I had the opportunity to learn from a young patient with asthma recently. Although it is not his real name, I will refer to him as Bill. Bill is African-American, bright, athletically built and currently in middle school. He has taken a number of different asthma meds, none of which achieved the miraculous results of making his asthma go away, but all of which have helped to some degree. He currently takes Flovent.
When Bill presented to the office he was having some difficulty breathing. I could see the fear in his eyes that I have noticed is common when a person is having difficulty taking in enough air. I worked with his pediatric nurse practitioner (PNP) to get a baseline peak flow before treatment of any type. The result was 350. Rather than give the inhaler right away, I asked Bill if I could treat him first and that we could use the inhaler if the treatment did not work. He agreed.
I screened Bill out to look for the place to begin. I noted the rib cage was the place that had the most restricted somatic dysfunction. I treated in order:
1) Left rib 1 expired – functional method.
2) Angle of Louis (the joint between the manubrium and the sternal body) – functional method.
3) Right rib 4 transversus thoracis muscle – direct inhibitory pressure combined with muscle shortening.
4) Left rib 2 transversus thoracis muscle – direct inhibitory pressure combined with muscle shortening.
5) Right ribs 3-10 expired – muscle energy.
6) Respiratory diaphragm – myofascial release with respiratory assist.
After each of the above numbered treatments, I would ask Bill to take a deep breath. With each breath he took, I could hear ribs audibly “pop” as they were able to return to their normal articulations. As the treatment progressed, I also noticed that Bill’s fear was diminishing rapidly, that his respiratory rate was not as rapid and that his chest wall movement was noticeably improved. Bill and I were both satisfied that the treatment had resolved his symptoms and that he did not need to use his inhaler at this time.
We talked for a few moments before retesting his peak flow. I was anticipating a wonderful improvement. I felt like I had worked with Bill to achieve at least today’s resolution of his symptoms. Everyone around him could see that he was breathing better. The retest value was 350 – the same as before the test. It was not what I expected. OK, so it may have been 355 if I read it with the unit tilted just the right way. I asked Bill to test again – still 350. This placed him in the yellow zone on the asthma chart for his age and weight. Even though he was visibly breathing better, I felt like I had failed in my treatment. After all, I did not have numbers that could validate what I had done. That is what evidence-based medicine is all about.
I heard Dr. Ed Stiles talking in my head. I hear his words often when I “get stuck” during a treatment. Being one of his students has been one of the biggest blessings in my life. Dr. Stiles encouraged us to think osteopathically and to apply everything we had learned in treating patients. It then dawned on me that medically asthma IS a problem in the smaller airways. Nothing I had done thus far had directly addressed that aspect of Bill’s symptoms. I decided to treat the airways by treating the lungs viscerally. I screened viscerally and found the left lung to be more restricted. I treated that first and then had Bill do another peak flow. This time it was 380. Still in the yellow zone, but improved! After treating the right lung, the peak flow crept up to 400. This placed Bill in the green zone.
After hearing more of Dr. Stiles’ advice in my head my pharmacological advice was clear. In Bill’s case, we needed to assist his airway size. Without running expensive tests, it seemed to only make sense that if the rib cage was moving well but the peak flow remained unchanged that I had some very usable results. If I remember my physics correctly, Poiseuille’s Law is used to calculate fluid flow through a cylindrical pipe. The applicable portion here is that the fluid flow is related to the radius of the pipe to the fourth power – thus a small change in the radius of the pipe can make a large change in the flow of fluid. Poiseuille’s Law is why there are two large bore IV’s started on any trauma patient – so fluid can be moved rapidly. Bill’s air could not get in and out because of the narrowing of the bronchioles. I believe that is why the visceral treatment achieved the desired increase in peak flow – it changed the size of the smaller airways. Using this as my treatment rationale, I stepped up his inhaled steroid dose for one week to reduce any inflammatory component and recommended to the PNP to follow him with his smaller airways in mind.
Patients like Bill continue to teach me how to apply the osteopathic principles to effectively manage their complaints and diseases. Many thanks to Dr. Stiles and Dr. Still for encouraging us as a profession to “Dig On”.