Asthma and Chiropractic Spinal Adjustments (Specific Manipulation) A literature review and research proposal Jay Shetlin, DC St. George, UT USA / Lisbon, Portugal THE PURPOSE OF THIS PAPER is to illustrate the effects of Chiropractic adjustments and spinal manipulation on asthmatic patients. This paper will address a number of small studies that have been performed over the last 80 years, as well as, current case studies collected by the author. Finally, the author recommends a nation wide or world wide inter disciplinary study be performed in a collaborative format. (Original compilation 2003, Updated 2006) Asthma has become a serious challenge to clinical medicine today, with an increase in incidence, morbidity, and mortality over the past two decades. Bronchial Asthma is responsible for more than 5000 deaths each year in the United States. 7 Asthma deaths have increased since the 1970 s by over 50%. About 17 million Americans suffer from Figure 1 Bronchial asthma, with 5 million being younger than 18 years of age. The point is, despite our increased understanding of the pathophysiology of asthma, mortality rates have continued to increase for asthmatics while decreasing in many other diseases. Mechanism: Most authorities agree that the cellular and biochemical mechanism involved in the pathogenesis and pathophysiology of asthma are not yet fully understood (Sears et al. 1991) Many mediators have been implicated in asthma, including platelet activating factor. This seems to cause a prolonged increase in bronchial responsiveness by attracting eosinophils into bronchial tissues. This may lead to damage, the key feature in asthmatic patients. 5 A New Zealand study showed correlation between the use of antibiotic and childhood asthma. 8 Others studies have sited vaccinations as a possible instigator for the rise in asthma cases. 18 Scoliosis may be another contributing factor to asthma and other allergic conditions. 9 A Study by O Donovan 10 showed that a misalignment of the articulations of the spine could stimulate the preganglionic fibers of the dorsolumbar spine. He presented three specific cases in which reduction of scoliosis corresponded with a complete remission of asthma symptoms. Obstructed (left) vs. Non obstructed airway (right) Figure 2 Smooth muscle constriction and epithelial damage combined or alone result in airway obstruction. This is the problem for Asthmatics; not transfer of oxygen in the lungs but simple getting air to the lungs and carbon dioxide out.
Basis: Research shows that Chiropractic adjustments affect both the sympathetic and parasympathetic aspects of the nervous system. Definitions: Subluxation Simply put is a mis alignment of the vertebral bodies thus resulting in disc or joint inflammation thus impeding nerve flow. A subluxation, as defined by the Association of Chiropractic Colleges is as follows: "A subluxation is a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health." When a subluxation is present it causes nerve interference hampering the proper function of target tissues supplied by those nerves. The subluxation causes changes to the structure as well as the nerves. These changes become progressively worse resulting in degenerative changes when left uncorrected. These changes take the form of ongoing degeneration known as "subluxation degeneration". By understanding the type and amount of changes, it is possible to reasonably estimate the length of time a subluxation has been present in a spine. Having this information is useful in understanding the time and effort needed for correction. 16 Chiropractic spinal adjustment "The ICA holds that the chiropractic spinal adjustment is unique and singular to the chiropractic profession. The chiropractic adjustment shall be defined as a specific directional thrust that sets a vertebra into motion with the intent to improve or correct vertebral malposition or to improve its juxtaposition segmentally in relationship to its articular mates thus reducing or correcting the neuroforaminal / neural canal encroachment factors inherent in the chiropractic vertebral subluxation complex. The adjustment is characterized by a specific thrust applied to the vertebra utilizing parts of the vertebra and contiguous structures as levers to directionally correct articular malposition. Adjustment shall be differentiated from spinal manipulation in that the adjustment can only be applied to a vertebral malposition with the express intent to improve or correct the subluxation, whereas any joint, subluxated or not, may be manipulated to mobilize the joint or to put the joint through its range of motion. Chiropractic is a specialized field in the healing arts, and by prior rights, the spinal adjustment is distinct and singular to the chiropractic profession." 17 Hypothesis: Adjusting subluxated vertebral segments decreases nerve interference thereby breaking the somatoviseral reflex of the muscle spasm. This aids in reducing impingement of peripheral nerves to targeted bronchial tissues, bronchial smooth muscle, and organs vital to the immune response. Anatomy: Figure 3 Bronchi and smooth muscle of trachea and bronchi Figure 4 Lymphatic drainage of lungs, bronchi and trachea
Diagnosis and Medical Management: Asthma diagnostically could be defined as a reversible episodic airway obstruction. The definitions of severity are given by G. Bronfort, DC as follows: Mild Asthma characteristically has intermittent episodes of brief symptoms, which last less than one hour and occur up to twice weekly. Recommended therapy (1) 2 puffs of β 2 agonists are prescribed to prevent symptoms before exposure to allergens or other provoking stimuli; and (2) inhaled β 2 agonists are prescribed on an asneeded basis to control ongoing symptoms. Chronic Asthma is characterized by episodes of dypsnea more than once or twice weekly, which may last several days, and occasionally require emergency care. Therapy β 2 agonist on an as needed daily basis to control symptoms. Usually combined with inhaled anti inflammatory corticosteroids or Cromolyn. Chronic severe asthma is characterized by continuous symptoms, limited physical activity level, frequent exacerbation, nocturnal symptoms and occasional hospitalization. Therapy inhaled β 2 agonists on a daily basis, inhaled corticosteroids four times daily, oral sustained release β 2 agonists, and Therophyllin or Cromolyn. Patient education and recognition of its triggers are an important part of asthma management. 5 Study Findings: There have been numerous small scale studies performed and case studies collected. Most are reported as interdisciplinary between Medical Doctors and Doctors of Osteopathy or Medical Doctors and Doctors of Chiropractic. Please note the following examples and references: A 1925 Osteopathic study, albeit poorly controlled, showed that 15 of the patients studied had some temporary relief and 10 patients had 50% fewer asthmatic attacks over an extended period of time. This study also demonstrated the reproducibility of certain neuromuscular palpatory findings in patients with asthma. 7 1959 John A Kline, DO found that during acute asthma, lesions will always be found in the second to fourth thoracic vertebra and the fourth rib of the right will be elevated. The only other constant finding is a lesion of the third cervical vertebrae with rotation to the left. 7 Doctors of osteopathy have treated asthma by adjusting upper thoracic vertebra and costovertebral junctions. Although adjusting the first (T1) through the fourth (T4) thoracic vertebrae seem to be the most common method employed. 9 In a study by Jamison, Leskovec, Lepore and Hannan, fifteen asthmatics were provided chiropractic care to determine the effects of spinal manipulation on respiratory function. The subjects were evaluated using subjective and objective methods. Subjectively, the patients reported the chiropractic manipulation had improved their condition. However, it was not confirmed by the objective respiratory indices. 5 Edward Cohen, DC, printed a case history of an 8 year old female who suffered from asthma. Dr. Cohen set up a treatment plan of three times per week for one month and mild changes to her diet (decreasing sugar and refined foods) she was to a point that she could be taken completely off medications. 11 William C. Amalu, DC conducted a study following 47 asthmatic cases. Each patient case was tracked over the course of two full years under chiropractic care. Dr. Amalu
reports objective improvement in all 47 asthmatic cases were 87 100 percent. 14 The New England Journal of Medicine 1998 published a study of 91 children with continuing symptoms of asthma. They were separated into two groups, one treated with high velocity chiropractic adjustments and the other treated with low velocity chiropractic adjustments. The findings were (1) A small increase in peak expiratory flow. (2) Symptoms and the use of β agonists were decreased. (3) No significant difference between groups. (4) Conclusion: No benefit. 1 In the following issue, however, there was a rebuttal where the writer states you cannot use a low force treatment as a placebo. Chiropractic manipulative therapy is defined as a form of specific manual treatment used to influence joint and neurophysiologic function, and it may be accomplished with a variety of techniques. 2 In the same follow up issue three other doctors point out that the study found both forms of treatment resulted in improvement in symptoms, decreased use of medication, and improvement in quality of life. 2 [I find it interesting that reduced meds and improved quality of life did not strike those performing the study as Conclusion: Benefit. ] 1999 to 2004 St. George Study. During this time, I personally treated a number of asthmatic patients with Chiropractic care to follow their reported change of condition, if any. I had established with the local pulmonary unit to take pre and post inspiratory volume readings. Several of the pediatric participants were monitored as well by their local pediatrician. Specific chiropractic adjustments were administered 3 times per week for 6 weeks with minimal dietary changes (reducing sugars and increasing H 2 O consumption). A pattern of common verteral subluxations is noted being C2, T2 4, and T12. Thought patients varied in age, from 15 months to 70 years old, all reported some kind of improvement. It was clear, however, that children responded faster with long term benefits when compared with the over 20 years of age population. Video interviews were performed to document 2 of the pediatric patients and their mothers. These were documented in excess of a year following the 6 week treatment program. They describe the changes noticed from their prospective throughout and following the study period. It is clearly stated that the children either reduced or stopped using inhalant medication completely and were able to enjoy a much improved quality of life. Both parents and both children reported improvements such as, being able to run and play with friends, engage in sports, and sleep better. Here are just a few of the case followed in the St. George study: Case 1 15 month old female. She began the study following 1 year of repeated antibiotic prescriptions and finally a diagnosis of asthma. Prescription changed to inhalant treatments 3 times daily and 2 3 times per night. Mother reports patient had never slept a full night in her 15 months of life. Mother needed to treat her daughter with inhalant medication 2 3 times nightly. One week into treatments patient slept through the night for the first time without waking and needing inhaler. Three weeks in she no longer needed inhaler on a regular basis. Via a video interview her mother
reports using her inhaler 1 2 times per year. Currently she reports no use of inhaler at all. [Think of not only the immediate benefit but the long term effect of adding years to her life by minimizing the inhalant meds.] Case 2 8 year old female. Part of an active athletic family, she was unable to participate in sports without heavy use of inhaler. Following the study she and her mother report she had greatly reduced her use of inhalant medication and was able to participate in sports. Following the sixweek study, she chose to continue with occasional chiropractic care for 1 year reporting it helped stabilize her improved condition. In a video interview 1 year following the study, the mother states, We noticed improvements immediately when we began participating in the study. The daughter said, I stopped coughing and could run further without coughing. I noticed I didn t need my inhaler and could run and do more sports. (In soccer) I could play forward instead of being stuck at defense. [Same comment as above.] Case 3 23 year old female. Patient had poor health, diet, and work conditions. Stated improvement from daily to 1 2 times per week. Strikingly, on one visit to the office she was in the midst of an asthma attack. It was triggered from walking to the office in cold weather. After being adjusted, she experienced instant relief restoring normal breathing in under 5 seconds. Case 4 35 year old female. Patient is a teacher and mother of three. Responded to the study with improved comfort and reduction of medication. Reduced from daily to 1 time per week. Following the study, she opted to continue Chiropractic care 1 2 times per week. Following 5 months she reported using her inhaler on an as needed basis. She states only needing her inhaler 1 2 times per month. Case 5 70 year old male. Extreme asthma condition. Even with the use of his inhaler and other medications, he was hospitalized often. During the study he responded well stating, I have never felt better. Regarding to his asthma. Effects of treatment would only last for 1 2 days. He had improved breathing but remained on his medication. Sadly, it was reported that 3 weeks following his release from the study, the patient had passed away. St. George Study Conclusion: (1) No measurable change regarding inspiratory volume. (2) Reduced medicine dependency. (3) Increased quality of life. Conclusion: Asthma is growing with no known medical cure. The drugs prescribed for its treatment are also under scrutiny. These drugs are a two edged sword in that they relieve the strains of labored breathing at the moment they are having an asthmatic attack. While the drugs help the are suspected as the cause of increased morbidity and mortality to the growing number of asthma patients. 3 Consequently, if a drug free alternative to the treatment of asthma were used, resulting in, (1) Reduced symptoms (2) Increased quality of life (3) Decreased the use of inhalant β 2 agonists and corticosteroids thereby (4) Increasing the longevity and mortality of the patient. These outcomes are clearly to the patient s benefit with no harmful side effects or dependency.
Approach: The doctor of the future will give no medicine, but will interest patients in the care of the human frame, in diet and in the cause and prevention of disease. Thomas A. Edison It is my suggestion that doctors of varying specialties should take a team approach for the common good of the patient. It would be the responsibility of doctors participating in a projected nation wide study to use the latest technology possible to chart a better patient profile from beginning to end. Thermal scans of skin temperature, surface EMG, palpation, x ray and proper documentation in mass would create a great pool of comparative information. Figure 5 Pediatricians, Pulmonary specialists, Nutritionists and Chiropractors can and should work together to help find drug free answers the public is looking for. May we all join and work together in this common goal, the betterment of our patients, naturally.
References: 1. New England Journal of Medicine, Vol. 339; No.15; October, 8, 1998; A comparison of Active and Simulated Chiropractic Manipulation as Adjunctive Treatment for Childhood Asthma 2. New England Journal of Medicine; Vol. 340; Num. 5; February, 4, 1999 Correspondence ; Page 391 Brian V. Jongeward, D.C. Douglas G. Richards, Ph.D.; Eric A. Mein, M.D.; Carl D. Nelson, D.C. 3. Merck Manual 4. Dynamic Chiropractic, DC Archives; 8/21/99 Antibiotics = Childhood Asthma? Quoting article: Journal of Clinical and Experimental Allergy; Antibiotic use in Early Childhood and the Development of Asthma ; Wickens K, Pearce N, Crane J, Beasley, R 5. European Journal of Chiropractic, 1996, 44, 1 7; Asthma and Chiropractic ; G. Bronfort, D.C. Northwestern College of Chiropractic, Bloomington, Minnesota, USA 6. JAOA, Vol. 99; No. 5; May 1999; An Osteopathic Approach to Asthma ; William A. Rowane, DO, FACOI; Michael P. Rowane, DO, MS, FAAFP 7. JAOA Vol. 93; No. 6; June 1993; Editorials; Investigating the role of osteopathic manipulation in the treatment of asthma. 8. Journal of Clinical and Experimental Allergy, Antibiotic use in early childhood and the development of asthma. Wickens K, Pearce N, Crane J, Bealley R.; 1999;29:766 771 9. CHIROPRACTIC: The Journal of Chiropractic Research and Clinical Investigation Volume 8 Number 2 July 1992 Manipulative Therapy an alternative Treatment for asthma: A Literature Review ; Damon Dennis, D.C. and Daniel Golden, D.C. 10. O Donovan D. the possible significance of scoliosis of the spine in the causation of asthma and allied allergic conditions. Ann Allergy 1951;9:184 189 11. Case Study An Eight Year Old Asthma Patient by Edward Cohen, D.C. 12. Case Study 13. Bronchial Images by A.D.A.M. software version 2.3 Figure 3 Bronchi and smooth muscle of trachea and bronchi. Figure 4 Lymphatic drainage of lungs, bronchi and trachea 14. Today s Chiropractic Nov/Dec 2000; Chiropractic Management of 47 Asthma Cases ; William C. Amalu, D.C 15. Case Studies on Asthma Patients, by Jay Shetlin, DC. Performed 1999 to 2004, St. George, UT, US 16. http://www.echiropractic.net/subluxation_degeneration.htm 17. http://www.echiropractic.net/sample_what_is_an_adjustment.htm 18. Several asthma and allergy researchers have found results similar to the earlier described relationship between immunization and IDDM. A group from New Zealand (Kemp, Pearce, Fitzharriset al.1997) found that asthma and allergies were more common in children that received pertussis vaccine than in those that were not immunized. Similar results have been suggested by others (Odent, Culpin & Kimmel, 1994). More recently Dr. Julian Hopkin presented data at the British Thoracic Society meeting in 1997 which linked asthma to immunization. He has also published data that early immunization with BCG in Japan is associated with a decreased risk of IDDM (Shirakawa, Enomoto, Shimazuet al.1997).