Pneumonia is one of the top ten leading causes of death in the U.S. Osteopathic manipulative techniques (OMT) may be utilized as an adjunctive therapy in the treatment of pneumonia to enhance biomechanical and immune function; and ultimately, to reduce hospital stay, duration of antibiotics, incidence of respiratory failure, and mortality. In this video-article, we will review randomized controlled studies on the use of OMT in pneumonia patients, as well as demonstrate specific hands-on techniques that are routinely practiced by osteopathic physicians when treating pulmonary infections.
Pneumonia, the inflammatory state of lung tissue primarily due to microbial infection, claimed 52,306 lives in the United States in 20071 and resulted in the hospitalization of 1.1 million patients2. With an average length of in-patient hospital stay of five days2, pneumonia and influenza comprise significant financial burden costing the United States $40.2 billion in 20053. Under the current Infectious Disease Society of America/American Thoracic Society guidelines, standard-of-care recommendations include the rapid administration of an appropriate antibiotic regiment, fluid replacement, and ventilation (if necessary). Non-standard therapies include the use of corticosteroids and statins; however, these therapies lack conclusive supporting evidence4. (Figure 1)
Osteopathic Manipulative Treatment (OMT) is a cost-effective adjunctive treatment of pneumonia that has been shown to reduce patients’ length of hospital stay, duration of intravenous antibiotics, and incidence of respiratory failure or death when compared to subjects who received conventional care alone5. The use of manual manipulation techniques for pneumonia was first recorded as early as the Spanish influenza pandemic of 1918, when patients treated with standard medical care had an estimated mortality rate of 33%, compared to a 10% mortality rate in patients treated by osteopathic physicians6. When applied to the management of pneumonia, manual manipulation techniques bolster lymphatic flow, respiratory function, and immunological defense by targeting anatomical structures involved in the these systems7,8, 9, 10.
The objective of this review video-article is three-fold: a) summarize the findings of randomized controlled studies on the efficacy of OMT in adult patients with diagnosed pneumonia, b) demonstrate established protocols utilized by osteopathic physicians treating pneumonia, c) elucidate the physiological mechanisms behind manual manipulation of the respiratory and lymphatic systems. Specifically, we will discuss and demonstrate four routine techniques that address autonomics, lymph drainage, and rib cage mobility: 1) Rib Raising, 2) Thoracic Pump, 3) Doming of the Thoracic Diaphragm, and 4) Muscle Energy for Rib 1.5,11
Children, elderly individuals, and immunocompromised patients are especially susceptible to pneumonia. Patients may present with fever, cough, dyspnea, tachypnea, tachycardia, sputum production, pleuritic chest pain, nausea, vomiting, diarrhea, and fatigue4. Clinical chest examination may reveal dullness to percussion and crackles upon auscultation over the affected lung12. Laboratory results may show a leukocytosis with left-shift, as well as an increase in erythrocyte sedimentation rate and C-reactive protein4. Tests to elucidate the specific causative microbe include the urine antigen test, polymerase chain reaction, sputum analysis, and blood culture4. Finally, radiographic imaging, which serves as the gold standard for diagnosis, may display consolidation or inflammatory changes over the various lobes of the lungs12. While no specific algorithm or constellation of symptoms have consistently proven to establish the clinical diagnosis of pneumonia, temperature > 100º F and abnormal breath sounds (rales or rhonchi) are generally accepted as criteria for ordering a chest x-ray or sputum sample13. Additionally, the Pneumonia Severity Index (PSI) and CURB-65 criteria have been proven to accurately predict mortality in pneumonia patients.14, 15
Once the diagnosis of pneumonia has been confirmed, traditional standard-of-care management should be administered. For patients in a stable condition, osteopathic evaluation and adjunctive treatment may be beneficial and should be considered.
In addition to being fully-licensed to practice conventional medicine, osteopathic physicians utilize a multi-step holistic approach to diagnosis and treatment that improves structure, function, and the body’s intrinsic ability to heal. Management begins with taking a standard history and performing a physical exam. If necessary, laboratory and imaging studies are conducted. An osteopathic structural exam is then performed, which includes an evaluation and assessment of the following parameters which are beyond the scope of this article: presence of segmental and regional restrictions of motion, thoracic cage immobility, muscle spasms, tenderpoints, viscerosomatic reflexes, Chapman’s points, lymphatic obstructions, autonomic abnormalities, and structural irregularities. The patient then receives hands-on manipulation aimed at addressing any specific dysfunctions, in addition to standard-of-care treatment protocols. Finally, reassessment is performed in order to evaluate the efficacy of intervention.
Literature Review
Our initial inclusion criteria were randomized controlled trials (RCTs) indexed in PubMed studying the efficacy of OMT on adults (> 18 years old) diagnosed with community-acquired pneumonia. We searched PubMed for “osteopath* pneumonia randomized controlled trial”, which yielded a return of six articles. Of these results, three fit the scope of the inclusion criteria.
Because of the limited number of RCTs on the efficacy of OMT in pneumonia patients, we expanded our inclusion criteria to include studies on the efficacy of another manual, non-pharmacologic, adjunctive therapy used in the treatment of pneumonia, namely chest physiotherapy. Chest physiotherapy is defined as a set of techniques designed to improve respiratory efficiency by promoting expansion of the lungs, strengthening respiratory muscles, and eliminating secretions from the lungs16. Chest physiotherapy includes techniques such as percussion and postural drainage along with coughing and deep breathing exercises, which are indicated for the management of pneumonia17. It is clear that the ideal goal of chest physiotherapy is similar to OMT in that both of these manual modalities assist in decreasing the work of breathing and promoting lung expansion. This, it was logical for us to expand our search to include chest physiotherapy.
We then searched PubMed for “physiotherapy pneumonia randomized controlled trial”, which yielded a return of 59 articles. Of these results, three additional studies fit the scope of the inclusion criteria.
When combining the two searches, a total of six RCTs fit our criteria for inclusion. These RCTs are described below, summarized and displayed in Figures 3-4:
Osteopathic medicine, when applied to pneumonia patients, aids in restoring health by encouraging normal circulation and immunological function. This is achieved in three sequential steps: removal of dysfunctions obstructing drainage, maximization of respiratory function, and augmentation of flow through lymphoid tissue26. The roles of the lymphatic system include: balancing the composition of interstitial fluid, transportation of excess substances, distribution of immune cells from lymphoid tissues to systemic circulation, and filtration and removal of foreign material from interstitial fluid.
Literature suggests that techniques targeting lymphatic flow are advantageous for treatment of pneumonia by way of altering pressure differentials in the thoracic diaphragm26, improving respiratory function31,32, enhancing antibody response7,33, reducing edema34, activating autonomic-mediated intrinsic lymphatic contractility28, and increasing the abundance of white blood cells in peripheral blood8. Lymphatic pump techniques have been shown to increase cytokines and chemokines in thoracic and intestinal lymph vessels35, while mechanical pressure to certain body regions distant from the location of lymph formation enhances flow into lymphatic systems36. In addition, it has been shown that lymphatic OMT augments leukocyte mobilization and flow in dogs and rats, primarily from gut-associated lymphoid tissue37,38,39,40,41.
Contraindications to performing OMT include osseous fractures, thrombotic events, certain stages of carcinoma, and bacterial infections with a current temperature over 102 degrees Fahrenheit. Osteopathic manual manipulations should only be performed by trained osteopathic physicians. If the physician has difficulty performing the techniques described, we suggest re-positioning and/or further examination of the patient for additional structural abnormalities.
In practice, clinicians may utilize various modifications of the techniques described. For example, a similar version of the rib raising technique can be performed while the patient is supine. In this arrangement, the physician should use the finger-pads of both hands to contact the patient’s rib angles. Utilizing the metacarpophalangeal joints and the treatment table as a fulcrum, the physician should pull laterally by leaning back. This position should be held until a release is felt, then repeat the steps in other areas of the ribs. A modification to the thoracic pump technique involves providing vibratory compressions to the rib cage during patients’ exhalation phase.
In conclusion, we believe that OMT is a valuable adjunctive tool in the treatment of pneumonia. We reviewed established protocols by discussing the steps, mechanisms, and physiologies associated with these therapies. Armed with a better understanding of these techniques, we hope that more physicians will opt to incorporate osteopathic principles into infectious disease protocols.
The authors have nothing to disclose.
The authors would like to thank the entire New York Institute of Technology College of Osteopathic Medicine’s Department of Osteopathic Manipulative Medicine. This project is funded by the Department of Osteopathic Manipulative Medicine at the New York Institute of Technology College of Osteopathic Medicine.