Introduction
Breathing is one of the most vital biological functions of the body that ensures the continuum of life. Without oxygen, human beings cannot live for more than a few minutes. Pathologies of the respiratory system are some of the biggest problems modern medicine faces today. According to WHO statistics, these pathologies occupy the sixth place among the most common causes of death in the world and it is expected that by 2030 it will have taken the third place [1]. Typical symptoms of pulmonary diseases are dyspnoea, coughing, depression/anxiety, exhaustion and pain [2].
The osteopathic manual therapy (OMT) approach is not traditionally seen as part of standard treatment of pulmonary diseases but each year more and more researchers conduct studies in this area. Presently, OMT could serve as an adjunctive therapy for respiratory problems with a potential impact on the mobility of the thorax (the intervertebral joints, the costovertebral joints, bony structure, all ligaments, muscles, and fascia) and innervation of the lungs, pleura, diaphragm etc. [3].
Most often, studies in this area focus on the effects of OMT on patients suffering from COPD (Chronic Obstructive Pulmonary Disease) [1,4–6]. Nevertheless, specific soft tissue techniques used for treating COPD patients have not shown any statistically significant effects on lung function or on the level of dyspnoea. However, Barinow-Wojewódzki [6] wrote about a positive influence of the rehabilitation program on lean body mass and water level in COPD patients. Asthma is another similar area of research in which the same treatment approach is used [7–10]. Guiney et al. [7] noted that pediatric patients with asthma who underwent OMT treatment experienced statistically significant improvement in pulmonary function measured in PEF compared to the control group. Lowhagen and Bergqvist [11] observed that after soft tissue therapy and breathing exercises in asthma patients, PEF parameter improved significantly and such symptoms as ‘tightness in the chest’, ‘difficulty breathing in’ and ‘air hunger’ were significantly reduced in the active group.
The purpose of this study was to estimate the effects of using a combined set of both manipulative and soft OMT techniques on the respiratory system. The manipulative techniques included manipulations of the intervertebral and costovertebral joints, while the soft techniques included all fascial and muscle techniques. Several studies investigated the effects of either soft techniques [3,12] or manipulative techniques [8] on respiratory function. The present study combined both manipulative and soft techniques for potentially increased efficacy.
Discussion
The effects of osteopathic and manual therapy treatment on respiratory function is a very broad subject of research. There are studies that have shown positive effects on patients [3,4,6,8,11,12,18], but there are no established standards or clear guidelines for the use of osteopathic and manual therapy (OMT).
For our treatment protocol, four osteopathic manual techniques were used which aimed to improve respiratory function: sternal pump-recoil, manipulation of the thoracic intervertebral joints and the costotransversal joints, diaphragm mobilization and rib mobilization. The thoracic thrust techniques and ribs mobilization performed on the upper thoracic spine T1-T5 may have a normalizing effect on the sympathetic innervation of the lungs by the pulmonary plexus sympathetic chain, located closely to the rib heads. These techniques may affect joint mobility of the thoracic cage, which is very important for proper respiratory function. Without sufficient mobility of each joint of the chest, expansion of the lungs is likely to be reduced or limited.
The recoil technique, which is performed on the sternum, may increase the mobility of the cartilaginous connections between the sternum and the ribs as well as improve lung expansion.
Stretching of the diaphragm was considered the most important technique in this set, as the diaphragm is the most important respiratory muscle with direct influence on lung function. Proper function of the diaphragm (contraction and release) has a major influence on inspiratory and expiratory capacity and the mobility of the rib cage, especially in its lower parts. Each technique used in the chosen set is known to have either a direct or indirect influence on respiratory function. The majority of authors use manipulation techniques and diaphragm mobilization, two most popular osteopathic techniques employed to improve respiratory function [4,8].
Research has shown that a combination of different osteopathic techniques which include joint manipulations, joint mobilizations as well as soft tissue and cranial techniques is more effective than using only one technique [4,9,18]. We would suggest further investigations follow this multi-technique approach for increased effectiveness and results. PEF parameter levels seem to be the best and most obvious methods to evaluate the effects of such osteopathic treatments. Spirometry is the most typical tool for measuring respiratory function and is used by most authors [3,4,7,8,19]. Another common tool is a questionnaire [9].
Mehl-Madrona et al. [9] conducted a comparative randomised control trial on 89 individuals with asthma (68 completed the study) and compared four groups, i.e., the first group that underwent 12 sessions of cranial osteopathy, the second group that had 12 sessions of acupuncture, the third group that received a combination of both, i.e., 6 sessions of cranial therapy and 6 sessions of acupuncture, and the control group. The evaluated variables included the lung function test, the Asthma Quality of Life questionnaire, medication use as well as depression and anxiety levels. The results showed no statistically significant differences in pulmonary function tests for all groups. The quality of life increased and drug usage was reduced in the treatment group, but the levels of depression and anxiety remained unchanged.
Despite these weak study results, there is some evidence supporting the hypothesis that specific techniques of osteopathic treatment can be beneficial for patients with lung problems. One direct benefit is relaxation of any spinal dysfunction causing irritation of autonomic and somatic nerves contributing to muscle stiffness and pain [18]. Some authors claim that mechanical correction of vertebral subluxation by joint manipulation can restore normal function of the joint and nerve function and should therefore improve airway function as well [10]. Cranial osteopathy has also been found to be beneficial for the parasympathetic flow in patients with disturbances of the respiratory system [9].
Abdelaal Ashraf et al., studied 195 male patients with COPD [4]. They created a 12-week protocol, including two sessions per week to study ventilatory functions (VF) and functional capacity (FC) responses to diaphragmatic manipulation, costal manipulation or both. Each group showed statistically significant improvement, although the group with the combined diaphragmatic and costal manipulation treatments had the best results.
A statistically significant improvement in PEF was observed in the participants who received osteopathic manipulative therapy [19]. This positive effect was attributed to several factors: a decrease in the levels of anxiety, changes in the overall autonomic nervous system that have caused airway relaxation and balanced muscle tone and, what is particularly significant, an improvement in mechanical chest mobility.
Swender et al. [3], investigated the effects of osteopathic manual therapy in a group of 33 patients diagnosed with cystic fibrosis. Their manipulative protocol included rib rising, abdominal diaphragm release, thoracic inlet myofascial release, thoracic lymphatic pump and suboccipital decompression. No changes were found between the OMT group and the control group with spirometry of FEV1%. There were significant changes between both groups in the questionnaire on breathing, pain and anxiety. Fifteen out of 16 patients from the OMT group showed an improvement, whereas only 8 out of 16 individuals in the control group reported a positive change.
A combination of soft tissue techniques and joint manipulations had a short-term, though statistically significant effect on dyspnoea level and exercise performance [5]. This suggested the importance of the innervating value of the manual approach for patients with lung problems.
Most researchers have performed short-term studies without tracking long-term results and only a few studies have been conducted on large groups of participants [18]. There is no clear consensus in the literature regarding non-pharmacological methods of treatment for asthma symptoms; however, osteopathy offers a valuable alternative approach, as research has shown the benefits of osteopathic manipulative treatment in clinical conditions treating diseases such as asthma.
Limitations
There are some limitations in this study. Firstly, it involved only one session per one participant. Naturally, extended treatment and study should give more significant results. It is estimated that an exchange of collagen fibers in the fascia and an improvement in other parameters take 9 months. Secondly, other techniques such as visceral manipulation, which is directly connected with the intercostal muscle fascia, could have been included in the study to focus more directly on the pleura of the lungs [20]. Another limitation was a small number of study participants. An estimated test group for the assumed test power should be 164 persons for relevant tests, which will be considered by the authors in the next study.
It is also worth noting that there is a lack of strong evidence for osteopathic treatment in lung conditions. Only few studies revealed certain benefits of osteopathic manipulative techniques, which could be part of the therapy of the patients with pulmonary diseases together with pharmacology, surgery, physiotherapy, occupational therapy and a diet [3,4,5,9,18,19]. Therefore, at present it seems impossible to prepare specific standard protocols for osteopathic manipulative therapy in lung disorders, and further studies are needed in this area.
Clinical relevance
This study showed that this specific set of osteopathic manual techniques has limited effects on respiratory function. To obtain significant positive effects, a combination of manipulative techniques such as manipulations of the intervertebral joints and the costovertebral joints combined with soft techniques including a diaphragm stretch, myofascial releasing of the cervical and thoracic region and sternal pump or visceral manipulations should be used.