Treatment of Asthma with a Systems Approach using Integrative Manual Therapy: A Case Report
Author: Regina Rosenthal MA, PT
Abstract: This article is a single subject case report documenting the effectivity and efficiency of using a Systems Approach with Integrative Manual Therapy (IMT) relating to respiratory complaints and asthma.
Key Words: Asthma, Bronchodilator, Steroid, Respiratory
Discussion
This is a single subject case report documenting the effectivity and efficiency of using a Systems Approach with Integrative Manual Therapy (IMT), developed by Dr. Sharon W. Giammatteo (Dialogues in Contemporary Rehabilitation, Bloomfield, Connecticut), to assess and treat asthma.
Over the past ten years, the incidence of asthma in America has increased by one third, affecting over 10 million people (3 million children and 7 million adults), or 4% of the U.S. population. Children under sixteen and adults over sixty-five are more likely to be involved, with hospitalization for asthma increased fivefold in the last 29 years for children and the rate for adults doubled (1). It is speculated that environmental pollution may be a strong contributing factor. "Asthma is the leading cause of disease and disability in children and teens ages two to seventeen years" (2).
"Looking at the anatomy of the lungs: air reaches the lungs by passing through the windpipe (trachea), which divides into two large tubes (bronchi), one for each lung. Each bronchi further divides into many little tubes (bronchioles), which eventually lead to tiny air sacs (alveoli), in which oxygen from the air is transferred to the bloodstream, and carbon dioxide from the bloodstream is transferred to the air. Asthma involves only the airways (bronchi and bronchioles) and not the air sacs. The airways are cleaned by trapping stray particles in a thin layer of mucous which covers the surface of the airways. This mucous is produced by glands inside the lung, and is constantly being renewed. The mucous is then either coughed up or swept up to the windpipe by cilia, tiny hairs on the lining of the airways. Once the mucous reaches the throat, it can again be coughed up or, alternatively, swallowed" (3).
Asthma is a lung disease that causes obstruction of the airways. It is a condition in which the airways of the lungs become either narrowed or completely blocked, impeding normal breathing. Asthma usually manifests itself in the form of an asthmatic attack, characterized by a narrowing of the bronchial passages, excessive excretion of mucous, and impaired breathing. Attacks usually begin with an unproductive cough, followed by rapidly progressive difficulty in breathing. Expiration becomes prolonged and labored, resulting in wheezing. "During an asthma attack, spasms in the muscles surrounding the bronchi constrict, impeding the outward passage of stale air….often described as ‘starving for air.’…These spasms do not cause the disorder, but result from chronic inflammation and hypersensitivity of the airways to certain stimuli (allergens or irritants…animal dander, chemicals, drugs, dust mites, environmental pollutants, feathers, foods and/or food additives such as preservatives/sulfites and food coloring, sensitivity to aspirin, fumes, mold, tobacco smoke)… These stimuli cause swelling of the bronchial tubes, which become plugged with mucous. Symptoms associated with asthmatic attacks are coughing, wheezing, tightness in the chest, and difficulty breathing" (4).
"The most common triggers of asthma are:
It should be noted that gastroesophageal reflux has been considered as a possible irritant in relation to asthma. This occurs when acidic stomach contents pass back up the esophagus, irritating and inflaming the esophagus and airways of the lung (if any of the liquid is aspirated). This irritation can trigger an asthma attack, more commonly at night, when supine lying makes it easier for stomach contents to pass upward (6).
Dr. John A. Sherman, N.D., of Portland, Oregon, notes that asthma originating during infancy is generally due to food allergies; between 10-30 years usually due to inhalants; and after age 45 is commonly due to infections. These factors, however, could exist at any age and in any combination. Dr. Sherman notes that "organisms only grow in the body when the soil is right…congestion provides fruitful soil for the growth of infection" (7).
Although everyone’s airways have the potential for constricting in response to allergens or irritants, the asthmatic’s airways are oversensitive, or hyperactive. In response to stimuli, the airways may become obstructed by one of the following:
Once the airways have become obstructed, it takes more effort to force air through them, so that breathing becomes labored. This forcing of air through constricted airways can make a whistling or rattling sound, called wheezing. Irritation of the airways by excessive mucous may also provoke coughing.
Because exhaling through the obstructed airways is difficult, too much stale air remains in the lungs after each breath. This decreases the amount of fresh air which can be taken in with each new breath, so not only is there less oxygen available for the whole body, but more importantly, the high concentration of carbon dioxide in the lungs causes the blood supply to become acidic. This acidity in the blood may rise to toxic levels if the asthma remains untreated" (8).
Chronic asthmatic bronchitis is the condition in which the airways in the lungs are obstructed due to both persistent asthma and chronic bronchitis. Bronchitis is an inflammation of the bronchi, which often leads to increased mucous production in the airways. Bronchitis is generally caused either by a virus or by exposure to irritants such as dust, fumes, or cigarette smoke. If caused by a virus, the bronchitis will likely be only temporary. In the case of prolonged exposure to irritants, particularly cigarette smoke, if there is permanent damage to the bronchi, bronchitis may become chronic (9).
Asthma is diagnosed by history, physical examination, and pulmonary function tests. "The NHLBI Guidelines for the Diagnosis and Management of Asthma state that…."Pulmonary function studies are essential for diagnosing asthma and for assessing the severity of asthma in order to make appropriate therapeutic recommendations" (10). This may include use of a peak flow meter or a spirometer, and/or a battery of spirometry tests in a pulmonary function lab.
Asthma is normally treated by use of inhaled bronchodilators (usually corticosteroids), and with more involved and/or chronic cases, use of bronchodilators and anti-inflammatories to address the airway constriction and inflammation. When strongly triggered by allergens, avoidance and/or anti-allergic medications or shots for allergy desensitization are also tried. With acute asthma attacks, intravenous adrenalin and theoplylline are given in emergency rooms where bronchodilators have not been effective. Oral steroids (i.e. Prednisone) may also be given with severe attacks.
History
The patient is a 37-year-old, female, physical therapist assistant, with initial onset of complaints in l989. She was first hospitalized in l990 for a 10 day period of time. Treatment at that time included intravenous Prednisone and oxygen. At the time she was concerned about long-term use of steroids and possible side effects: fluid retention, high blood pressure, eye problems such as cataracts or glaucoma, Cushing’s syndrome, weight gain, muscle weakness, brittle bones/osteoporosis, hives, esophageal inflammation, pancreatitis, peptic ulcer (11). She was also concerned about long-term use of antibiotics and the possibility of developing "leaky gut syndrome"(12). Testing for allergies proved negative. Cardiac testing was pursued due to tachycardia without chest pains, very low blood pressure, and paroxysmal elevations in pulse rate (day and/or night, standing or lying). Testing stated that c/o were of undetermined etiology, possibly medication related. At this time she was out of work for one month. A subsequent hospitalization occurred during 1990 s/p flu shot (flu shots have, subsequently, been eliminated) when she became extremely ill when airways closed down. Treatment again included intravenous Prednisone and oxygen, and again she was out of work for one month. Following this antibiotics were prescribed when she became ill every 2 weeks with upper respiratory infections. Over this course of time additional complaints included: night sweats, insomnia, weight gain, diminished immune response.
The client changed physicians at this time, desiring to come off use of Prednisone and antibiotics, especially with the tachycardia complaints. This was the first time (1995) pulmonary function testing was pursued. She was taken off Prednisone and antibiotics, and instead given complete bedrest, with Integrative Manual Therapy performed initially by the author of this study. She was given a corticosteroid inhaler which was used several times daily.
Treatment
In 1997, she was first seen at Regional Physical Therapy, Connecticut, for evaluation and treatment plan. Treatment has included: Myofascial Release (13); Visceral Mobilization (14); Advanced Strain and Counterstrain (15); Compression Syndromes (16); Manual Lymphatic Drainage (17); Hyperbaric Oxygen treatment (one treatment in portable unit) at Desert Light Health Associates affiliated with Regional Physical Therapy; Systems Work relative to oxygen/carbon dioxide dysfunctions (18). The patient was given a home program including respiratory rehabilitation exercises and Neurofascial Process (19).
Outcome
Initial pulmonary function tests (1996) showed lung age 66 years with subsequent testing (1996) showing lung age 45 years, and most recent testing (1997) showing lung age 38 years (20). Other improvements following treatment included:
Conclusion
It has been the experience of this therapist and client that the use of IMT and the Systems Approach provided effective and efficient treatment for asthma. The need for chronic use of corticosteroid medications (often a first line of defense with moderate to severe asthma) was reduced and ultimately eliminated, after 7 years of chronic usage. Overall quality of life as well as physical stamina and endurance markedly improved.
Dr. John A. Sherman suggests that respiratory difficulties which thrive on excessive mucous need to have dietary considerations such as a diet low in mucous-forming foods. This would involve restricting the intake of dairy (including goat’s milk and yogurt), eggs, gluten-rich grains (wheat, oats, rye, barley), sugar, potatoes, and other starchy root vegetables. Fresh fruits/fruit juices are good substitutes (21). The client noted in this study made small dietary changes, primarily balancing proteins, carbohydrates, and fats, and eliminating white breads and starches.
Asthma varies from person to person, with symptoms varying and attacks from mild and infrequent to acute episodes which may be severe and life threatening. Integrative Manual Therapy can greatly assist with management as has been shown with this case report. Active participation in care is essential. Self-management tools such as avoiding triggers that make symptoms worse, monitoring lung function to prevent symptoms and acute attacks, and learning how to breathe effectively and efficiently can assist with developing a plan with a health-care team, enabling the individual to lead a full, active life.
References