"I did not exhale!" - The osteopathic approach to asthma

Before attempting to treat asthma it is important that the osteopath understands the pathophysiology of the disease and the biomechanics.

Asthma is a disease triggered by factors such as dust, anxiety, cold air and animal-hair, defined as the chronic hyperactivity of lung tissue resulting in constriction of the bronchial tree. The constriction of the bronchial tree causes dysponea (difficulty breathing), wheezing and coughing. It results in excess production of mucous, bronchospasm and oedema. Since the airways are narrowed, the asthmatic finds it difficult to exhale, the exhalation phase is prolonged leading to hyperinflated lungs and the osteopath may observe "barrel-chest".

Exposed to the allergen, the acute asthmatic responds with the production of inflammatory cells and mast cells which initiate mucous production and bronchospasm. However when asthma becomes chronic it results in the hypertrophy of the smooth muscle, fibrosis and an increase in the number of blood vessels in the bronchiole mucosa. This is why it is so important to treat the asthmatic from an early age.

Observation:
Observation of the patient by the osteopath is focused mainly on the respiratory mechanics – the relationship between the thoracic spine, ribs, sternum, clavicle, scapulae, cervical spine, cervical fascia and diaphragm. The osteopath should palpate for somatic dysfunction in all of these areas, observing compliance and flexibility. The osteopath should check to what extent each area is able to accommodate inhalation and exhalation and to what degree the lower 6 ribs are compliant to allow the diaphragm to descend. The secondary respiratory muscles are often hypertonic in the asthmatic patient and the osteopath should check to what extent this is the case and whether there is any asymmetry of hypertonicity in the body. The osteopath should observe the face and the relationship of the mouth, nose, eyes, forehead, ears and palate noting any asymmetry and compression that may cause obstruction in the sinuses and airways.

A common cause of asthma in children is gastric reflux so the osteopath should take into consideration the overlapping areas of the respiration and digestion, in other words, the diaphragm, the upper lumber spine, the lower ribs and the sternum.

Examination:
When examining the asthmatic patient the osteopath needs to pay due attention to the areas directly related to breathing:
Upper thoracic vertebrae and ribs.
Sympathetic nerve supply to the lungs (T1-5).
Vagus nerve (cranial nerve X) which innervates the smooth muscle of the bronchioles.
Anterior cervical musculature
Diaphragm locally – the lower 6 ribs, the attachments of the crura – L1 and 2 and its nerve supply C3,4,5 – phrenic nerve.
Accessory muscles of respiration –sternocleidomastoid, scalene muscles and the intercostal muscles.

Treatment:
There are a few objectives to the osteopathic treatment:
a) To improve the breathing mechanics.
b) To balance the sympathetic and parasympathic nervous system.
c) To encourage lymphatic drainage.

The order of treatment should obviously be what the osteopath deems appropriate but a simple guide after checking for somatic dysfunction could be to first treat any dysfunction observed in the primary breathing mechanics that is the ribs, thoracic spine, sternum and diaphragm. Next the osteopath moves on to the more peripheral areas such as the scapulae, the secondary respiratory mechanics, that is the cervical muscles and fascia.

Next the osteopath can address the sympathetic nerve supply to the bronchioles – T1-6 as well as paying due attention to vagus nerve specifically as it exits the occipito-atlantal joint and the phrenic nerve which innervates the diaphragm.

The osteopath can end off with a gentle lymphatic pump either thoracic or pedal.

Treatment of the asthmatic patient by the osteopath really does require a holistic approach and the osteopath should remember to address more than just the patient's musculo-skeletal system. The approach needs to be multifactorial, combining environmental advice, dietary advice, exercises and relaxation techniques.

A brief review of the history and philosophy of osteopathy

The Common Cold - An Osteopathic Approach

It is that time of the year when many of us have patients presenting at our clinics with the common cold. Although they may arrive for a different matter, with the patient's permission, it is a chance for the osteopath to treat some of the less-known conditions that osteopathy addresses.

At the back of the throat sits a ring of lymphoid tissue – the pharynx, the adenoids and the tonsils. They serve as the first line of defense against infections of the mouth and throat. The main virus that causes the common cold is the rhinovirus.

On examining the patient with a cold, the osteopath may find that the posterior pharyngeal muscles are inflamed, the hyoid bone is restricted in movement on one side, the cervical lymph nodes are enlarged, there is restriction in movement of the cervical vertebrae and there is hypertonic cervical-erector-spinae.

The aim of osteopathic treatment is two-fold:
a) To improve fluid drainage to and from the problem area.
b) To boost the immune system.

In conjunction with a general osteopathic treatment, the osteopath should focus on a number of relevant areas. The clavicle and first rib, between which lie the left and right thoracic ducts, must move freely so that drainage from the head and neck is not restricted. The same applies to the thoracic outlet. The diaphragm is also important in intrathoracic pressure and fluid dynamics. Furthermore the osteopath should address sternocleidomastoid (SCM) making sure that it is relaxed and not restricting sound fluid drainage from the throat by either local hypertonia or pinching the thoracic ducts between clavicle and first rib.

To boost the immune system the osteopath can apply the lymphatic pump, splenic and pedal pump.

Local soft tissue work to SCM and articulation with gentle muscle-energy to the pharangeal muscle can be executed in the following way:

With the patient lying supine, the osteopath stands to the side of the patient and clasps the hyoid between two fingers (it is worth explaining to the patient the procedure in advance). Gently, the osteopath articulates the hyoid bone laterally and asks the patient to swallow. The osteopath will feel a gentle tension increase around the hyoid and this produces an effective accurate stretch to the surrounding musculature.

Gentle inhibition can be applied to the sub-occipital muscles and cervical-erector-spinae.

The osteopath can finish with some gentle effleurage around the ears, eyes nose and throat.

The order in which these techniques are used is up for debate but there is some logic in beginning with the peripheral areas first to create pools for the fluid to drain into.

The osteopath may wish to advise the patient to rest and to reduce complex and artificial foods, sticking mainly to boiled vegetables in the first 24 hours.

In conclusion, the osteopath applies skilled hands to knowledge of anatomy and physiology, creating an optimum environment for the body to combat the virus, bringing symptomatic relief, reducing pain and hopefully speeding the recovery.