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Original Contribution  |   March 2019
Assessment of Pulmonary Function After Osteopathic Manipulative Treatment vs Standard Pulmonary Rehabilitation in a Healthy Population
Author Notes
  • From the Lake Erie College of Osteopathic Medicine-Bradenton in Florida (Drs Lorenzo, Hussein, and Quinn); the Rowan University School of Osteopathic Medicine in Clementon, New Jersey (Dr Nicotra); Larkin Community Hospital in Miami, Florida (Dr Mentreddy); Virginia Commonwealth University Health System in Richmond, Virginia (Dr Padia); and the David Grant Medical Center in Fairfield, California (Dr Stewart). Drs Nicotra, Mentreddy, Padia, and Stewart were all osteopathic medical students at the Lake Erie College of Osteopathic Medicine-Bradenton at the time of this study. 
  • Financial Disclosures: None reported. 
  • Support: The Lake Erie Consortium for Osteopathic Medical Training. 
  •  *Address correspondence to Santiago Lorenzo, PhD, 5000 Lakewood Ranch Blvd, Bradenton, FL 34211-4909. Email: slorenzo@lecom.edu
     
Article Information
Osteopathic Manipulative Treatment / Physical Medicine and Rehabilitation / Pulmonary Disorders
Original Contribution   |   March 2019
Assessment of Pulmonary Function After Osteopathic Manipulative Treatment vs Standard Pulmonary Rehabilitation in a Healthy Population
The Journal of the American Osteopathic Association, March 2019, Vol. 119, 155-163. doi:https://doi.org/10.7556/jaoa.2019.026
The Journal of the American Osteopathic Association, March 2019, Vol. 119, 155-163. doi:https://doi.org/10.7556/jaoa.2019.026
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 study14 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 authors14 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. 
Methods
Participants
Adult participants were recruited from the Lake Erie College of Osteopathic Medicine-Bradenton Schools of Pharmacy and Dental Medicine as well as the College of Osteopathic Medicine via emails and classroom announcements. Potential participants then completed a prestudy survey regarding lung function, smoking history, exercise frequency, and medical history. Eligible participants were healthy men or women without skin disorders or open wounds precluding skin contact, fasciitis or fascial tears, muscle strains or inflammation, neoplasia, bone fracture, osteomyelitis, osteopenia, osteoporosis, coagulation problems, deep vein thrombosis, adrenal disease/syndromes, current respiratory disorders (including COPD and asthma), immunosuppressive syndromes, radiation or chemotherapy within the past 3 years, lupus, and any other autoimmune disease. These exclusionary criteria are primarily related to contraindications of certain OMT techniques used in this study. Current and former smokers were also excluded from the study, as well as individuals with a body mass index of 30 or higher.16 
Procedure
Participants were randomly assigned to 1 of 2 groups: OMT or SPR. Total time to complete all study procedures was 6 weeks. Each participant attended 1 session per week and received a different treatment or treatment combination each week (Table 1). Each session was approximately 30 minutes in duration. Osteopathic medical students performed all treatments. They were trained by a licensed osteopathic physician on all techniques, and the same osteopathic physician (T.A.Q.) supervised all treatments administered during the study. 
Table 1.
Effect of OMT vs SPR on Pulmonary Function: Group and Procedure Assignment by Weeka (N=53)b
Weekc OMT Groups (n=28) SPR Groups (n=25)
1 Thoracic lymphatic pump (n=16) Pursed lip breathing (n=23)
2 Thoracic HVLA (n=17) Tapotement (n=17)
3 Rib raising (n=9) Saline nebulizer (n=17)
4 Doming of diaphragm (n=9) Rest (n=14)
5 Rib raising, then lymphatic pump (n=18) Pursed lip breathing, then tapotement (n=22)
6 Rib raising, then pursed lip breathing (n=19) Pursed lip breathing, then rib raising (n=21)

a Participants were randomly assigned to either the osteopathic manipulative treatment (OMT) or standard pulmonary rehabilitation (SPR) group.

b Number of trials utilized for each protocol is specified within parentheses. Trials that were not acceptable (eg, poor participant effort, air leaking during forced vital capacity maneuver, high variability in spirometry values, subject fatigue) were not included in the analyses.

c During weeks 1 through 4, each participant received 1 treatment per session. By the end of 4 weeks, all participants received all 4 treatments listed in their respective group. During week 5, participants received a combination of the highest-ranked treatment followed by the second highest-ranked treatment in each group. During week 6, all participants received a combination of the highest-ranked treatments in both groups.

Table 1.
Effect of OMT vs SPR on Pulmonary Function: Group and Procedure Assignment by Weeka (N=53)b
Weekc OMT Groups (n=28) SPR Groups (n=25)
1 Thoracic lymphatic pump (n=16) Pursed lip breathing (n=23)
2 Thoracic HVLA (n=17) Tapotement (n=17)
3 Rib raising (n=9) Saline nebulizer (n=17)
4 Doming of diaphragm (n=9) Rest (n=14)
5 Rib raising, then lymphatic pump (n=18) Pursed lip breathing, then tapotement (n=22)
6 Rib raising, then pursed lip breathing (n=19) Pursed lip breathing, then rib raising (n=21)

a Participants were randomly assigned to either the osteopathic manipulative treatment (OMT) or standard pulmonary rehabilitation (SPR) group.

b Number of trials utilized for each protocol is specified within parentheses. Trials that were not acceptable (eg, poor participant effort, air leaking during forced vital capacity maneuver, high variability in spirometry values, subject fatigue) were not included in the analyses.

c During weeks 1 through 4, each participant received 1 treatment per session. By the end of 4 weeks, all participants received all 4 treatments listed in their respective group. During week 5, participants received a combination of the highest-ranked treatment followed by the second highest-ranked treatment in each group. During week 6, all participants received a combination of the highest-ranked treatments in both groups.

×
To measure FEV1, FVC, and FEV1/FVC ratio, SPR-BTA spirometers (Vernier Software and Technology) were used and connected to computers for automatic data collection. 
Each weekly treatment session was conducted using the following method: 
  • Before treatment: Each participant performed spirometry maneuvers up to 6 times until 3 acceptable spirometry trials were obtained. An acceptable trial was determined by the American Thoracic Society guidelines.17
  • Treatment: Immediately after obtaining baseline data, each participant underwent the assigned treatment based on his or her treatment group (OMT or SPR) and particular week (Table 1). Treatments were administered in a random order until each participant received each treatment once between weeks 1 through 4.
  • After treatment: Three acceptable spirometry maneuvers were again obtained from each participant adhering to the same guidelines used before treatment.
  • Subjective evaluation: Upon completion of each session, each participant subjectively reported his or her change in breathing after treatment on a scale from 1 (much worse) to 5 (much improved).
Weeks 1–4:
Each participant underwent 1 treatment per weekly session. At the end of 4 weeks, each participant had received each of the 4 treatments available in his or her corresponding OMT or SPR group. The order in which the treatments were administered week to week in each treatment group was deliberately varied to ensure integrity of the effect of each treatment. 
Week 5:
Data from weeks 1 to 4 were analyzed. During the fifth week, the OMT group received the 2 OMT techniques that yielded the largest positive change in FEV1 and FVC, and the SPR group received the 2 SPR treatments that yielded the largest positive change in FEV1 and FVC in a single session. The treatment order for each group was the treatment with the largest improvement immediately followed by the treatment with the second largest improvement. 
Week 6:
The most successful single treatment from each group determined by the largest positive change in FEV1 and FVC was selected using the results from weeks 1 through 4. During the sixth week, the OMT group received the most successful OMT technique followed by the most successful SPR treatment. Similarly, the SPR group received the same 2 treatments but in the reverse order (SPR treatment followed by the OMT technique). 
Treatments
Techniques for OMT were selected based on previous literature and input from an osteopathic physician (T.A.Q.) with many years of experience performing these techniques.10 Techniques for SPR were determined based on known techniques used by respiratory therapists in hospitals and clinics.1 
The 4 OMT techniques included rib raising, doming of the diaphragm, thoracic lymphatic pump, and thoracic high velocity, low amplitude (HVLA). The 4 SPR techniques included rest, saline nebulizer, tapotement, and pursed lip breathing. The OMT techniques were administered according to procedures described in Foundations of Osteopathic Medicine.18 The protocol for SPR techniques was collected from several sources. Pursed lip breathing and rest (relaxation breathing) were derived from Therapeutic Exercise for Physical Therapist Assistants.19 The procedure for tapotement was adapted from Tappan's Handbook of Healing Massage Techniques.20 The protocol for administering saline nebulizer treatments followed guidelines indicated in Foundations of Respiratory Therapy.21 
Data Analysis
Spirometer data were analyzed to ensure that only trials meeting American Thoracic Society guidelines17 were used in final analyses. The finalized spirometry data and subjective change in breathing scores were analyzed using 1-way analysis of variance and 2-tailed paired t tests to compare all treatment types and combinations and subjective ratings of the effects of treatment on breathing. 
Results
Fifty-three participants completed all study procedures (age range, 21-38 years; median age, 24 years; 50% male). Twenty-eight participants were in the OMT group and 25 were in the SPR group. There were no demographic differences between groups. Trials that were not acceptable (eg, poor participant effort, air leaking during FVC maneuver, high variability in spirometry values, participant fatigue) were not included in the analyses. 
After the first 4 weeks, the raw spirometry data were used to find the 2 treatments within each group with the most positive changes using the sums of the FEV1 and FVC changes (Table 2). These treatments were used for weeks 5 and 6. 
Table 2.
Effect of OMT vs SPR on Pulmonary Function: Spirometer Results During the First 4 Weeks of Treatment
Mean (SD) Δ in Litersa
Treatment FEV1 FVC Sum of Changes
OMT Group
 Doming of the diaphragm −0.131 (0.199) −0.064 (0.186) −0.195
 Thoracic high velocity, low amplitude −0.017 (0.158) −0.025 (0.147) −0.042
 Thoracic lymphatic pumpc 0.080 (0.169) −0.031 (0.229) 0.049
 Rib raisingb 0.001 (0.136) 0.052 (0.183) 0.053
SPR Group
 Pursed lip breathingb 0.101 (0.278) 0.031 (0.179) 0.133
 Rest −0.062 (0.183) −0.052 (0.163) −0.115
 Saline nebulizer −0.190 (0.202) −0.043 (0.299) −0.233
 Tapotementc 0.045 (0.229) 0.061 (0.239) 0.106

a Data represent mean changes of forced expiratory volume in the first second of expiration (FEV1) and forced vital capacity (FVC) in each participant before and after treatment (average of pre- to posttreatment measures).

b Most successful treatment within group.

c Second most successful treatment within group.

Abbreviations: OMT, osteopathic manipulative treatment; SPR, standard pulmonary rehabilitation.

Table 2.
Effect of OMT vs SPR on Pulmonary Function: Spirometer Results During the First 4 Weeks of Treatment
Mean (SD) Δ in Litersa
Treatment FEV1 FVC Sum of Changes
OMT Group
 Doming of the diaphragm −0.131 (0.199) −0.064 (0.186) −0.195
 Thoracic high velocity, low amplitude −0.017 (0.158) −0.025 (0.147) −0.042
 Thoracic lymphatic pumpc 0.080 (0.169) −0.031 (0.229) 0.049
 Rib raisingb 0.001 (0.136) 0.052 (0.183) 0.053
SPR Group
 Pursed lip breathingb 0.101 (0.278) 0.031 (0.179) 0.133
 Rest −0.062 (0.183) −0.052 (0.163) −0.115
 Saline nebulizer −0.190 (0.202) −0.043 (0.299) −0.233
 Tapotementc 0.045 (0.229) 0.061 (0.239) 0.106

a Data represent mean changes of forced expiratory volume in the first second of expiration (FEV1) and forced vital capacity (FVC) in each participant before and after treatment (average of pre- to posttreatment measures).

b Most successful treatment within group.

c Second most successful treatment within group.

Abbreviations: OMT, osteopathic manipulative treatment; SPR, standard pulmonary rehabilitation.

×
After the sixth week, spirometry data from all 6 weeks indicated that lung function did not significantly improve for any single or combination treatment in either the OMT or SPR group (Figure 1 and Figure 2). However, t tests did show that saline nebulizer significantly decreased lung function based on mean (SD) FEV1 and FEV1/FVC (FEV1: 5.76 [1.52] L before treatment vs 5.57 [1.65] L after treatment; P<.005; FEV1/FVC: 0.87 [0.07] L before treatment vs 0.84 [0.08] L after treatment; P<.05). This finding coincides with the subjective results. Although not statistically significant, there was a slight decrease in FEV1 with doming of the diaphragm (ΔFEV1: −0.131 [0.199] L). 
Figure 1.
Change in forced expiratory volume in the first second of expiration (FEV1) and forced vital capacity (FVC) after each weekly treatment technique was applied in the (A) osteopathic manipulative treatment group and (B) standard pulmonary rehabilitation group. aSaline nebulizer showed statistically significant worsening of FEV1 in participants. Abbreviations: DD, doming of the diaphragm; HVLA, high velocity, low amplitude; LP, lymphatic pump; PLB, pursed lip breathing; RR, rib raising.
Figure 1.
Change in forced expiratory volume in the first second of expiration (FEV1) and forced vital capacity (FVC) after each weekly treatment technique was applied in the (A) osteopathic manipulative treatment group and (B) standard pulmonary rehabilitation group. aSaline nebulizer showed statistically significant worsening of FEV1 in participants. Abbreviations: DD, doming of the diaphragm; HVLA, high velocity, low amplitude; LP, lymphatic pump; PLB, pursed lip breathing; RR, rib raising.
Figure 2.
Change in the ratio of forced expiratory volume in the first second of expiration (FEV1) to forced vital capacity (FVC) after each weekly treatment in (A) the osteopathic manipulative treatment group and (B) the standard pulmonary rehabilitation group. aSaline nebulizer showed statistically significant worsening of FEV1/FVC. Abbreviations: DD, doming of the diaphragm; HVLA, high velocity, low amplitude; LP, lymphatic pump; PLB, pursed lip breathing; RR, rib raising.
Figure 2.
Change in the ratio of forced expiratory volume in the first second of expiration (FEV1) to forced vital capacity (FVC) after each weekly treatment in (A) the osteopathic manipulative treatment group and (B) the standard pulmonary rehabilitation group. aSaline nebulizer showed statistically significant worsening of FEV1/FVC. Abbreviations: DD, doming of the diaphragm; HVLA, high velocity, low amplitude; LP, lymphatic pump; PLB, pursed lip breathing; RR, rib raising.
After the posttreatment spirometry trials, participants subjectively rated the change in the quality of their breathing, with 1 indicating “much worse,” 3 indicating no change, and 5 indicating “much improved.” Only acceptable trials as determined by the American Thoracic Society guidelines17 were used for the analyses of subjective breathing ratings. A 1-way analysis of variance indicated significant differences among some treatments (P<.001). Pursed lip breathing was rated as having the lowest mean (SD) score (2.9 [0.4]) and was significantly lower than all other treatments (P<.05), except for saline nebulizer. Additionally, the ratings of saline nebulizer (3.0 [0.7]) and thoracic lymphatic pump (3.3 [0.5]) were significantly lower than rib raising plus pursed lip breathing, rib raising, doming of the diaphragm, rib raising plus lymphatic pump, and HVLA, in increasing order of statistical significance (all P<.05). The HVLA technique was rated the highest for breathing improvement (3.9 [0.7]) and was significantly higher than pursed lip breathing, saline, lymphatic pump, pursed lip breathing then tapotement, rest, tapotement, and pursed lip breathing then rib raising, in increasing order of significance (all P<.05). 
To compare treatment types, the average subjective ratings were calculated for each group (OMT, SPR, and combination) using t tests. Overall SPR ratings were significantly less than both OMT (P<.001) and combination (OMT+SPR) treatments (P<.005) (Figure 3). 
Figure 3.
Participants’ subjective scores regarding breathing improvement after each weekly treatment and overall and combination treatments in the (A) osteopathic manipulative treatment (OMT) group and (B) standard pulmonary rehabilitation (SPR) group. Scores were on a 5-point scale, with 1 indicating “much worse” breathing and 5 indicating “much improved” breathing. aOverall, participants in the OMT group and participants receiving combination treatment (OMT+SPR) felt their breathing improved significantly more than did the participants in the SPR group. Abbreviations: DD, doming of the diaphragm; HVLA, high velocity, low amplitude; LP, lymphatic pump; PLB, pursed lip breathing; RR, rib raising.
Figure 3.
Participants’ subjective scores regarding breathing improvement after each weekly treatment and overall and combination treatments in the (A) osteopathic manipulative treatment (OMT) group and (B) standard pulmonary rehabilitation (SPR) group. Scores were on a 5-point scale, with 1 indicating “much worse” breathing and 5 indicating “much improved” breathing. aOverall, participants in the OMT group and participants receiving combination treatment (OMT+SPR) felt their breathing improved significantly more than did the participants in the SPR group. Abbreviations: DD, doming of the diaphragm; HVLA, high velocity, low amplitude; LP, lymphatic pump; PLB, pursed lip breathing; RR, rib raising.
Discussion
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 FEV1, FVC, or FEV1/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 techniques13 or compared OMT with only a sham group.11,14 
Saline nebulizer was the sole treatment that resulted in a significant decrease in FEV1 and FEV1/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 studies10,14 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. 
Conclusion
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. 
Acknowledgments
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. 
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Figure 1.
Change in forced expiratory volume in the first second of expiration (FEV1) and forced vital capacity (FVC) after each weekly treatment technique was applied in the (A) osteopathic manipulative treatment group and (B) standard pulmonary rehabilitation group. aSaline nebulizer showed statistically significant worsening of FEV1 in participants. Abbreviations: DD, doming of the diaphragm; HVLA, high velocity, low amplitude; LP, lymphatic pump; PLB, pursed lip breathing; RR, rib raising.
Figure 1.
Change in forced expiratory volume in the first second of expiration (FEV1) and forced vital capacity (FVC) after each weekly treatment technique was applied in the (A) osteopathic manipulative treatment group and (B) standard pulmonary rehabilitation group. aSaline nebulizer showed statistically significant worsening of FEV1 in participants. Abbreviations: DD, doming of the diaphragm; HVLA, high velocity, low amplitude; LP, lymphatic pump; PLB, pursed lip breathing; RR, rib raising.
Figure 2.
Change in the ratio of forced expiratory volume in the first second of expiration (FEV1) to forced vital capacity (FVC) after each weekly treatment in (A) the osteopathic manipulative treatment group and (B) the standard pulmonary rehabilitation group. aSaline nebulizer showed statistically significant worsening of FEV1/FVC. Abbreviations: DD, doming of the diaphragm; HVLA, high velocity, low amplitude; LP, lymphatic pump; PLB, pursed lip breathing; RR, rib raising.
Figure 2.
Change in the ratio of forced expiratory volume in the first second of expiration (FEV1) to forced vital capacity (FVC) after each weekly treatment in (A) the osteopathic manipulative treatment group and (B) the standard pulmonary rehabilitation group. aSaline nebulizer showed statistically significant worsening of FEV1/FVC. Abbreviations: DD, doming of the diaphragm; HVLA, high velocity, low amplitude; LP, lymphatic pump; PLB, pursed lip breathing; RR, rib raising.
Figure 3.
Participants’ subjective scores regarding breathing improvement after each weekly treatment and overall and combination treatments in the (A) osteopathic manipulative treatment (OMT) group and (B) standard pulmonary rehabilitation (SPR) group. Scores were on a 5-point scale, with 1 indicating “much worse” breathing and 5 indicating “much improved” breathing. aOverall, participants in the OMT group and participants receiving combination treatment (OMT+SPR) felt their breathing improved significantly more than did the participants in the SPR group. Abbreviations: DD, doming of the diaphragm; HVLA, high velocity, low amplitude; LP, lymphatic pump; PLB, pursed lip breathing; RR, rib raising.
Figure 3.
Participants’ subjective scores regarding breathing improvement after each weekly treatment and overall and combination treatments in the (A) osteopathic manipulative treatment (OMT) group and (B) standard pulmonary rehabilitation (SPR) group. Scores were on a 5-point scale, with 1 indicating “much worse” breathing and 5 indicating “much improved” breathing. aOverall, participants in the OMT group and participants receiving combination treatment (OMT+SPR) felt their breathing improved significantly more than did the participants in the SPR group. Abbreviations: DD, doming of the diaphragm; HVLA, high velocity, low amplitude; LP, lymphatic pump; PLB, pursed lip breathing; RR, rib raising.
Table 1.
Effect of OMT vs SPR on Pulmonary Function: Group and Procedure Assignment by Weeka (N=53)b
Weekc OMT Groups (n=28) SPR Groups (n=25)
1 Thoracic lymphatic pump (n=16) Pursed lip breathing (n=23)
2 Thoracic HVLA (n=17) Tapotement (n=17)
3 Rib raising (n=9) Saline nebulizer (n=17)
4 Doming of diaphragm (n=9) Rest (n=14)
5 Rib raising, then lymphatic pump (n=18) Pursed lip breathing, then tapotement (n=22)
6 Rib raising, then pursed lip breathing (n=19) Pursed lip breathing, then rib raising (n=21)

a Participants were randomly assigned to either the osteopathic manipulative treatment (OMT) or standard pulmonary rehabilitation (SPR) group.

b Number of trials utilized for each protocol is specified within parentheses. Trials that were not acceptable (eg, poor participant effort, air leaking during forced vital capacity maneuver, high variability in spirometry values, subject fatigue) were not included in the analyses.

c During weeks 1 through 4, each participant received 1 treatment per session. By the end of 4 weeks, all participants received all 4 treatments listed in their respective group. During week 5, participants received a combination of the highest-ranked treatment followed by the second highest-ranked treatment in each group. During week 6, all participants received a combination of the highest-ranked treatments in both groups.

Table 1.
Effect of OMT vs SPR on Pulmonary Function: Group and Procedure Assignment by Weeka (N=53)b
Weekc OMT Groups (n=28) SPR Groups (n=25)
1 Thoracic lymphatic pump (n=16) Pursed lip breathing (n=23)
2 Thoracic HVLA (n=17) Tapotement (n=17)
3 Rib raising (n=9) Saline nebulizer (n=17)
4 Doming of diaphragm (n=9) Rest (n=14)
5 Rib raising, then lymphatic pump (n=18) Pursed lip breathing, then tapotement (n=22)
6 Rib raising, then pursed lip breathing (n=19) Pursed lip breathing, then rib raising (n=21)

a Participants were randomly assigned to either the osteopathic manipulative treatment (OMT) or standard pulmonary rehabilitation (SPR) group.

b Number of trials utilized for each protocol is specified within parentheses. Trials that were not acceptable (eg, poor participant effort, air leaking during forced vital capacity maneuver, high variability in spirometry values, subject fatigue) were not included in the analyses.

c During weeks 1 through 4, each participant received 1 treatment per session. By the end of 4 weeks, all participants received all 4 treatments listed in their respective group. During week 5, participants received a combination of the highest-ranked treatment followed by the second highest-ranked treatment in each group. During week 6, all participants received a combination of the highest-ranked treatments in both groups.

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Table 2.
Effect of OMT vs SPR on Pulmonary Function: Spirometer Results During the First 4 Weeks of Treatment
Mean (SD) Δ in Litersa
Treatment FEV1 FVC Sum of Changes
OMT Group
 Doming of the diaphragm −0.131 (0.199) −0.064 (0.186) −0.195
 Thoracic high velocity, low amplitude −0.017 (0.158) −0.025 (0.147) −0.042
 Thoracic lymphatic pumpc 0.080 (0.169) −0.031 (0.229) 0.049
 Rib raisingb 0.001 (0.136) 0.052 (0.183) 0.053
SPR Group
 Pursed lip breathingb 0.101 (0.278) 0.031 (0.179) 0.133
 Rest −0.062 (0.183) −0.052 (0.163) −0.115
 Saline nebulizer −0.190 (0.202) −0.043 (0.299) −0.233
 Tapotementc 0.045 (0.229) 0.061 (0.239) 0.106

a Data represent mean changes of forced expiratory volume in the first second of expiration (FEV1) and forced vital capacity (FVC) in each participant before and after treatment (average of pre- to posttreatment measures).

b Most successful treatment within group.

c Second most successful treatment within group.

Abbreviations: OMT, osteopathic manipulative treatment; SPR, standard pulmonary rehabilitation.

Table 2.
Effect of OMT vs SPR on Pulmonary Function: Spirometer Results During the First 4 Weeks of Treatment
Mean (SD) Δ in Litersa
Treatment FEV1 FVC Sum of Changes
OMT Group
 Doming of the diaphragm −0.131 (0.199) −0.064 (0.186) −0.195
 Thoracic high velocity, low amplitude −0.017 (0.158) −0.025 (0.147) −0.042
 Thoracic lymphatic pumpc 0.080 (0.169) −0.031 (0.229) 0.049
 Rib raisingb 0.001 (0.136) 0.052 (0.183) 0.053
SPR Group
 Pursed lip breathingb 0.101 (0.278) 0.031 (0.179) 0.133
 Rest −0.062 (0.183) −0.052 (0.163) −0.115
 Saline nebulizer −0.190 (0.202) −0.043 (0.299) −0.233
 Tapotementc 0.045 (0.229) 0.061 (0.239) 0.106

a Data represent mean changes of forced expiratory volume in the first second of expiration (FEV1) and forced vital capacity (FVC) in each participant before and after treatment (average of pre- to posttreatment measures).

b Most successful treatment within group.

c Second most successful treatment within group.

Abbreviations: OMT, osteopathic manipulative treatment; SPR, standard pulmonary rehabilitation.

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