Letters to the Editor  |   October 2008
Immediate Effects of Osteopathic Manipulative Treatment in Elderly Patients With Chronic Obstructive Pulmonary Disease
Author Affiliations
  • Subramanyam R. Vemulpad, PhD
    Department of Health and Chiropractic Macquarie University Sydney, New South Wales Australia
    Senior Lecturer
Article Information
Geriatric Medicine / Osteopathic Manipulative Treatment / Pulmonary Disorders
Letters to the Editor   |   October 2008
Immediate Effects of Osteopathic Manipulative Treatment in Elderly Patients With Chronic Obstructive Pulmonary Disease
The Journal of the American Osteopathic Association, October 2008, Vol. 108, 541-542. doi:
The Journal of the American Osteopathic Association, October 2008, Vol. 108, 541-542. doi:
To the Editor: We read with interest the May original contribution by Donald R. Noll, DO, and colleagues.1 We would like to suggest that patients with nonchronic conditions—or even healthy individuals—might have been better as study subjects for testing the immediate effects of osteopathic manipulative treatment (OMT). To expect a single application of OMT to produce a demonstrable effect in patients with chronic obstructive pulmonary disease (COPD) is rather ambitious. 
In addition, readers will note that all study participants assigned to the OMT group in the Noll et al study1 did not receive the same treatment. Specific OMT techniques for somatic dysfunction found during structural examinations were administered to patients only “if applicable.” Therefore, each patient received some mixture of seven standardized OMT techniques commonly used for respiratory disorders. 
We concur with the authors1 that the configuration of their manual treatment protocol may have contributed to the trial's results. In other words, a single multitechnique session of OMT can produce measurable changes in pulmonary function parameters. We likewise agree with the authors that it would be impossible to know the individual contribution of each OMT technique to the final outcome in any given patient. Similar to the authors' suggestion that the beneficial effect of one technique may have “cancelled out” the adverse effect of another, any interaction between somatic dysfunction treatments and the OMT protocol cannot be calculated. Given these confounding variables, it is intriguing that the authors1 reported their results as though the intervention group was a single homogenous unit. 
Furthermore, though we agree with the authors1 that chest wall compliance and diaphragm capacity decrease with age, we beg to differ with their claim that an aging population could become “more responsive” to treatment because of the physical effects of advancing age. In fact, musculoskeletal responsiveness has proven less efficient with age as a result of morphologic changes,2 with a reduction in soft tissue elasticity3 that leads to reduced outward recoil of the chest wall.4 Thus, it is logical to surmise that repeated sessions of OMT are required when managing musculoskeletal conditions in elderly patients—that is, the “dosage” of manual therapy needs to be increased to produce an effect that is achievable in younger patients with fewer applications. 
As pointed out by the authors,1 manual treatment carries with it the potential either to help or to harm patients. The challenge facing all clinical researchers is to design study protocols and use techniques that maximize OMT benefits while diminishing OMT risks. 
In support of the continued use of manual therapy for improving the functional mobility of the thorax, we would like to share our approach to treating elderly patients who have mild to moderate COPD (ie, forced expiratory volume in 1 second [FEV1] ≤80% and ≥50%, respectively).5 Our approach involves the application of a series of manual treatment sessions during a 4-to-6-week period. Each session consists of a single soft tissue technique together with spinal manipulative therapy (ie, somatic dysfunction treatment)—and the intensity of these treatments increases with each session. Gradually increasing the intensity of the same treatment technique over successive treatment sessions is likely to circumvent the immediate adverse effects on airway obstruction reported by Noll et al.1 
We commend Dr Noll and his colleagues for their work in this field. We trust that they will continue to rise to the challenge of advancing osteopathic medicine's contribution to the management of COPD. 
 Editor's Note: Readers are welcome to view study designs developed by Drs Engel and Vemulpad for the use of spinal manipulative therapy to treat patients with mild and moderate chronic obstructive pulmonary disease by visiting the Australian New Zealand Clinical Trials Registry Web site, at, and typing in the reference numbers ACTRN01 2606000369527 and ACTRN012607000 388415.
Noll DR, Degenhardt BF, Johnson JC, Burt SA. Immediate effects of osteopathic manipulative treatment in elderly patients with chronic obstructive pulmonary disease. J Am Osteopath Assoc. 2008;108:251-259. Available at: Accessed September 23, 2008.
Nitz JC, Hourigan SR. Physiotherapy Practice in Residential Aged Care. London, England: Butterworth-Heinemann;2004 : 22.
Bougie JD, Morgenthal AP. The Aging Body: Conservative Management of Common Neuromusculoskeletal Conditions. New York, NY: McGraw-Hill Medical; 2001.
Dyer CAE, Stockley RA. The aging lung. Rev Clin Gerontol. 1999;9:103-115.
Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. Edgewater, NJ: MCR Vision Inc; 2007:3. Available at: Accessed September 23, 2008.