Treatment • Treatment of Fournier’s gangrene is aimed at stabilizing the thermodynamics of the patients and beginning antimicrobial infection as rapidly as possible cheap quetiapine 200mg overnight delivery symptoms you have cancer. Penile Emergencies Phimosis • Condition in which the foreskin cannot be retracted behind the glans penis • By 3 yr of age buy quetiapine once a day treatment 4 pink eye, 90% of foreskins can be retracted • Fewer than 1% of males have phimosis by age 17 • Usually not painful discount 200 mg quetiapine with visa medications for schizophrenia, but may produce urinary obstruction with ballooning of foreskin • May occur as a result of recurrent balanitis • May lead to chronic inflammation and carcinoma • Treatment in boys older than 4 or 5 yr of age and in those who develop balanitis or balanoposthitis is topical corticosteroids (0. This loosens the phimotic ring in two-thirds of cases and usually allows the foreskin to be retracted manually. Genitourinary Emergencies 153 Paraphimosis • Condition in which the foreskin has been retracted and left behind the glans penis, constricting the glans and causing painful vascular engorgement and edema of the foreskin distal to the phimotic ring. Short-term ice-packing may help as an analgesic or a local anesthetic block of the penis may be indicated in marked discomfort. Reduced paraphimosis should be scheduled for a dorsal slit or circum- cision at a later date, as paraphimosis tends to recur. Balanitis 6 • Inflammation of the glans, which occurs usually as a result of poor hygiene, from failure to retract and clean under the foreskin. Balanoposthitis • Severe balanitis, in which the phimotic band is tight enough to retain inflammatory secretions, creating a preputial cavity abscess. Penile Fracture • Acute tear of the tunica albuginea, presenting with acute swelling, discoloration, and tenderness. Peyronie’s Disease • Condition that results in fibrosis of the tunica albuginea, the elastic membrane that surrounds each corpus cavernosum, producing curvature of the penis during erection. Priapism • Prolonged painful and tender erection that persists beyond or is not related to sexual activity 154 Emergency Medicine • Occurs most commonly in patients with sickle cell disease but can also occur in those with advanced malignancy or coagulation disorders, those on total parenteral nutri- tion, certain drug therapy, and after trauma or idiopathically. An evaluation of the management of periurethral phleg- mon in 272 consecutive cases at the Cook County hospital. Outcome of medical treatment of bacterial abscesses without therapy drainage: Review of case reported in the literature. Clinical and radiological findings in patients with gas forming renal abscess treated conservatively. Percutaneous drainage in the treatment of em- physematous pyelonephritis: 10-yr experience. Evaluation of urethral strictures and associated abnormalities using high-resolution and color doppler ultrasound. Acute bacterial nephritis: A clinicoradiologic corre- lation based on computed tomography. Emphysematous pyelonephritis: Clinicoradiological classification, management, prognosis, and pathogenesis. Acute focal bacterial nephritis: Focal pyelo- nephritis that may simulate renal abscess. Medically sound, cost-effective treat- ment for pelvic inflammatory disease and tuboovarian abscess. Bilateral emphysematous pyelonephritis: A case report and review of the literature. Transvaginal catheter drainage of tuboovarian abscess using the trocar method: technique and literature review. Acute gas-producing bacterial renal infection: Correla- tion between imaging findings and clinical outcome. The protective effects of nitric oxide on the contralateral testis in prepubertal rats with unilateral testicular torsion. A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages. Is the conservative management of the acute scro- tum justified on clinical grounds? Suspected testicular torsion: A survey of clinical practice in North West England. Capsaicin effectively prevents apoptosis in the contralateral testis after ipsilateral testicular torsion. Glucocorticoid hormone can suppress apoptosis of rat testicular germ cells induced by testicular ischemia. Docherty Part A: Selected Obstetric Emergencies Ectopic Pregnancy Definition • Any pregnancy occurring outside the uterine cavity Location • 95% of all ectopic pregnancies occur in the fallopian tubes with 5% being ovarian or abdominal pregnancies. Incidence • Annually 70,000 cases of ectopic pregnancy occur in the United States with a current incidence of 20 ectopics per 1000 pregnancies. Clinical Presentation • Classic triad—Seen in <50% of patients • Abdominal or pelvic pain • Missed menstrual period with associated abnormal vaginal bleeding • Pelvic examination demonstrates a tender adnexal mass • The pelvic pain when it is present is usually unilateral, severe and sudden, although there may be significant variability in quality, intensity, duration and location. Differential diagnosis of ectopic pregnancy • Appendicitis • Salpingitis • Ovarian torsion • Threatened abortion • Gastroenteritis • Urinary tract infection in early pregnancy • Urolithiasis in early pregnancy • Dysfunctional uterine bleeding • Normal intrauterine pregnancy • Corpus luteum cyst • The presence of a palpable adnexal mass or fullness with associated tenderness is present in up to two-thirds of patients however its absence does not rule out the possibility of an ectopic pregnancy. Uterine decidual tissue casts may be passed in 5-10% of patients and can be mistaken for tissue from a spontaneous abortion. In the case of ec- topic pregnancy rupture, peritoneal signs may be present on abdominal examination secondary to hemoperitoneum. In the unruptured ectopic pregnancy, the vital signs are more likely to be normal. Rupture of an Ectopic Pregnancy • Rupture of an ectopic pregnancy is associated with: • syncope • sudden onset of severe pelvic/abdominal pain • hypotension • When an ectopic pregnancy ruptures, there occurs hemorrhage into the peritoneal cavity leading to peritoneal signs. A progesterone level >25 ng/ml is consistent with a viable intrauterine pregnancy with a 97. Lower levels however do not reliably correlate with the location of the patient’s pregnancy. Initial values may be normal, however a low Hg/Hct initially or an acute drop over the first several hours is concerning when considering the possibility of ectopic pregnancy in your differential diagnosis. May be helpful for identifying other potential entities in your differential diagnosis once ectopic pregnancy has been ruled out. The possible options are laparoscopy with appropriate surgical intervention if an ectopic pregnancy is identified. Indications for methotrexate usage in ectopic pregnancy • Ectopic pregnancy unruptured and <3. The procedure is done by aspiration of the con- tents from the pouch of Douglas entered by way of the posterior fornix. The aspira- tion of nonclotting blood is considered a positive test that is suspicious for ectopic pregnancy. Vaginal Bleeding in the First Half of Pregnancy Forty percent of pregnant patients present with some degree of vaginal bleeding 7 during early pregnancy. The vast majority of these spontaneous abortions occur prior to 8 wk of gestation. At least half of all spontaneous abortions are due to genetic abnormali- ties; the rest being due to a combination of factors such as uterine abnormalities, incompetent cervix, progesterone deficiency, tobacco or alcohol use. Once again, one must always consider ectopic pregnancy in the differential when evaluating the pregnant patient with vaginal bleeding. The patient with unilateral pelvic pain and vaginal bleeding needs thorough evaluation to differentiate early abortion from ectopic pregnancy.
It is to be anticipated cheap quetiapine online master card symptoms 3 weeks into pregnancy, homeopathic and/or nutritional approaches; therefore proven 200 mg quetiapine conventional medicine, that aspects of the sequencing buy quetiapine 300 mg low cost medicine urinary tract infection, as described physical/structural methods including therapeutic below, will modify and change as these ideas are exercise, manipulation, massage, etc. Tonify weakened systems tions, embracing the principles outlined above, sug- Many systems and modalities have system-speciﬁc gesting that in treating people who are ill it is (or may strategies (botanical, homeopathic and/or nutritional be) necessary to follow a model of care as laid out in approaches; physical/structural methods including Box 1. Examples of objectives therapeutic order are to: The concepts expressed in the naturopathic therapeu- • strengthen the immune system tic order are derived from Hippocrates’ writings and • decrease toxicity those of medical scholars, nature doctors and naturo- • normalize inﬂammatory processes pathic physicians concerning the function and activa- • optimize metabolic function tion of the self-healing process. The recognition of a • balance regulatory systems sense of order in the healing processes, and in the • enhance regeneration selection of therapeutic and restorative practices, has • harmonize with the life force. Prescribe speciﬁc natural substances: clinical theory, and has evolved to recognize the Appropriate modalities or interventions. Prescribe speciﬁc pharmacological or therapeutic order and its accommodation to patient synthetic substances: Appropriate modalities or individuality. Use higher force interventions: Examples are force, although all modalities can be found within the surgery, suppressive drugs, radiation, chemotherapy various steps and stages, depending on their applica- and other approaches. The spiritual aspect of the patient’s health is considered to begin with Step 1 (Pizzorno & Snider Note: The actual therapeutic order may change depending on the 2004). The philosophy represented in the naturopathic therapeutic order does not determine what modalities are ‘good or bad’, useful or useless. Rather, it provides a clinical framework for all modalities, used in the order consistent with that of the natural self-healing process. Benedict Lust’s magazines: Herald of Health and The therapeutic order schematically directs the The Naturopath’ (Zeff et al 2006). These publications naturopathic practitioner’s therapeutic choices in an displayed the prodigious writings of Lust, but did not efﬁcient order, based on individual patient needs and contain a comprehensive and deﬁnitive statement of priorities for safe and effective care, rather than using either philosophy or clinical theory. It is this common philosophy that all natural therapies fell under the purview of and theory that both distinguishes the ﬁeld of modern naturopathy. As none of stability/instability/vulnerability of the area these agents of rejuvenation can cure every disease, the and tissues affected, the individual’s nutritional Naturopath rightly employs the combination that is status, the surface onto which the fall occurred best adapted to each individual case. Kirchfeld & Boyle 1994) • In simple cases, addressing the acute strain or There were also several other deﬁning texts used by break would probably be sufﬁcient – the emerging profession. These included: immobilizing and possibly compressing the damaged tissues, use of ice, elevation, etc. Such spatial thinking – which mirrors attention to the basics of diet, dress, exercise, much naturopathic clinical decision-making – may rest, etc. Elementary remedies – water, air, light, problems, avoiding naive cause–effect (and ‘cure’) electricity considerations. Chemical remedies – botanicals, homeopathy, considerations with speciﬁc reference to naturopathic etc. These books presented the physical medicine somewhat opposing perspectives of the more A central concept that distinguishes naturopathic science-based, or ‘green allopathic’, and the physical medicine from other forms of manual medi- purist ‘nature cure’ camps. Naturopathic physical medicine: For example, an individualized protocol combining – as appropriate to the person involved and their • is the practice of physical medicine, in the current condition – mind–body approaches/ context of naturopathic medicine stress management (Berman & Singh 1997, Lundgren • integrates both scientiﬁc knowledge in physical & Stenstrom 1999, Stevens 2005), nutritional strategies medicine and the principles of naturopathic (Egger et al 1983, Gottlieb 1997, Maheu et al 1998), medicine into a distinct approach to physical use of botanical substances (Ernst & Chrubasik 2000, medicine practice. Mills et al 1996), manual methods (Bonfort 1999, Brat- tberg 1999, Garﬁnkel et al 1994; see Chapters 7 and 8), Core components exercise and education (Fitzcharles et al 2006, Gowans et al 1998; see Chapter 9), acupuncture 1. A respect for the traditional and empirical and/or moxibustion (Berman et al 1999, Ernst & naturopathic approach to knowledge of the White 1998), hydrotherapy (Evcik et al 2002, physical aspect of the human being in health Faull 2005, Mannerkorpi et al 2000; see Chapter 11) and disease. Recognition of the value of individualization Chapter 12) can be signiﬁcantly beneﬁcial in treat- of therapy and constitutional needs. A concentration on holistic diagnosis and the back pain, migraine, ﬁbromyalgia and degenerative interaction of all bodily systems. In an athletic (or any other) injury setting the need to consider both the context and all aspects of the The meaning of symptoms individual and the injury event becomes obvious. Within the framework of naturopathic thinking there Crown et al (1997) have observed: exists an appreciation that symptoms are frequently evidence of self-regulation in action – to be under- Both extrinsic and intrinsic factors can increase the stood, respected, assisted and possibly modulated if risk of injury. Extrinsic factors include training errors, excessive (inﬂammation is a clear example) – and faulty technique, poor environmental conditions, ideally not to be suppressed (Lindlahr 1913). Intrinsic factors Pain, arguably the most common symptom of all, include biomechanical deﬁciencies including epitomizes the need to understand the sources and malalignment of limbs, muscular imbalances, mechanisms involved, and the processes associated degenerative processes, and other anatomical factors. Merely suppressing A fuller list of additional factors might also include pain without such understanding, and where possible nutritional imbalances, past and present pathological the taking of appropriate action to relieve symptoms processes, adaptive changes to previous injury or and remove causes, is a prescription for chronicity. Pain may represent: Speciﬁc examples will be offered in later chapters, • a warning (hand touches a ﬂame) emphasizing the naturopathic approaches to such • a caution not to move the area (due to a tear, common features as restriction and pain, as well as a break or a process of degeneration) the wider range of conditions that are treated using naturopathic physical medicine approaches. Amongst the most widely beneﬁcial manual methods Understanding the processes involved in the pro- of treatment commonly incorporated into naturo- duction and maintenance of pain (or other symptoms) pathic care is traditional massage therapy, which has Chapter 1 • Physical Medicine in a Naturopathic Context 15 been shown in numerous research studies to have chamomile infusions, or by taking mastic capsules or value in the care of conditions as diverse as preg- probiotics. The concept of tolle in Massage Therapy Research (2006) by Tiffany Field causum (identify and treat the cause, as discussed PhD, of the Touch Research Institute, University of earlier in this chapter) requires further evaluation if a Miami Medical School. Examination from a naturopathic physical medicine perspective may reveal facilitated mid-thoracic spinal Osteopathic and chiropractic treatment segments (see Box 2. McKenzie rehabilitation exercises and supportive It is worth emphasizing at this point that the (‘unloading’) taping methods, are all suitable for causes of disease and dysfunction, as perceived use in a naturopathic practice (see Chapter 7). The broad scope of ‘causes’ will be more fully outlined in relation to speciﬁc conditions in Chapter 10. Are all ‘natural’ modalities necessarily • An inclusive assessment should be made of, naturopathic? Non-naturopathic manual methods This points to the fact that the same modality may be used either allopathically or naturopathically – Examples of manual medicine approaches that offer depending largely on the context in which it is short-term gain, without consideration of the context employed, the intent behind its use and the condition out of which the symptoms have emerged, can be of the person to whom (as well as the tissues to which) described for almost all modalities. However, these statement as to what constitutes manipulative methods will not be being employed naturopathically therapy as viewed from a naturopathic unless the causes of the individual’s health problems perspective). This would be This suggests that much that is currently done in seen as offering a naturopathic solution to a massage therapy, chiropractic, osteopathic and physi- problem if used as part of a comprehensive cal therapy settings may fail to meet the basic naturo- approach to the needs of the tissues and the pathic requirements of dealing with the whole person person. If naturopaths mimic symptom-oriented approaches in dealing with mus- • The same thrust, utilized without recourse to culoskeletal dysfunction they are not living up to the prior soft tissue treatment (which may well core principles on which their profession is based. Medicine is: reduced self-regulatory potential) • the science of diagnosing, treating, or preventing • Leading to acute and chronic illnesses, toxicity. Practicing a system of medicine (as opposed to a • Diagnoses somatic dysfunction – circulatory/neural/ therapy, modality or technique) requires an established lymph effects. Treatment of Therapies and techniques are open for all practitioners immune and organ dysfunction. Australian States • Physiotherapy is concerned with human function and limit spinal manipulation to registered medical movement, maximizing potential. Traditional Chinese Medicine and Ayurvedic medicine Biomedicine • Identify constitutional types with imbalanced energy as Features of the biomedical profession: a feature of ill-health. Case example The use of many physical medicine techniques by a A 42-year-old male presented with mid-thoracic pain and practitioner of biomedicine may be limited by the stiffness following increased manual labor. Most of the uncertain answers to the questions: seven practitioners from the listed professions utilized • What is the condition?
The pressure exerted to hold the pencil needs to be This ﬁrst sign of resistance is the point at which the constant so you can extend your perception to [the] mechanical properties of the tissue reach the end of pencil tip and thereby control the complex task of their easy elasticity order quetiapine with a visa 9 medications that can cause heartburn. This can easily be missed if the of the saw 300mg quetiapine with visa medicine 031, a machinist’s to the end of a wrench cheap 300mg quetiapine overnight delivery medications xanax, a searching digit moves too rapidly or too heavily. Introduction • The contact between the examiner’s hands and the Examiners should always strive to use the least amount patient’s body should be as broad as possible (i. When • The hands should increase pressure slowly, move palpating deeper structures, it is more difﬁcult to slowly, and transition from one area to another slowly. This exercise allows the student to In learning to trust that the examiner will be gentle and experience palpation of a deep structure (the psoas not perform any unexpected movements, the patient muscle in the abdomen) and pay especially close will relax and allow for easier access to deeper attention to the amount of pressure applied. Examiner’s mind • Visualizing the structures being palpated can be very General tips for making palpation easier and helpful. Mental tension can be patient to be tense or guarded, palpation and therapy decreased by ﬁrst noticing its presence, slowly taking are impeded. The air should be warm enough for the the hands off the patient’s body, taking two or three patient to stay warm with skin exposed. Attention must deep breaths, shaking and softening the hands, and be paid to noise and light. Blankets and an eye mask gently, slowly, replacing the hands on the patient’s are useful. Patient positioning Practical exercise: palpating the psoas • The patient should be well-supported with pillows, in the abdomen bolsters, etc. Note: This exercise should not be performed on anyone • A comfortable, stable treatment table of adequate with inﬂammatory bowel disease or a history of width is essential. The This exercise should take about 10 minutes for a novice examiner should not be reluctant to ask the patient to palpation student to complete. Patient position • When palpating deeper structures, position the Supine with the abdomen exposed, the knees and hips patient so that more superﬁcial muscles are passively slightly ﬂexed by propping the knees on a bolster or shortened. This position puts slack in the abdominal and soften them so that palpating through them is easier. Standing at the side of the table at the level of the umbilicus or slightly inferior to the umbilicus, facing the Examiner positioning patient. The examiner should be positioned to easily reach the Procedure structures being palpated, to minimize tension in the body. A good rule of thumb is that at all times the examiner’s The examiner begins by simply placing the hands on the umbilicus should directly face the area being examined. This makes the • The examiner’s hands should be relaxed but engaged contact broad and comfortable for the patient. With very gentle pressure Note: If the examiner feels a sensation of pulsation deep and small circular movements of the hands, the in the abdomen where the psoas muscle should be, the examiner glides the skin over the underlying tissues. The examiner should The examiner gently increases pressure, enough to gently but immediately release the palpating pressure slightly depress the anterior abdominal wall toward the and the exercise should be stopped. At the lateral explored its characteristics, pressure should be border of the rectus a deﬁnite softening of the anterior decreased very slowly and steadily until contact with the abdominal wall will be noted. Having the patient psoas is securely contacted again, at which time raise the head and shoulders off the table will increase variations in tone may be noted, synchronous with the tone of the rectus, making it easier to identify. The psoas muscle and palpation of the soft, homogeneous direction of pressure should be medially and posteriorly viscera. The examiner can spend a few moments through the abdomen, toward the anterior surface of the investigating this transition before decreasing the pressure patient’s spine. The examiner will ﬁrst feel the oblique and transverse With pressure heavy enough to palpate the viscera but abdominal muscles. These will feel elastic and ﬁbrous, too light to directly contact the psoas, the examiner may and will offer some resistance. This resistance is best still sense the tone and texture of the psoas muscle overcome by maintaining a slow, steady increase in beneath by moving the ﬁngertips medial and lateral (i. The pressure is increased not by increasing perpendicular to the grain of the psoas muscle ﬁbers). This is the tissue of the abdominal again moves the ﬁngertips across the grain of the psoas. This tissue will often be quite tender, and the There is still the possibility of sensing the ﬁrm tone, patient is probably not accustomed to deep pressure rounded shape and ﬁbrous texture of the muscle even on the abdomen. Simply maintaining steady pressure, though direct contact with the muscle has been or decreasing pressure slightly before slowly deﬁnitely lost. Visualization of the muscle is of enormous increasing it again, will help the patient to relax into value during this part of the exercise. This procedure continues with the examiner slowly and The examiner slowly increases pressure until a ﬁrm incrementally decreasing pressure, holding onto the tissue is reached. This is the anterior surface of the mind’s visual picture of the muscle, and working to psoas muscle and will most likely be very tender. This is done until Maintaining this deep pressure, the examiner moves the the examiner can no longer sense any trace of the ﬁngertips across the ﬁbers of the psoas, slowly, to get a muscle’s ﬁrmness or texture. This ﬁbrous investigate this transition place – where the muscle is texture, along with the ﬁrmness of the muscle, absolutely no longer palpable. Having the The examiner should then very slowly decrease pressure patient brieﬂy ﬂex the hip will increase the tone of the until the hands are simply resting on the patient’s psoas, conﬁrming that this is what is being palpated. The examiner should create a visual picture of the Thank your palpation partner and switch roles. The way the tissues respond when the barrier is released can also offer information. Both are capable of being employed in therapeutic How we make sense of what we feel when palpating settings to treat localized dysfunction (such as myo- has been researched, as have issues of sensitivity fascial trigger points – see Chapter 7) as well as and interpretation. Some of these were discussed in in more general, whole-person applications (see Box 6. Note: It is worth keeping in mind that palpation and assessment, when performed improperly (heavy handedly, clumsily, too rapidly, too persistently, etc. A small spring-loaded, rubber-tipped, pressure thresh- Such action would not be in line with the tenets of old meter (algometer) can be used to measure the naturopathy – ﬁrst do no harm. When treatment has been successful, the pres- a short space of time, deﬁnite changes occur that may sure threshold over the trigger point should increase distort the ﬁndings – for example, in the ﬁring markedly (Fig. Here the hand is stationary and (the cream is to ensure that no dragging occurs on only the thumb moves. Reproduced with permission from Chaitow (2003b) from Chaitow (2003b) Continued 136 Naturopathic Physical Medicine Box 6. Reproduced with permission • If trigger points are located, their target (referral) area from Chaitow (2003b) should also be noted (trigger point assessment is described below). Reproduced with permission from Chaitow (2003b) A B 138 Naturopathic Physical Medicine cephalad than the right. The pelvis will roll passively easier to the right than to the left because the lumbar spine is side-ﬂexed left and rotated right. The left infraclavicular parasternal area is more prominent anteriorly, because the thoracic inlet is side-ﬂexed right and rotated right. Tissue preference is the sense that the palpating hands derive from the tissues being moved, as to the preferred direction(s) of movement (for example, at its simplest, ‘this area turns more easily to the right than the left – and therefore has a “preference” to turn right’).
Breathing rehabilitation and anxiety states: In one symptoms purchase genuine quetiapine on-line medications ibs, and their intensity: constriction in the study (Lum 1987) more than 1000 anxious and chest cheap 300 mg quetiapine overnight delivery symptoms of colon cancer, shortness of breath purchase quetiapine 50mg line medications not to take when pregnant, accelerated or deepened phobic patients were treated using a breathing, inability to breathe deeply, feeling tense, combination of breathing retraining, physical tightness around the mouth, stiffness in the ﬁngers or therapy and relaxation. Symptoms were arms, cold hands or feet, tingling ﬁngers, bloated usually abolished in 1–6 months, with some abdominal sensation, dizzy spells, blurred vision, younger patients requiring only a few weeks. Breathing retraining and anxiety disorders: In Physical medicine therapeutic measures another study (Han et al 1996) the effects of for symptoms linked to anxiety states breathing retraining were evaluated in patients • Physical medicine approaches aimed at with hyperventilation syndrome in which most normalization of breathing pattern disorders of the patients met the criteria for an anxiety include selective use of many of the modalities disorder. After breathing therapy, computer monitor, results are commonly more the sum scores of the Nijmegen rapid. Reproduced with permission from Chaitow et al (2002) • Psychotherapy, counseling and stress management cures the patient. The asthmatic is condemned to a life can also usefully be combined with the of medication. Concepts and methods as outlined in the previous • Nutritional strategies require attention to section on anxiety, insofar as they relate to respiratory maintenance of a stable blood-sugar status, as well as function, can therefore be applied in full to patients to replenishment of potentially unbalanced nutrients with asthma, as well as to individuals whose breath- such as calcium, magnesium and potassium. It is thus a or two to complete), such individuals could be recog- matter of individual preference whether the clinician nized and helped towards normality by simple means calls such cases asthma or hyperventilation. The instructions involve A Cochrane systematic review (Hondras et al 2005) focus on breathing in through the nose (slowly has been conducted to evaluate the evidence for the if possible) and then exhaling slowly (taking 4– effects of manual therapies (such as massage, chiro- 6 seconds) through pursed lips (‘kiss position’, practic, physiotherapy) for treatment of patients with as though blowing a balloon). The beneﬁts include insufﬁcient evidence to support, or refute, the use of slowing the breathing rate, increased amount manual therapies for patients with asthma, and that of air movement through the lungs (‘tidal air’), there is a need to conduct adequately sized random- so improving oxygen supplies to the blood and ized controlled trials that examine the effects of producing an anti-arousal effect (Cappo & manual therapies on clinically relevant outcomes. Studies that support the use of manual methods in treatment of asthmatics (alongside the nutritional, • Buteyko breathing and asthma: The Russian botanical, pharmacological and other strategies that Buteyko rehabilitation method uses exercises may assist self-regulation to operate more efﬁciently) that include variations of controlled breathing, include the following: including pursed-lip breathing. Daily practice of this • Soft tissue manipulation and asthma: Studies have is recommended in which the breath is slowly demonstrated that soft tissue manipulation can exhaled, and then held out for as long as is improve movement of the chest, increase the comfortable, followed by breathing shallowly ﬂow of air, and generally ease the symptoms of (i. An Australian study of this osteopathic methods) can signiﬁcantly relax the method, involving 39 patients, resulted in respiratory muscles and mobilize the spine and reduced steroid medication usage and ribs. Many osteopaths and chiropractors, as signiﬁcantly improved breathing function in well as those physiotherapists who are trained asthma patients (Bowler et al 1998). For example, 3 manipulative attention to the upper thoracic months of chiropractic manipulation (involving spine (to the ﬁrst four or ﬁve vertebrae just 20 treatments sessions) was shown to reduce below the neck) and to the ﬁrst joint of the the symptoms of persistent childhood asthma, neck (occipitoatlantal joint) can inﬂuence the with beneﬁts still present a year after treatment activity of the vagal nerve, relax the ceased (Bronfort et al 2001). Nevertheless, there diaphragm, and help to ease asthma seems to be a consensus that although quality symptoms. When the sympathetic nervous of life and bronchodilator use have been system is in an ‘alarm’ phase (as it is likely to demonstrated, there is currently not sufﬁcient be when someone is stressed or anxious), evidence to support the use of chiropractic as a breathing becomes more rapid, and shallower, primary treatment for asthma (Balon & Mior and asthma symptoms increase. However, there is some evidence nerve controls the parasympathetic nerve suggesting that chiropractic care, in conjunction supply to the diaphragm (among other things) with standard medical treatment, may be of and stimulation of this nerve, by careful value (Gibbs 2005). The author notes: manipulation of the area, has been shown to Three cases of asthma where patients, being help normalize the excessive degree of treated by conventional pharmacological means, sympathetic activity that accompanies asthma had chiropractic manipulation administered to the (Szentivaneji & Goldman 1997). Objective measurements were collected anti-arousal, yoga-type diaphragmatic using a peak ﬂow meter and subjective data using breathing exercises have been shown to be very an asthma speciﬁc questionnaire. Naturopathic clinicians should be aware of this • Hydrotherapy and asthma: The effect on 25 inﬂuence when prescribing exercise and when inform- patients with bronchial asthma (10 male, 15 ing asthmatic female patients of times when particu- female, mean age 60 years) of complex spa lar attention to breathing retraining should be therapy (swimming training in a hot spring considered. Physical symptoms and respiratory Exercise-induced asthma is a well-known phenome- system function improved signiﬁcantly after non (Caffarelli et al 2005) that can lead to an avoidance spa therapy. Instead of this course of (in)action, complex spa therapy improves psychological education should be offered as to the value of sub- factors in patients with bronchial asthma maximal exercise. It is not known had been on long-term corticosteroid therapy whether improved ﬁtness is translated into before spa therapy. Exercise, asthma and the menstrual cycle • Submaximal exercise and asthma: To investigate In the previous section on anxiety it was noted that the effects of regular submaximal exercise on progesterone is a respiratory accelerator, making the quality of life in children with asthma, exercise postovulation (pre-period) segments of the cycle a capacity and pulmonary function of 62 children time when symptoms emerging from breathing with mild/moderate asthma were evaluated. The exercise group ing the effects of these cyclical phases on female underwent a moderately intensive basketball athletes, have conﬁrmed this connection. This study groups, but symptom scores improved only in demonstrates that menstrual cycle phase is an impor- the exercise group. All 21 participants were found to be physically active in daily life, less limited by their disease, and better able to control their Cardiovascular disease asthma, irrespective of whether they were Manipulation and cardiovascular health adherent with exercise recommendations or Segmental spinal changes and heart disease not. The study ﬁndings suggest that physical activities in daily life are sufﬁcient to maintain Beal (1983) has noted that it is almost always possible a good physical condition (Emtner & Hedin to predict that cardiovascular disease is present (or is 2005). The results showed a reduction in use Burns (1943) has also explained this phenomenon as of drugs and improved breathing function, resulting from afferent stimuli, arising from dysfunc- which was still apparent 4 years after the study tion of a visceral nature. The Sahaja yoga does have limited beneﬁcial effects stimuli are then conveyed to sympathetic and motor on some objective and subjective measures of efferents, resulting in changes in the somatic tissues, the impact of moderate to severe asthma such as skeletal muscle, skin and blood vessels. Abnormal stimulation of the visceral efferent neurons • Diet therapy, yoga and asthma: 37 asthmatic may result in hyperesthesia of the skin, and associated patients (19 men, 18 women) were involved in vasomotor, pilomotor and sudomotor changes. Similar a study in which yoga therapy was combined stimuli of the ventral horn cells may result in reﬂex with ‘a non-pharmacological approach of rigidity of the somatic musculature. The various parameters, to produce such changes will differ, because factors including lung function test, were measured on such as prior sensitization of the particular segment, admission and once a week. The patients reported a cases, viscerosomatic reﬂex activity may be noted feeling of well-being, freshness and before any symptoms of visceral change are evident, comfortable breathing (Sathyaprabha et al and that this phenomenon is therefore of potential 2001). The ﬁrst signs of viscerosomatic reﬂexive inﬂuences are vasomotor reactions (increased skin temperature), Physical medicine therapeutic sudomotor (increased moisture of the skin) and skin measures for asthma textural changes (e. There involving the diaphragm and upper thoracic region, is value in using light skin palpation for identiﬁcation offers beneﬁts to asthmatics. Deep musculature may become hard, The osteopathic physician must try to restore normal tense and hypersensitive. This may result in deep physiologic motion in the upper thoracic and lower splinting contractions, involving two or more seg- cervical areas, since these are the sites of origin of the ments of the spine, with associated restriction of spinal sympathetic innervation supplying the coronary motion. Such changes by affecting the sympathetic ganglia, affect the would be readily identiﬁable using neuromuscular sympathetic motor supply to the cardiac plexus. Since the parasympathetic supply to the More on the facilitated segment cardiac plexus is via the vagus, somatic dysfunction in Patterns of somatic response will be found to differ this area, from the atlanto-occipital area, through the from person to person, and to be unique, in terms of cervical region, and into the upper dorsal junction, can location, the number of segments involved, and have adverse effects on vagal innervation and thus on whether or not the pattern is unilateral or bilateral. The degree of intensity will also differ, and is related to the degree of acuteness of the visceral condition Another reason for uneven heart rhythm can be the (Hix 1976). Jarmel (1989) explains that: cardiac symptoms) As far back as 1948, mainstream medical journals Disturbances in sympathetic and parasympathetic were reporting the phenomenon of pseudo-coronaries regulation of the heart are associated with increased and pseudo-angina (Davis 1948). Destabilizing of angina where the symptoms did not derive from neural input to the vagus and cardiac sympathetic the cardiovascular system, but were musculoskeletal nerves may originate from mechanically irritated in origin. Asymptomatic spinal joint dysfunction can affect the autonomic nervous system • Hyperventilation and pseudo-angina: Angina-like and may activate potent somato-cardiac reﬂexes. Such these articulovisceral reﬂexes may have beneﬁcial stress-induced changes can occur during effects in decreasing vulnerability to sudden cardiac hyperventilation, which frequently have death. One study suggests up to 90% of non-cardiac chest Congestive heart failure pain can be brought on by hyperventilation syndrome and other breathing pattern Structural changes and cardiovascular disease disorders (De Guire et al 1992). It is therefore Stiles (1977) observes, in relation to individuals with important that chest pain associated with congestive heart failure, that once the condition has breathing pattern disorders such as been stabilized, physical evaluation and treatment hyperventilation are investigated, so that heart should focus on the rib cage to ensure optimal dia- disease can be excluded as a diagnosis, and phragmatic function, as well as the region of ribs 1, 2 breathing rehabilitation started (see below and and 3, where the thoracic duct joins the internal discussion of breathing pattern disorders in jugular and subclavian veins. This is much more common treatment of trigger points by lidocaine in women than in men (Kumar & Clark 1998, injections, as well as massage, hydrotherapy Nakao et al 1997). One series of also identiﬁed the costovertebral joints as a 164 such cases of pseudo-angina were reported, source of back pain and/or pseudo-angina, with all patients experiencing angina which may be ameliorated by spinal symptoms as well as neck pain, headaches and manipulation.