OSTEOPATHIC TREATMENT OF ASTHMA
(LETTER TO THE EDITOR, AMERICAN ACADEMY OF OSTEOPATHY)
David L. McMillin, MA; Douglas G. Richards, PhD; Eric A. Mein, MD; Carl
D. Nelson, DC
Virginia Beach, VA 23454
[NOTE: This letter was published in The AAO Journal (Volume
10, No. 1, Spring, 2000). See
below for continuing
education credit for this article.]
We very much appreciated the excellent article by
Jackson and Steele , "Osteopathic treatment of asthma: A literature
review and call for research" and would like to pass along some additional
information on this important topic.
With regard to asthma pathogenesis, the autonomic
imbalance model in its various forms has been widely explored. However,
the vasomotor component of asthma, with respect to autonomic imbalance,
represents a significant although relatively obscure aspect that holds
great potential as a research model linking somatic dysfunction to the
pathophysiology of asthma. Charles Hazzard, an influential early
osteopath, summarized the effects of lesions in asthma as abnormal motor
effects, and abnormal vaso-motor effects:
". lesions cause abnormal motor effects both in arousing spasmodic conditions
of the muscles of the bronchial walls, and in the vaso-motor activity that
produces the hyperemia of the mucous membrane." 
The traditional osteopathic perspective coincides
with modern views on nervous system involvement in asthma. Dysautonomia
has been described in asthma with an emphasis on hyperresponsiveness of
the parasympathetic system [3, 4], beta-adrenergic hyporesponsiveness 
or both [6,7]. In contrast to the relatively dense parasympathetic
nerve supply to airways, sympathetic (adrenergic) innnervation is sparse
in humans . However, sympathetic innervation of the bronchial
blood vessels is considerable. Thus, beta-adrenergic hyporesponsiveness
may reflect an inhibition of the sympathetic system which results in vaso-dilation
of the bronchial blood vessels. Hyperemia of bronchial vessels in
asthmatics has been noted [9,10,11,12] and attributed to sympathetic vaso-dilation
. Exercise-induced asthma is thought to be produced by
increased bronchial circulation [14,15].
With regard to the widely publicized asthma study
by Balon et al. , "active" and "simulated" chiropractic manipulation
were used as adjunctive treatment for childhood asthma. The active
treatment consisted of "manual contact with spinal or pelvic joints followed
by low-amplitude, high velocity directional push often associated with
joint opening, creating a cavitation, or "pop". This treatment is
a standard direct technique used by a wide variety of manual therapy practitioners,
primarily chiropractors and osteopaths. The simulated treatment involved
soft-tissue massage and gentle palpation to the spine, paraspinal muscles,
and shoulders. Jongeward questioned the appropriateness of
the simulated treatment, noting that standard chiropractic practice commonly
includes soft tissue work . Furthermore, the sham treatment
in the Balon et al. study bears a marked similarity to a traditional osteopathic
treatment for asthma [2,18,19,20]; all documented on the Internet .
The authors of the study summarized the simulated
treatment by stating, "Hence, the comparison of treatments was between
active spinal manipulation as routinely performed by chiropractors and
hands-on procedures without adjustments or manipulation." Apparently,
these investigators were unaware of the early osteopathic works addressing
asthma and the more recent literature on OMT for respiratory problems in
general, particularly as cited in Osteopathic Considerations in Systemic
The results as reported by the researchers were,
"Symptoms of asthma and use of ß-agonists decreased and the quality
of life increased in both groups, with no significant differences between
the groups." Based on this equality of improvement, the authors concluded,
"the addition of chiropractic spinal manipulation to usual medical care
provided no benefit," . In our view, this is unfortunate, because
the data indicates that the subjects in both groups improved after being
treated by standard chiropractic and a rather crude form of traditional
Our letter published in the New England Journal of
Medicine  pointed out the methodological flaws of such designs where
sham treatments closely resemble specific traditional osteopathic techniques.
Our article in the Journal of Manipulative and Physiological Therapeutics
 addresses the question of physiological effects of manual therapy
and appropriate sham treatments in more detail, and, like the Jackson and
Steele article, emphasizes the need for more research.
1. Jackson KM and Steele KM: Osteopathic treatment of asthma: A literature
review and call for research. AAO Journal, 1999; 9(4):23-27
2. Hazzard C: The Practice and Applied Therapeutics of Osteopathy.
3rd ed. Kirksville, MO: Journal Printing Company, 1905:75-80.
3. Kallenbach JM, Webster T, Dowdeswell R, Reinach SG, Millar RN, Zwi
S: Reflex heart rate control in asthma. Chest, 1985; 87:644-648.
4. Shah PKD, Lakhotia M, Mehta S, Jain SK, Gupta GL: Clinical dysautonomia
in patients with bronchial asthma. Chest, 1990; 98:1408-1413.
5. Casale TB: The role of the autonomic nervous system in allergic
diseases. Annals of Allergy, 1983; 51:423-429.
6. Kaliner M, Shelhamer JH, Davis PB, Smith LJ, Venter JC: Autonomic
nervous system abnormalities and allergy. Annals of Internal Medicine,
7. Jindal SK, Kaur SK: Relative bronchodilatory responsiveness
attributable to sympathetic and parasympathetic activity in bronchial asthma.
Respiration, 1989; 56:16-21.
8. Nadel JA, Barnes PJ: Autonomic regulation of the airways.
Ann Rev Med, 1984; 35:451-467.
9. Baier H, Long WM, Wanner A: Bronchial circulation in asthma.
Respiration, 1985; 48:199-205.
10. Lockhart A, Dinh-Xuan AT, Regnard J, Cabanes L, Matran R:
Effect of airway blood flow on airflow. Am Rev Respir Dis,
11. Li X, Wilson JW: Increased vascularity of the bronchial muscosa
in mild asthma. Am J Respir Crit Care Med, 1997; 156:229-233.
12. Kumar SD, Emery MJ, Atkins ND, Danta I, Wanner A: Airway mucosal
blood flow in bronchial asthma. Am J Respir Crit Care Med, 1998;
13. Widdecombe JG: Neural control of airway vasculature and edema.
Am Rev Respir Dis, 1991; 143:S18-S21.
14. McFadden ER: Hypothesis: Exercise-induced asthma as a vascular
phenomen. The Lancet, 1990; 335:880-883.
15. Anderson SD, Daviskas E: The airway microvasculature and exercise
induced asthma. Thorax, 1992; 47:748-752.
16. Balon J, Aker PD, Crowther ER, Danielson C, Cox PG, O'Shaughnessy
D, Walker C, Goldsmith CH, Duku E, Sears MR: A comparison of active and
simulated chiropractic manipulation as adjunctive treatment for childhood
asthma. N Engl J Med, 1998; 339:1013-20.
17. Jongeward BV: Chiropractic manipulation for childhood asthma.
N Engl J Med, 1999; 340:391-392.
18. Barber ED: Osteopathy Complete. 4th Ed. Kansas City, MO: Hudson-Kimberly
Publishing Company, 1898:60-68.
19. Goetz, EW: A Manual of Osteopathy. 2nd ed. Cincinnati, OH: Natures's
Cure Co., 1909:85-86.
20. Murray CH: Practice of Osteopathy (6th Edition). Elgin, Illinois:
CH Murray, 1925.
21. McMillin D: The Early American Manual Therapy website is located
at: http://members.visi.net/~mcmillin/ 1998.
22. Kuchera M, Kuchera WA: Osteopathic Considerations in Systemic Dysfunction.
Kirksville, MO: KCOM Press, 1991.
23. Richards DG, Mein EA, Nelson CD: Chiropractic manipulation for
childhood asthma. N Engl J Med, 1999; 340(5):391-392.
24. Nelson C, Redwood D, McMillin D, Richards DG, Mein EA: Manual healing
diversity and other challenges to chiropractic integration. J Manipulative
Physiol Ther (2000, in press).
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