a child pees in their sleep, or not?
So I decided to see whether this is a bogus* treatment, or not.
Some Basic Facts
Although this complaint can cause stress** and social isolation for a child, the UK NHS Choices website says that bedwetting is very common in children. It usually affects those under six or seven years old. Fortunately, it usually stops by the age of seven or slightly later. They estimate that around, “one in seven children aged five, and one in 20 children aged 10, wet the bed.” Boys are more commonly affected than girls. Older children can also have this problem.
The children’s health charity ERIC (Education and Resources for Improving Childhood Continence) identifies three likely causes:
- The child not developing an awareness of the link between having the feeling of a full bladder and the need to wake up;
- Not producing enough of the hormone that reduces urine production at night;
- An overactive bladder.
They also identify the false belief that bedwetting is the child’s fault. This fits in with the NHS’s advice that, “it is very important not to punish the child or make them worried about the bedwetting.”
[A more comprehensive and technical article can be found on the Patient UK website.]
There are many who claim that chiropractic can help with bedwetting. One of these is from my rough geographical area: Walsall Chiropractic Health Clinic. They are proud members of the British Chiropractic Association (BCA)***.
They claim that:
“[…] countless children have been helped with safe and natural chiropractic care”
But temper this with:
“[…] Since chiropractic isn’t a treatment for bedwetting, a thorough examination is necessary. If the bedwetting is caused by nerve interference from the spine, many children see great results with chiropractic care.”
And also add:
“Chiropractic has produced tremendous results amongst bedwetters with neurological compromise.”
This is sending mixed messages. But I interpret this as a claim that chiropractic is very effective in treating a sub-group of bedwetting children; those with “neurological compromise”, whatever that means.
So what evidence is provided to support this claim? They claim that, “The Journal of Manipulative and Physiological Therapeutics document many studies showing the positive benefits of chiropractic care.” And cite three studies.
Before discussing these it is important to note that this journal is, “is dedicated to the advancement of chiropractic health care.” This would seem to call into question whether this is anything approaching a good quality peer-reviewed journal. It seems to me that it is highly likely to have some bias towards chiropractic. Also, as a general principle: CAM journals are not to be trusted.
The evidence starts with a study by Reed et al (1994).
“A study of 46 children received chiropractic care for a 10-week period. A quarter of those receiving chiropractic care had 50% or more reduction in the wet night frequency, while none amongst the control group saw a reduction.[…]”
The summary says that, “Forty-six nocturnal enuretic children (31 treatment and 15 control group), from a group of 57 children initially included in the study, participated in the trial.” This is a 19% attrition rate, not fatal, but not good either. It’s also a small study.
And what was the result? Although the authors tried to argued that:
“The post-treatment mean wet night frequency […] significantly less than its baseline mean wet night frequency […]” and, “For the control group, there was practically no change […] The mean pre- to post-treatment change in the wet night frequency for the treatment group compared with the control group did not reach statistical significance (p = 0.067).”
Everything else is posturing. The whole point of trial with a control group is the comparison between treatment and control. This is a negative trial no matter what the authors or chirophiles claim.
Next, a trial reported by Leboeuf et al (1991):
“Children with a history of persistent bed-wetting received eight chiropractic adjustments. Number of wet nights fell from seven per week to four.”
This was a “prospective outcome study”. As such it had no control group and so cannot be trusted. The trial looked at, “One hundred and seventy-one enuretic children, aged 4 to 15” who were, “were treated with chiropractic adjustments”. The outcome measure was the number of “wet nights” which was monitored by their parents.
With the children acting as their own ‘controls’ the number of “wet nights” had decreased during a two week period with no treatment from a median of seven per week to 5.6 (p = .01). By the end of the treatment this was 4.0 per week (p less than .0001).****
Was this a success? No – the authors noted that, “This result is less favourable than the therapeutic success of other common types of therapy, which have reported “cure” rates well above 50%.” And, “In the absence of a control group there appears to be no validity in the claim that chiropractic is a treatment of choice for functional nocturnal enuresis.” How anyone who has read this can offer this trial as evidence in favour of chiropractic escapes me.
The final article cited is Blomerth (1994).
“The lumbar spine of an eight-year-old male bed wetter was adjusted once and at a one-month follow-up. There was a complete resolution of enuresis. This happened in a manner that could not be attributed to time or placebo effect.”
This is just a single case study. The author notes that, “The patient had several recurrences of bed-wetting” but opines, “all of which were associated with minor injury to the lower back.” It is a bit much for the author to have us take this on trust.
The claim that, “This happened in a manner that could not be attributed to time or placebo effect.” Is odd. Without a time-machine, how could the author be so sure?
So, all we are left with from the ‘evidence’ provided by Walsall Chiropractic Health Clinic is the case of a single child published in a journal whose express aim is the, “advancement of chiropractic health care.”
In my view, this amounts to absolutely no credible evidence. Also, none of these articles talk about a neurologically compromised sub-group of sufferers.
Just to make sure that I was being fair, I searched PubMed for relevant studies.
Most significantly, there is a Cochrane review from 2005 that looked at CAM interventions for nocturnal enuresis in children that included chiropractic. (Glazener et al, 2005). It concluded that:
“[…] chiropractic may help, but the evidence was weak.”
This conclusion was based on two of the articles cited by the Walsall Chiropractic Health Clinic (Leboeuf et al, 1991; Reed et al, 1994). Given that both of these were negative trials, this conclusion seems excessively generous. My unease is exacerbated by the summary of the characteristics of the trials provided by the review.
Evidently Reed et al (1994) did not provide details of the RCT. So we are not able to know how patients were assigned to either treatment or control, for instance. Also, urinary tract infections (UTI) were not excluded as a possible cause. Only eight out of 31 treated children were deemed to be successfully treated (50% improvement) – 26%.
Leboeuf et al, (1991) was an RCT with patients randomly divided into the two groups – but only for first two weeks. It did exclude organic causes and daytime wetting.
There were also two adverse reactions: headache and stiff neck and acute pain in lumbar spine. This should be a worry.
The trial was further compromised by the groups not being comparable at baseline (significant difference in initial estimate of severity of wetting). There was no blinding, no follow up and no comparison with a control group after first 2 weeks. This is just not credible.
Taking these two studies together the evidence seems less than weak to me.
My search did turn up some other articles: a comment on Leboeuf et al (1991) which is on the wrong side of a pay-wall; along with several other articles (Côté and Mierau, 1995; Culbert and Banez, 2008; Keating, 1995).
However a review by Kreitz and Aker (1994) makes some useful observations. They made a, “comprehensive review of the literature concerning the etiology, diagnosis, and the natural history of primary nocturnal enuresis”. They conducted, “a computer-aided search of papers indexed in Medline and the Index to Chiropractic Literature from 1989 to 1993” along with searching the, “Chiropractic Research Abstracts Collection and bibliographies from pertinent articles” manually. They concluded that:
“The success of each therapeutic option must, in part, be attributed to the natural history of enuresis, as well as any educational or placebo aspects of treatment. Conditioning therapy utilizing the urine pad alarm may be the most reasonable initial mode of intervention. Spinal manipulative therapy has been shown to possess an efficacy comparable to the natural history.”
I take it that this means that chiropractic works as well as leaving the child alone.
What the chiropractor said
Out of fairness I put my main concerns to the Walsall Chiropractic Health Clinic:
“I’m a bit confused about whether you think that Chiropractic can help with nocturnal bedwetting in children. Your quotes from The Journal of Manipulative and Physiological Therapeutics would seem to claim that it can. Yet you go on to say, “Chiropractic isn’t a treatment for bedwetting” and then “Chiropractic has produced tremendous results amongst bedwetters with neurological compromise.”
Is it that you can help some, but not all, children with this complaint? How do you tell who is neurologically compromised?
A 2005 Cochrane review concluded that, for Chiropractic, “the evidence was weak”. Do you agree or do you have more recent research evidence that you would base your treatment on?”
“[…] thank you for enquiry. you appear very well read on matters. I would answer your questions in summary by suggesting that nocturnal eneuresis my be a consequence of a variety of factors. having exhausted all allopathic avenues, and providing that there are no contraindications to chiropractic care, then sometimes the results have been favourable. “
Which is very nice, and I’m sure sincere, but much weaker than the claims made on their website. Contrasting these:
- “countless children have been helped with safe and natural chiropractic care”
- “many children see great results with chiropractic care”
- “tremendous results amongst bedwetters with neurological compromise”
With, “sometimes the results have been favourable”: it doesn’t even seem that this chiropractor has much faith in chiropractic.
Also, the more I think about this the less impressed I am. If a child has, “exhausted all allopathic avenues” that means training with alarms (how these can be ‘allopathic’ escapes me) and perhaps even treatment with drugs have not resolved the problem. It must also mean that infection has been ruled out. It seems to me that a child in this position has a problem that is difficult to treat. All the evidence suggests that chiropractic is not effective on children whose care has not exhausted proper medical options. Given this, how can chiropractic hope to help with the more difficult cases?
It is clear that chiropractic is a bogus* treatment for bedwetting in children. There is no good evidence outside of the chiropractic literature and the two trials that made it into the Cochrane review are essentially negative and of poor quality.
There is a much better evidence base for the use of alarms (Glazener, Evans and Peto, 2005), which apparently help children develop an awareness of the link between having the feeling of a full bladder and the need to wake up:
[…] The review of trials found 56 studies involving 3257 children. Alarm interventions reduce night-time bed wetting in about two thirds of children during treatment, and about half the children remained dry after stopping using the alarm. […]”
A success rate of two-thirds with half remaining dry after stopping using the alarm would appear to be vastly superior to the success rate reported by Leboeuf et al (1991): 26% of children improving by 50%.
Another hint that chiropractic is a bogus* treatment for bedwetting is the explanation of causation given by chiropractors. The ‘explanation’ offered by the Walsall Chiropractic Health Clinic is typical:
“Two key muscles control the emptying of the bladder. Their technical names are the detrusor and trigone muscles. Nerves that exit the spinal column in the lower back and sacrum control these muscles.
During the early years of life, the sacrum has five separate segments. Later, they fuse together to form the triangular-shaped bone that adults have at the base of the spine. If these segments misalign (falling, learning to walk, ride a bike, etc.) they can compromise nerves that are responsible for bladder function.”
They offer no evidence that the compromise of these nerves is a cause of bedwetting; neither do they offer evidence that misalignment of the sacrum can compromise the nerves, or that chiropractors can detect such compromise. I could be wrong, but when a reputable health charity like ERIC mentions three likely causes that don’t involve this sort of convenient speculation then I’m on my guard.
So, why is chiropractic a bogus* treatment for bedwetting, in my opinion?
- Not even the (n>1) trials reported in the chiropractic literature I’ve found support it. (Leboeuf et al, 1991; Reed et al, 1994).
- A Cochrane Review assesses the evidence as “weak”. (Glazener et al, 2005)
- A review published in the chiropractic literature says it, “[…] possess an efficacy comparable to the natural history.” (Kreitz and Aker, 1994)
- The theory of causation looks distinctly convenient and implausible.
Finally, it’s unnecessary: the use of alarm interventions appears to be way more effective. (Glazener, Evans and Peto, 2005). The evident sincerity of the practitioners and their representative bodies is not a counter-argument: the treatment itself is simply bogus*.
So, my advice, for what it’s worth is: consult a real medical doctor and, if you live in the UK, talk to ERIC (or at least watch their video, below).
This does not constitute medical advice. If you need that please consult a medical doctor.
* Deliberate deception not implied. I use the word in its contemporary sense of something that is false in itself, but may be taken in good faith as true by the unwary or uninformed. (See “Knowing bogosity” at the Language Log)
****After 2 weeks without treatment the median rate of “wet nights” had fallen by 1.4 per week. It would appear that the treatment phase lasted a further 2 weeks, during which time the median rate of “wet nights” fell by a further 1.6. The further reduction of 0.2 “wet nights” per week, compared to the initial rate, seems deeply unimpressive for a condition that generally tends to improve with time.
Blomerth PR. Functional nocturnal enuresis. Journal Of Manipulative And Physiological Therapeutics. 1994 June;17(5):335–338. Available from: http://view.ncbi.nlm.nih.gov/pubmed/7930968.
Chiropractic care of children with nocturnal enuresis: a prospective outcome study. Journal Of Manipulative And Physiological Therapeutics. 1991 October; 14(8):485–487. Available from: http://view.ncbi.nlm.nih.gov/pubmed/1796964.
Côté P, Mierau D. Chiropractic management of primary nocturnal enuresis. Journal Of Manipulative And Physiological Therapeutics. 1995;18(3):184–185. Available from: http://view.ncbi.nlm.nih.gov/pubmed/7790801.
Culbert TP, Banez GA. Wetting the bed: integrative approaches to nocturnal enuresis. Explore (New York, NY). 2008;4(3):215–220. Available from: http://dx.doi.org/10.1016/j.explore.2008.02.014.
Glazener CM, Evans JH. Desmopressin for nocturnal enuresis in children. Cochrane Database Of Systematic Reviews (Online). 2002;(3). Available from: http://dx.doi.org/10.1002/14651858.CD002112.
Glazener CM, Evans JH, Peto RE. Tricyclic and related drugs for nocturnal enuresis in children. Cochrane Database Of Systematic Reviews (Online). 2003;(3). Available from: http://dx.doi.org/10.1002/14651858.CD002117.
Glazener CM, Evans JH, Cheuk DK. Complementary and miscellaneous interventions for nocturnal enuresis in children. Cochrane Database Of Systematic Reviews (Online). 2005;(2). Available from: http://dx.doi.org/10.1002/14651858.CD005230.
Glazener CM, Evans JH, Peto RE. Alarm interventions for nocturnal enuresis in children. Cochrane Database Of Systematic Reviews (Online). 2005;(2). Available from: http://dx.doi.org/10.1002/14651858.CD002911.pub2.
Keating JC. Chiropractic management of primary nocturnal enuresis. Journal Of Manipulative And Physiological Therapeutics. 1995;18(9):638–641. Available from: http://view.ncbi.nlm.nih.gov/pubmed/8775030.
Kreitz BG, Aker PD. Nocturnal enuresis: treatment implications for the chiropractor. Journal Of Manipulative And Physiological Therapeutics. 1994 September;17(7):465–473. Available from: http://view.ncbi.nlm.nih.gov/pubmed/7989880.
Leboeuf C, Brown P, Herman A, Leembruggen K, Walton D, Crisp TC. Chiropractic care of children with nocturnal enuresis: a prospective outcome study. Journal Of Manipulative And Physiological Therapeutics. 1991 February;14(2):110–115. Available from: http://view.ncbi.nlm.nih.gov/pubmed/2019820.
Reed WR, Beavers S, Reddy SK, Kern G. Chiropractic management of primary nocturnal enuresis. Journal Of Manipulative And Physiological Therapeutics. 1994;17(9):596–600. Available from: http://view.ncbi.nlm.nih.gov/pubmed/7884329.
5th June 2009. Reference to the article “Nocturnal Enuresis in Children” on the Patient UK website added.
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