Download Complementary Treatments of Pulmonary Diseases

4/18/2012
Kim Mongeau, DO, FAAPMR, RRT
April 19, 2012
Who am I and why am I talking
about this?
 B.S. in Respiratory Care - RRT
 Doctor of Osteopathy – D.O.
 Physical Medicine & Rehabilitation Residency
 Musculoskeletal Spine & Sports Fellowship
 Neuromusculoskeletal Medicine Residency
 UCLA Medical Acupuncture for Physicians
 UA-CIM Integrative Medicine Fellowship
Objectives
 Discover non-invasive scientific based complementary
treatments for common pulmonary diseases such as
COPD and Asthma
 Develop an understanding and importance of the
inter-relationship among the pulmonary, neurologic,
skeletal and muscular systems
 Learn history behind Osteopathic Medicine
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Objectives
 Learn basic Osteopathic treatments to alleviate
dyspnea
 Understand the philosophy of Eastern medicine and
acupuncture in the treatment of asthma
 Learn basic acupuncture points for the treatment of an
acute asthma attack
Objectives
 Develop an awareness of how nutritional and dietary
supplements can impact COPD and asthma
 Mind – Body approaches for COPD and asthma
associated dyspnea
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Nutrition
 Related to respiratory status in a number of ways.
 Patients with COPD are frequently underweight and
malnourished as a result of inadequate nutrient intake
combined with increased energy utilization.
 Malnutrition in isolation or as result of acute or
chronic illness impairs respiratory function by
weakening diaphragmatic contractions.
 Malnutrition causes relative immunosuppression.
Malnutrition
 Ranges from 20 – 70% in obstructive airway disease
patients.
 Cause of increased mortality in COPD patients.
 Airway obstruction and higher respiratory rate
increases metabolic costs of breathing.
 Respiratory quotient of carbohydrate is 1, ie 1 molecule
of carb produces 1 molecule of CO2, RQ for fat is 0.7
and 0.8 for protein.
Malnutrition
 Elevated levels of tumor necrosis factor α and acute
phase reactant proteins reported in COPD patients
with weight loss.
 In COPD, energy intake of 1.4 to 1.6 times resting
energy expenditure is indicated during periods when
lean body mass is being recovered.
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Malnutrition
 Need to maintain 1 to 1.2 times resting energy
expenditure to avoid increased CO2 production.
 Pulmonary patients have limited respiratory reserve
and CO2 retention.
 Respiratory quotient of carbohydrate is higher than fat
or protein, therefore a carbohydrate restricted diet may
be very beneficial.
Malnutrition
 Protein supplementation increases oxygen and
ventilatory rate which may lead to dyspnea in patients
with limited reserve.
 Study: 90g/day for men and 80g/day for women of
powdered protein for 3 months improved nutritional
status, greater respiratory muscle and handgrip
strength, less fatigability of respiratory and skeletal
muscles and less breathlessness.
 Total caloric intake was 2,500 & 2,300kcal/day.
Malnutrition
 High fat, low carbohydrate diets are recommended for
patients with CO2 retention.
 Nutritional support is best given in small, frequent
feedings.
 Large meals creates considerable metabolic and
ventilatory load and can trigger acute respiratory
failure in patients with severe COPD
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Malnutrition
 In COPD, energy intake of 1.4 to 1.6 times energy
expenditure is indicated during periods when lean
body mass is being recovered.
 Energy maintained at 1 to 1.2 times resting energy
expenditure to avoid increased CO2 generation.
 Protein supplementation may be advised at
1.5g/kg/day after COPD exacerbation to restore lean
body mass.
Nutritional triggers in the
Asthmatic Patient
 Food allergy
 Frequently hidden
 More common in children than adults
 Sole cause of asthma or major contributing factor in 25 –
90 % of cases
 Sole cause of asthma in up to 40% of adults
 Manifestation of celiac disease
 Gluten free diet resulted in improvement of asthma.
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Nutritional triggers in the
Asthmatic Patient
 Foods that trigger exercise induced asthma
 Wheat
Nuts
 Milk
Apples
 Celery
Peaches
 Tomato
Grapes
 Shrimp
Lettuce
 Shellfish
Potato
 Chicken
Fennel
Nutrition
 Elimination diet is a good way to decrease body
inflammatory state by “calming” the GI tract.
 After 1 to 2 months then slowly reintroduce foods one
at a time for approximately one week to determine
reaction.
 Sometimes reintroduced food causes an exaggerated
response.
Nutrition related reactions in
asthmatics
 Sulfites in the form of sulfur dioxide is a common air
pollutant and are found in the following foods:
 Dried fruits
 Some fruit juices
 Wine
 Pickled foods
 Molasses
 Dried potatoes
 Corn based products
 Wine vinegars
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Nutrition related reactions in
asthmatics
 Monosodium
Glutamate – conflicting
information in studies.
One study funded by
MSG manufacturers was
negative for correlation
with decline in PFTs, but
excluded patients with
unstable airways or
severe asthma.
Nutrition related reactions in
asthmatics
 Other hypersensitivity reactions
 Aspirin (50% incidence)
 Tartrazine, aka FD&C Yellow #5 (4-20% incidence)
 Sodium benzoate
 Histamine (found in some wines and foods)
Nutrition related reactions in
asthmatics
 Reactive Hypoglycemia
 Study of 12 asthmatics, 100% incidence of reactive
hypoglycemia on a 6 hour glucose tolerance test.
 Nine of these patients elected to follow a diet excluding
refined sugar and that emphasized frequent feedings.
 100% had improved PFTs and asthma symptoms.
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Nutrition related reactions in
asthmatics
 Sodium Chloride
 Low-sodium diet improved asthma symptoms and highsodium diet worsened symptoms objectively.
 Exercise induced asthma also benefited from a lowsodium diet.
Nutrition related reactions in
asthmatics
 Trans fatty acids – might promote development of
asthma by interfering with essential fatty acid
metabolism.
 Vegan diet – Most likely due to avoidance of common
allergens (chocolate, tea, sugar, restrict or avoid grains,
pesticide free foods).
Study showed 71% of
participants improved after 4 months and 92%
improved after 1 year in PFTs to the point of DCing or
decreasing meds.
Nutrition related reactions in
asthmatics
 Obesity
 4 year prospective study demonstrated increasing body
mass index was associated with increasing risk of
developing asthma.
 Obese asthmatics who underwent a weight loss program
had reduced # of exacerbations, improved PFTs and
symptomatology.
 Breastfeeding
 Exclusive feeding until 4 months reduced incidence of
asthma at 6 years of age.
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Nutritional Supplements in
Asthmatics
 Magnesium – Oral, IV, Inhaled forms
 promotes relaxation of bronchial smooth muscle
 anti-inflammatory effect
 decreases responsiveness to histamine
 decreases the susceptibility of animals to developing
anaphylactic reactions.
Nutritional Supplements in
Asthmatics
 Magnesium
 Found to be low in suboptimal asthmatics (27% of
asthmatics and in 58% vs 9% of controls).
 May be due to Mg+ depleting meds: β adrenergic
agonists, theophylline, glucocorticoids, epinephrine.
 Low Mg+ may exacerbate toxic effects of asthma
medications (arrhythmias, seizures, osteoporosis)
Nutritional Supplements in
Asthmatics
 Vitamin C
 Inhibits phosphodiesterase (MOA of theophylline)
 A deficiency increases airway reactivity to histamine.
 Promotes relaxation of isolated tracheal smooth muscle
(? Direct bronchodilator effect)
 Required for the production of epinephrine in response
to stress.
 Plasma & BAL levels less in asthmatics vs controls.
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Nutritional Supplements in
Asthmatics
 Vitamin B6
 May exert an anti-allergy effect by forming a cyclic
compound with histamine eliminating it in vivo.
 Inhibits mast cell degranulation therefore inhibiting
histamine release.
 42-65% lower concentration in plasma of Asthmatics
verses healthy controls.
 If patient given Vit B6 must give Mg+ because B6
increases Mg requirements in system.
Nutritional Supplements in
Asthmatics
 Vitamin B12
 Promotes non-enzymatic oxidation of sulfites and in
sulfite sensitive asthmatics may protect them from
ingested or endogenously ingesting sulfites.
 Fish Oil
 Anti-inflammatory activity.
 Caution in aspirin sensitive patients due to fact that
omega-3 FAs influence prostaglandin and eicosanoid
metabolism.
Nutritional Supplements in
Asthmatics
 Vitamin D
 Study for influenza prevention: 430 children double
blind fashion received 1,200 IU/day of Vit D3 or placebo
for 15-17 months (December – March).
 110 had previous diagnosis for asthma.
 83% of the 110 did not suffer an asthma attack during the
study.
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Nutritional Supplements in
Asthmatics
 Vitamin B3
 Niacin (B3) found widespread as part of enriched grains
(we take it out to process then add it back in ).
 Niacin found to be useful in 60% of patients for
controlling acute asthma attacks and relieving chronic
continuous wheezing.
 Not recommended as primary asthma treatment.
Nutritional Supplements in
Asthmatics
 Beta-carotene
 64mg/day x 1 week protected against exercise- induced
asthma by scavenging free radicals.
 Natural beta-carotene or consumption of fruits and
vegetables rich in beta-carotene may help in prevention
of exercise-induced form.
 Potassium
 Asthma meds can reduce K+ and cause arrhythmias and
sudden death.
Other treatments for asthma
 DHEA (dehydroepiandosterone)
 Study: DHEA low in 71% of patients taking oral
glucocorticoids, 35% in inhaled form, 21% not taking
glucocorticoids.
 Glucocorticoids cause adrenal suppression.
 DHEA deficiency may contribute to adverse affects of
glucocorticoids such as bone loss and immune
suppression.
 Supplement only in adults
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Other treatments for asthma
 Hypochlorhydria
 Study: 200 children with asthma, 80% found to be
hypochlorhydric.
 Gastric acid levels rise around puberty which coincides
with spontaneous remission of childhood asthma.
 Asthma attacks less severe and less frequent after 3-4
months treatment with diluted HCL.
 Also common finding in adult asthmatics.
Nutritional Recommendations for
Asthma
 ID and avoid allergenic foods and additives
 ID and treat reactive hypoglycemia
 Avoid trans fatty acids
 Avoid excessive NaCl intake
 Weight loss if overweight
Nutritional Recommendations for
Asthma
 Magnesium: 200 – 600 mg/day
 Vitamin C: 500 – 3,000 mg/day
 Vitamin B6: 50 – 200 mg/day in adults
 IV nutrient therapy: Mg, Ca, Vits B & C and
occasional K.
 Thyroid hormones in select cases
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Nutritional Recommendations for
Asthma
 Vitamin B12: 1,000 mcg 1 – 3 times/week in selected
cases, taper and consider 100-1000 mcg/day for sulfite
sensitive patients.
 Vitamin D: 1000 – 2000 IU/day during winter and
maybe year around (check status)
 Fish Oil: 1-10g/day in selected cases. Not in patients
with aspirin sensitivity.
 DHEA in selected cases, no children.
Nutritional recommendations for
COPD
 Food Allergy: consider testing & avoidance of known
foods. May also need pollen desensitization.
 N-Acetylcysteine (NAC): Precursor to glutathione, a
major antioxidant in lung tissue. Used as a mucolytic
agent. Reduces dyspnea and cough, improves sputum
viscosity, easier expectoration and decreases in the
frequency of acute exacerbations and hospitalizations.
Nutritional recommendations for
COPD
 Magnesium
 Deficiency common in COPD patients by 22% vs
controls.
 56% of hospitalization COPD patients deficient.
 More pronounced in those receiving diuretics.
 Parenteral Mg supplementation should be accompanied
by oral potassium due to low INTRACELLULAR
potassium even when serum potassium levels are
normal.
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Nutritional recommendations for
COPD
 Potassium
 14% lower baseline and 27% lower when on diuretics
than in non-COPD patients.
 Potassium deficiency may contribute to muscle
weakness and fatigue.
 Increased potassium intake should be accompanied by
magnesium supplementation for intracellular uptake of
potassium.
Nutritional recommendations for
COPD
 Phosphorus
 22% of hospitalized COPD patients had
hypophosphatemia. Of those 22%, 91% had defect in
renal phosphate reabsorption associated with COPD
meds such as xanthine derivatives, glucocorticoids, loop
diuretics and β2 adrenergic bronchodilators
 Severe hypophosphatemia impairs diaphragmatic
function in acute respiratory failure.
Nutritional recommendations for
COPD
 Vitamin A
 Role in maintaining the cells of the alveolar epithelium
and may prevent RTIs.
 Deficiency demonstrated as a cause of emphysema in
rats.
 Cigarette smoke lowers vitamin A concentration in lung
tissue.
 Supplementation improved FEV1 by 23% and FVC by
25%. No real change in control group.
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Nutritional recommendations for
COPD
 L-Carnitine
 Facilitates transport of FAs into mitochondria and FAs
metabolized into energy.
 Deficiency can lead to muscle weakness.
 Supplementation of 4-6gm/d of L-carnitine for 1-2
weeks increased exercised tolerance in COPD
rehabilitation program.
 2gm/day for 6 weeks increased inspiratory muscle
strength.
Nutritional recommendations for
COPD
 Fatty Acids
 EPA & DHA intake associated with lower risk of
developing COPD in current and former smokers.
 EPA, DHA, ALA and GLA intake improved exercise
capacity in patients with COPD via anti-inflammatory
properties.
Nutritional recommendations for
COPD
 Vitamin C
 Antioxidant activity may help decrease oxidative damage
in the lung tissue from cigarette smoke, air pollution
and aging.
 Cofactor of collagen synthesis and aids in repair of
bronchial and alveolar tissue.
 May help prevent RTIs and improve asthma.
 Vitamin C supplementation or fresh fruit improved PFTs
in smokers and nonsmokers.
 Cigarette smoking depletes vitamin C.
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Nutritional recommendations for
COPD
 Copper
 Promotes connective tissue integrity, including the
alveolar wall.
 Positive association found between copper
concentration in water and PFTs.
 Copper in foods is lost when refined/processed.
Nutritional recommendations for
COPD
 Glutathione
 Major antioxidant in lung tissue.
 Cigarette smoke is known to deplete in the airways by
irreversibly degrading it to glutathione-aldehyde
derivatives.
 Inhaled form improved PFTs in COPD patients.
 Should not be given to patients with sulfite sensitivity,
due to aqueous solution contains sulfites and may cause
bronchospasms .
Nutritional recommendations for
COPD
 Proteolytic enzymes: Potential to decrease the
viscosity of mucopurulent secretions enhancing their
clearance.
 Chymoral
 Streptokinase
 Serrapeptase
 Bromelain
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Nutritional recommendations for
COPD
 Diet: General nutritional support with calories,
protein and essential nutrients. Avoid food allergens.
90g/d in males and 80g/d in females of protein in
malnutritioned patient.
 NAC: 200mg BID – TID for chronic bronchitis
 Vitamin C: 500 – 3,000 mg/day
 Magnesium Oroate: 300 – 600 mg/day
 Potassium: Increase intake with diuretic use
Nutritional recommendations for
COPD
 Nebulized Glutathione in selected cases.
 Parenteral nutrition of Mg, K, P, Vitamin B & C
 Phosphorus: per labs
 L-Carnitine: 1 – 3 g/day
 Vitamin A: 5,000 – 25,000 IU/day
Nutritional recommendations for
COPD
 Whole foods are the best source for complete nutrition
and intake of additional dietary requirements of fiber,
AA, essential minerals and elements.
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www.drweil.com
Mind-Body Treatment Considerations
Mind-Body Treatment
Considerations
 Guided Imagery
 Yoga
 Stress Management
 Biofeedback with EEG or handheld device
 All of the above engenders relaxation and assist with
breathing, balancing the autonomic nervous system and
decrease inflammatory mediators such as IL-1, IL-6, IL10, TNFα, NFκB and neuroendocrine hormones
serotonin, dopamine, GABA.
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Acupuncture
 Acupuncture is a health science which is used to treat
both pain and organ dysfunction in the body.
 Acupuncture has its roots deeply planted in China and
is considered to be 5000 to 7000 years old.
Acupuncture
 Acupuncture involves the insertion of very fine
needles into the body to stimulate acupoints.
 These points are located along 14 meridians traversing
the head, arms, legs and trunk.
 Meridians correlate with anatomical arrangement of
nerves, lymphatics, arterial and venous supplies.
Acupuncture Meridians
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Acupuncture
 These meridians are channels through which Qi (vital
energy) flows throughout the body.
 Acupuncture removes blockages in the flow of Qi
(“chee”)by diffusing lactic acid and carbon monoxide
that accumulate in muscle tissue and cause stiffness
and stagnation of blood.
Philosophy of Acupuncture
 In the traditional Chinese medicine (TCM) system, the
body is seen as a delicate balance of two opposing and
inseparable forces: yin and yang. Yin represents the
cold, slow, or passive principle, while yang (“yong”)
represents the hot, excited, or active principle.
 Symptoms of pain, or disease manifest when there is
an imbalance of yin and yang.
Acupuncture-Western Approach
 MSK pain (sprain or strain) causes stiffness which
creates abnormal pressure on nerves, lymph nodes,
and blood vessels. This adversely affects the function
of the skeletal system and internal organs. This is also
an imbalance between muscle, bone, nerve supply and
blood flow.
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Acupuncture-Western Approach
 Acupuncture can be used to reduce pain, reduce
inflammation, increase blood flow, increase range of
motion, decrease the side effect of medicationinduced nausea, promote relaxation in an anxious
patient, and reduce muscle spasm.
Acupuncture in the U.S.
 The first documented practice and research in the
United States of acupuncture was in 1826, by Franklin
Bache, MD, grandson of Benjamin Franklin. He
concluded that its primary value was for mitigating
and removing pain.
Acupuncture in the U.S.
 Acupuncture did not become well-known in the US
until 1971 when diplomatic relations between China
and the US were relaxed.
 Physicians & scientists have demonstrated that
acupuncture analgesia is linked to the CNS activities of
endogenous opioid peptides and biogenic amines.
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Efficacy of Acupuncture
 2004 NIH Consensus Conference on Acupuncture
concluded that clear evidence existed to support
acupuncture efficacy in postoperative &
chemotherapy-induced nausea & vomiting & in
postoperative dental pain. Useful as an adjunct
treatment or an acceptable alternative for addiction,
stroke rehabilitation, HA, menstrual cramps, tennis
elbow, fibromyalgia, myofascial pain, OA, LBP, CTS, &
asthma.
Adverse Effects of Acupuncture
Adverse Effects of Acupuncture
 Under the hands of a medically trained practitioner, it
is difficult to introduce new & lasting problems with
an acupuncture treatment. Possible side effects
include:
 Sense of well-being or relaxation
 May evolve into a feeling of fatigue or depression
 Light-headedness, anxiety, agitation or tearfulness
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Risks & complications of
Acupuncture
 Undesirable consequences of penetrating the body
with a sharp instrument:
 Syncope,
 Puncture of an organ
 Infection
 Retained needle
 Contact dermatitis
 Local inflammation
 Bacterial abscesses
 Chondritis
Application of Acupuncture for
Lung Disease
Goals of acupuncture in asthma
 Tonify the Lung and Kidney Defensive Qi systems
 Restore the descending of Lung-Qi
 Calm the mind
 In Late-onset asthma, tonify the Spleen.
Lung Meridian
 LU-9 tonifyKU & KI
 LU-7 restore Lung Qi
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Heart Meridian
 HT-7 calms mind
Kidney Meridian
 KI-16 tonify LU & KI
Bladder Meridian
 BL-13 tonify LU & KI
 BL-23 tonify LU & KI
 BL-52 tonify LU & KI
 BL-20 tonify SP
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Stomach Meridian
 ST-36 tonify SP
 ST-40 tonify SP
Du (Govenor Vessel) Meridian
 DU-24 calms the mind
Ren (Conception Vessel) Meridian
 Ren-4 tonify LU & KI
 Ren-8 tonify LU & KI
 Ren-15 calms mind
 Ren-17 restore
descending Lung-Qi
 Ren-12 tonify SP
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Osteopathic Manipulative
Medicine (OMM)
Osteopathic Manipulative
Medicine
 “To find health should be the object of the doctor.
Anyone can find disease.”
A.T. Still, MD, DO
 “The greatest mistake in the treatment of diseases is
that there are physicians for the body and physicians
for the soul, although the two cannot be separated.”
Plato
Osteopathic Manipulative
Medicine
 A unique approach
to treatment of
musculoskeletal
and organ problems
as they relate to the
overall functioning
of the body.
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Osteopathic Manipulative
Medicine
 Specialty of OMM/NMM
 Performed by D.O.s who are Fully licensed and able to
practice in all areas of medicine and surgery.
 Medical school training identical to M.D. with
additional classes in Osteopathic Priniciples,
Diagnosis and Treatment, and additional hours in
anatomy and neuroanatomy.
Osteopathic Manipulative
Medicine
 Develop an in-depth understanding and treatment
approach of the inter-relatedness between organ and
musculoskeletal problems and diseases.
 A hands-on treatment that emphasizes the
musculoskeletal system and the body's power of selfhealing.
 OMM is unique to the training of a D.O. and
encourages a "whole person" approach to medicine.
Osteopathic Manipulative
Medicine
 The goal of
manipulation, or
manual medicine is to
help maintain optimal
body mechanics & to
improve motion in
restricted areas, thus
enhancing maximal,
pain-free movement in
postural balance,
optimizing function.
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Osteopathic Manipulative
Medicine
 This is accomplished by
treatments that attempt
to normalize altered
reflex patterns as
evidenced by optimum
range of motion, body
symmetry and tissue
texture.
Osteopathic Manipulative
Medicine
 Sympathetic ANS:
 Spinal nerves T1-4
 Organs bronchi, bronchioles, lung parenchyma
 Ganglia: Sup, Mid, Inf cervical ganglia, pulm plexus
 Chapmans: ICS 2 (bronchus),ICS3 (upper lung),
ICS 4 (lower lung)
Osteopathic Manipulative
Medicine
 Parasympathetic
 Occipitomastoid suture OA/AA, C2 (vagus)
 Organs: bronchial muscle
 Action: constricts bronchial musculature
 Lymphatics
 Medialstinal, supraclavicular nodes
 Impingement sites: Cervical fascia, thoracic inlet, C3-5,
rib motion
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Osteopathic Manipulative
Medicine
 Manual medicine can
involve manipulation of
both spinal and
peripheral joints, fascia,
viscera, the cranium and
facial bones.
COPD & Asthma OMM treatment
Risks of Osteopathic Manipulation
 Transient increase in discomfort, usually related to
restoring motion in an area with decreased range of
motion due to spasm and pain, lasting 6-72 hrs.
 Rib or vertebral body fracture in a frail or osteoporotic
patient.
 Manipulation by a lay person, “bear hug”
 Vertebral artery dissection/CVA (case reports by
Chiropractic manipulation in neck region)
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Benefits of OMM
 Decrease medication use and Physical Therapy
 Superior to conventional treatment & placebo manual
care
 Most efficacious in persons with non-complicated
acute MSK pain, viscerosomatic, somatovisceral
problems.
 Results in less disability & faster recovery
 Greater improvement in pain & activity tolerance
Benefits of OMM
 Valuable as an adjunct to an ongoing exercise program
 Useful in the treatment of upper, middle &
perirespiratory infections, COPD and Asthma, as well
as advanced cardiopulmonary disease, headache, low
back and neck pain.
 Any musculoskeletal injury.
 Useful in constipation, GERD, pelvic floor issues,
cardiac & non-cardiac related chest pain.
CONCLUSION
 There are many scientifically proven and clinically
supported complementary treatment options for our
patients.
 For their benefit we need to be open to these
possibilities in their ability to alleviate discomfort,
facilitate the healing process and prevent disease
sequelae.
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Be Well and Enjoy Life!
References
 Nutritional Medicine by Gaby Nutrition in Clinical
Practice by Katz
 Clinical Nutrition: A Functional Approach by
Lukaczer
 Foundations of Chinese Medicine by Maciocia
 Acupuncture Energetics: A Clinical Approach for
Physicians by Helms
 Textbook of Functional Medicine by Bland
 Directed readings through Integrative Medicine
Fellowship, University of Arizona, College of Medicine
 Foundations of Osteopathic Medicine by AOA, Hruby
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