Abstract
Context:
Standard pulmonary rehabilitation (SPR) does not use osteopathic manipulative treatment (OMT), but OMT has potential to improve lung function and patient perception of breathing.
Objective:
To analyze the immediate effects of OMT and SPR techniques on pulmonary function using spirometry and subjective ratings in young, healthy persons.
Methods:
Participants were healthy students recruited from the Lake Erie College of Osteopathic Medicine-Bradenton and were randomly assigned to either the OMT or SPR group. During the first 4 weeks, each participant in the OMT group received 1 OMT technique (rib raising, doming of the diaphragm, thoracic lymphatic pump, and thoracic high velocity, low amplitude), and each participant in the SPR group received 1 SPR treatment (tapotement, pursed lip breathing, saline nebulizer, and rest) per week. Treatments were then ranked based on positive change in pulmonary function as measured by forced expiratory volume in the first second of expiration (FEV1) and forced vital capacity (FVC). During the fifth week, the OMT group received the 2 highest-ranked OMT techniques, and the SPR group received the 2 highest-ranked SPR treatments. During the sixth week, the OMT group received the highest-ranked OMT and SPR treatment, while the SPR group received the same treatment combination but in the reverse order. Pulmonary function, as measured through FEV1, FVC, and FEV1/FVC, were collected before and after each treatment or treatment combination. Participants subjectively rated change in breathing after each treatment.
Results:
A total of 53 students participated in the study, with 28 in the OMT group and 25 in the SPR group. In the OMT group, rib raising yielded the highest positive mean (SD) change of 0.001 (0.136) L in FEV1 and 0.052 (0.183) L in FVC, followed by lymphatic pump, with a change of 0.080 (0.169) L in FEV1 and −0.031 (0.229) L in FVC. In the SPR group, pursed lip breathing yielded the highest positive mean (SD) change of 0.101 (0.278) L in FEV1 and 0.031 (0.179) L in FVC, followed by tapotement, with a change of 0.045 (0.229) L in FEV1 and 0.061 (0.239) L in FVC. Saline treatment significantly decreased lung function. All other treatments did not result in any significant changes in lung function. Overall, SPR subjective ratings were significantly lower than ratings for both OMT and combination (OMT+SPR) treatments.
Conclusions:
Saline significantly reduced lung function and had low subjective posttreatment ratings in young healthy adults. Additionally, OMT and combination OMT and SPR significantly improved subjective breathing more than SPR alone. Future applications of this study include evaluating OMT and SPR effects on lung function in patients with various pulmonary conditions.
Standard pulmonary rehabilitation (SPR), a nonpharmacologic collection of techniques and education specifically used to treat patients with pulmonary disease, is consistently used in clinical practice.
1 The techniques used by respiratory therapists in SPR include tapotement, pursed lip breathing, saline nebulizer, and rest. Tapotement, in conjunction with postural therapy, is used to clear mucus in patients with various pulmonary conditions, such as cystic fibrosis and bronchiectasis.
2 Pursed lip breathing is an exercise that, in some studies, has resulted in increased tidal volume and oxygen saturation and reduced dyspnea.
3 Although nebulizer treatments are not routinely involved in SPR, nebulizer treatments with hypertonic saline have been shown to be effective in inducing sputum production and in the therapy of patients with cystic fibrosis.
4-6 Rest (relaxation breathing) is another component of SPR that may be of particular value in patients with chronic obstructive pulmonary disease (COPD) and acute respiratory failure, because respiratory muscles may fatigue when working against a sufficiently large resistance.
7-9
Although osteopathic manipulative treatment (OMT) is not included in SPR, previous reports indicate that OMT can improve pulmonary function in both acute and chronic pulmonary conditions.
10,11 The musculoskeletal components of respiration induce pressure changes in the thoracic cavity necessary for effective breathing.
12 Therefore, OMT directed toward the structures in this region have enormous potential to alleviate pulmonary disease symptoms by increasing the mobility of the diaphragm and chest wall muscles.
13 In one of the earliest studies assessing the effect of OMT on lung function, hospitalized patients with lower respiratory tract disease received thoracic lymphatic pump, which was associated with a more rapid cleansing of the tracheobronchial tree, greater production of sputum, and a shorter duration of cough compared with those who received standard treatment.
10 In 2005, researchers conducted the first known trial of OMT (comprising rib raising, muscle energy for ribs, and myofascial release techniques) on pediatric patients with asthma. The OMT group showed a statistically significant improvement in peak expiratory flow rates compared with the sham group.
11 However, a subsequent study
14 found detrimental effects of OMT on pulmonary function in patients with COPD 30 minutes after treatment. Thoracic lymphatic pump, myofascial release, and rib raising all increased residual volume. The authors
14 hypothesized that because the disease process of COPD includes chronic airway inflammation and susceptibility to bronchospasm, the immediate effects of OMT may temporarily worsen inflammation, trigger spasm, and loosen secretions that lead to air trapping.
In addition to treatment approaches, another important factor in overall disease management is patient perception of improvement and involvement in his or her own care. Positive subjective improvement of symptoms after treatment may have a real influence on disease outcomes by increasing patient satisfaction, quality of life, and compliance with treatment regimens.
15 In previous studies,
13,14 patients subjectively rated their breathing as improved after OMT when compared with SPR or sham therapy, even if this finding was not paralleled by objective data.
The motivation for the present study was to create a sound research protocol that can be used in future studies to determine the immediate effects of various OMT and SPR techniques in patients with conditions for which SPR is indicated. We also sought to evaluate whether the interventions, individually or in combination, would improve pulmonary function, as determined by forced expiratory volume in the first second of expiration (FEV1) and forced vital capacity (FVC) measured in liters and the ratio of FEV1/FVC. Decreased FEV1, FVC, and FEV1/FVC values are associated with multiple pulmonary dysfunctions, including COPD and asthma. Given the conflicting reports in the literature concerning the effects of OMT, further investigation is necessary.
Additionally, previous studies have not extensively evaluated both OMT techniques and SPR treatments independently to parse out the efficacy of specific treatments. The present study specifically analyzes the effects of various treatments in a healthy population to eliminate confounding factors seen in a population with respiratory issues. We hypothesized there would be no difference between OMT and SPR effects in FEV1, FVC, and FEV1/FVC values because a healthy population was used.
This study demonstrates a potential novel protocol for evaluating OMT's effectiveness in improving respiration in patients with pulmonary conditions. The results of this study, with the exception of saline nebulizer, support the null hypothesis that there would not be any statistically significant changes in FEV
1, FVC, or FEV
1/FVC in a healthy population immediately after a single treatment session of either OMT or SPR. These results were consistent with similar studies.
22 To our knowledge, this study is the first to compare multiple forms of both OMT and SPR in single treatment sessions. Previous studies used only soft tissue OMT techniques
13 or compared OMT with only a sham group.
11,14
Saline nebulizer was the sole treatment that resulted in a significant decrease in FEV
1 and FEV
1/FVC. Hypertonic saline is used as a component of bronchoprovocation testing for asthma as well as for secretion clearance for pulmonary conditions, such as pneumonia.
23 The subjective posttreatment improvement, as evaluated by participants, correlates with this objective finding in that saline nebulizer had the second-lowest rating. This correlation supports the clinical potential and validity of this research protocol.
Overall, participants in the OMT group felt that their breathing improved significantly more than did the participants in the SPR group, indicated by subjective ratings after treatment (
Figure 3). Additionally, there was a trend toward subjective improvement from SPR to combination treatment (OMT+SPR) to OMT. These results exemplify the tenets of osteopathic medicine, particularly demonstrating that the body functions as a unit. Receiving OMT may lead to an improved mindset regarding one's disease state, which can translate to better adherence to treatment regimens and, thus, improved treatment outcomes.
15
An important limitation of this study is that it only includes healthy young adults rather than patients with pulmonary conditions. However, the purpose of our study was to introduce a protocol that has applications in a population with pulmonary conditions for prospective studies. It is probable that the use of OMT may benefit patients with actual respiratory disease more than those with healthy lungs. Two studies
10,14 demonstrated that OMT has value in clearing mucus from the tracheobronchial tree and improving pulmonary function test results.
Although the present study was intended to be single blinded, some participants were osteopathic medical students and were thus aware of their group placement. Osteopathic medical students’ knowledge of OMT may have influenced their subjective breathing change rating based on their potential preexisting beliefs about OMT. Additionally, the age of our population ranged from 21 to 38 years. Given the effect of increased age on lung function, it is likely that our results would vary in an older population.
Not every participant completed all study protocols, which led to a reduced sample size. As previously mentioned, trials that were not acceptable were not included in the analyses. To maximize group size, no sham group was used. Sham groups have been used as placebos to rule out the potential that significant OMT results were due solely to human touch. However, because this theory has not been confirmed, and because the current study did not have any statistically significant objective pulmonary function results from the OMT group, this limitation is minor.
Future applications of this study include evaluating OMT, SPR, and combination treatments in patients with various pulmonary conditions. It is also imperative to determine the significance of the present study's subjective findings, which showed significant subjective breathing improvement in the OMT group and which correspond with the findings of other studies.
13 We propose that this subjective improvement may be related to the immediate increase in chest wall mobility that some OMT techniques cause, although future studies to explore this further are warranted. The potential relationship between patients’ perceptions of health benefits and their compliance also needs to be explored.
The present study did not demonstrate any statistically significant changes in pulmonary function test results immediately after OMT or combination OMT and SPR treatments. Only saline nebulizer resulted in deleterious effects on lung function in healthy adults as demonstrated by statistically significant decreases in FEV1 and FEV1/FVC. These findings support the original hypothesis that OMT would not show a significant change in pulmonary function in a healthy population immediately after a single treatment session. At the same time, it demonstrates a valid and thorough protocol that can objectively determine OMT's immediate efficacy in a patient with pulmonary disease.
Interestingly, participants in this study expressed a statistically significant subjective improvement in breathing following OMT, which supports OMT's utility regarding treatment of lung conditions. This perceived benefit may improve patients’ outlooks on their condition, ultimately translating into better treatment compliance. Further study of OMT's effects on lung function in populations with pulmonary conditions may yield favorable results, supporting the incorporation of OMT into current treatment guidelines.
We thank Jeffery A. Laborda from the Natural Sciences Department at the State College of Florida for use of the spirometers. We also thank the LECOM Student Research Association, especially second-year osteopathic medical students Richard Bravo, Nicky Cadiz, Elisa Chiu, Krista Perry, Jennifer Purcell, and Rebecca Scalabrino for participating as research assistants operating the spirometers. Finally, we thank the LECOM Student American Academy of Osteopathy, especially Lindsey Anderson, DO; Christopher Behringer, DO; Adriana Carpenter, DO; Stephen Goertzen, DO; Alexander Herrera, DO; Jacob Howard, DO; Christina Hunter, DO; Caitlin Martin, DO; Ian Sandford, DO; and Justin Williams, DO, who were students at the time of this study, for participating as research assistants providing the treatment techniques.