To the Editor: 

With regard to the article by Anderson et al titled “Doming the Diaphragm in a Patient With Multiple Sclerosis,”¹ I would like to make some clinical and anatomical clarifications. Multiple sclerosis (MS) has symptoms that depend on the brain areas affected (spasticity and progressive weakness of the muscles, loss of vision, cognitive decline), and the presentation over time changes (relapsing, remitting, progressive). In patients who walk, the diaphragm is sufficiently functional; fatigue is mainly related to a motor incoordination of limbs and trunk.² In patients using wheelchairs, the expiratory muscles rather than the diaphragm muscles are the most affected.³ 

A direct dysfunction of the diaphragm occurs in the terminal phases of the disease, when sclerotic plaques affect the central areas of respiration (brainstem, nucleus tractus solitarius, nucleus retroambiguous).³ Diaphragm dysfunction proven by instrumental and clinical examinations is the demyelinating response of the respiratory tract from the central nervous system.³ When this happens, the diaphragm muscle has difficulty descending (inspiratory act), with a greater tendency to rise (expiratory act), with a reduced muscular thickness. The behavior of the diaphragm in dysfunction is not always the same, likely resulting from different lesions or different patient adaptations. If the lesion affects the nucleus tractus solitarius, then an increase in respiratory minute ventilation will occur.³ If the affected centers are the areas of the corticospinal, medulla oblongata, and nucleus ambiguous, the motor patterns may be altered, with paradoxical breathing, apneustic breathing, loss of voluntary breath control, and apnea during the night.³ 

Personally, I do not know of studies using osteopathic approaches that demonstrate a recovery of the diaphragm morphology and an improvement of its function in the presence of demyelinating plaques in the central areas of the breath. In a healthy person, the diaphragm muscle has a greater excursion into the posterolateral area and not into the anterolateral area.⁴ The thoracic doming technique involves manipulating the anterolateral area with probable minor effect on the diaphragm. In previous work with sternotomized patients, my colleagues and I used a manual approach that involved the diaphragm in the posterolateral portion with excellent results.⁵ 

I thank the authors of the article¹; however, I believe it is important to highlight that the type of breath in patients with MS is not always the same and that their proposed approach is a working hypothesis with no certainty in the results.