The Clinical Effects of Manipulative Therapy in People with Chronic Obstructive Pulmonary Disease

Abstract

Objectives:

This study aimed to determine the effects of manipulative therapies (MT), including spinal manipulation, and diaphragmatic release techniques on lung function, exercise capacity, symptoms, and health-related quality of life (HRQOL) in people with chronic obstructive pulmonary disease (COPD).

Design:

Systematic review.

Participants:

People diagnosed with COPD.

Intervention:

Randomized controlled trials of MT (either with or without pulmonary rehabilitation [PR]) compared to other treatments (soft tissue [ST] therapy or sham therapy) applied in people with COPD were identified following the search of seven databases. Two reviewers independently assessed study quality and extracted data.

Outcome measures:

Lung function, exercise capacity, symptoms, and HRQOL.

Results:

Four studies were included, with a total of 68 participants. The heterogeneity between treatments prevented meta-analysis. There was no beneficial effect on spirometry measures of lung function with MT. MT combined with PR improved exercise capacity by 48–49 m more than ST therapy plus PR. Less dyspnea was reported with MT and ST therapy compared to ST therapy alone (p = 0.01), but there was no effect on HRQOL, or symptoms of anxiety or depression.

Conclusions:

In people with COPD, MT (either with or without PR) improved functional exercise capacity, but had no effect on lung function, or HRQOL. Further research is required to determine the underlying mechanism of this treatment approach and its relationship to exercise capacity.

Introduction

Chronic obstructive pulmonary disease (COPD) is characterized by persistent airflow limitation that is progressive and a major challenge to the global healthcare system.¹ Pulmonary hyperinflation is a common consequence of COPD and reduces inspiratory capacity. In addition, it contributes to dyspnea, altered breathing patterns, and decreased exercise capacity.² People with COPD are often elderly, with the aging process worsening symptoms of COPD.^3,4 Structural changes associated with aging include an increase in chest-wall rigidity secondary to calcification of costal cartilages and costovertebral joints.⁵ Osteoarthritis and osteoporosis are common in COPD, affecting up to 69% of individuals.^6,7 Together with age-related changes, these comorbidities have been linked to musculoskeletal pain, and postural abnormalities in COPD.^8
–10 Those with musculoskeletal pain have reported poorer health-related quality of life (HRQOL) compared to those without pain.^11,12

COPD is also characterized by skeletal muscle dysfunction, with muscle atrophy, shift in fiber type, increased muscle weakness, and reduced oxidative capacity.¹³ Muscle strength is 20%–30% lower in individuals with COPD compared to age-matched controls.¹³ Approximately 50% of people with COPD experience skeletal muscle fatigue, which limits exercise capacity.¹⁴ The combination of these factors contributes to exercise intolerance, and higher levels of dyspnea reported in COPD.^1,3,5

As part of usual medical care for people with COPD, pulmonary rehabilitation (PR) is routinely recommended.^1,15 While dyspnea, HRQOL, and exercise capacity are improved with PR, there is no impact on lung function. In addition, PR does not specifically address postural changes consistent with COPD.¹⁵ The anatomical relationship between the respiratory and musculoskeletal systems has supported the role of manual therapies in COPD. These therapies aim to improve postural abnormalities, lung function, and HRQOL. A previous systematic review found that a combination of proprioceptive neuromuscular facilitation and neuromuscular release massage therapy might address key musculoskeletal changes associated with COPD. However, the role of these treatment approaches remains inconclusive because no significant effects on lung function were identified in the included studies. In addition, there was an absence of evaluation of HRQOL, clinical symptoms, and exercise capacity.¹⁶

An alternative approach to treatment is spinal manipulative therapy (SMT), with a recent systematic review examining its effect in conjunction with other interventions in people with COPD.¹⁷ This treatment consists of high-velocity low-amplitude (HVLA) joint manipulation, or osteopathic manipulation to the thoracic intervertebral, costovertebral, and costotransverse joints. It is hypothesized that this could improve spinal and costal joint mobility and decrease chest wall rigidity.¹⁸ The review found that the combination of SMT with another intervention improved lung function and exercise capacity, but there was no effect on HRQOL. The methodological quality of the included studies in that review was poor, with high levels of bias, a mix of study designs, and insufficient statistical analysis.¹⁷

Another technique designed to improve hyperinflation, which has been more recently applied in COPD is diaphragmatic release. This technique uses a cephalic force below the 7th to 10th costal cartilages during inspiration and expiration, followed by release.¹⁹ This technique is designed to stretch the diaphragmatic muscle fibers, improve diaphragmatic mobility, and increase exercise tolerance.¹⁹ However, the effects of both SMT and diaphragmatic release in individuals with COPD on HRQOL, exercise capacity, and other patient-reported outcomes have not been systematically reviewed. A comparison of these treatment approaches to other forms of treatment or usual care will provide further insight for clinicians into the role of these interventions as part of COPD management.

The aim of this systematic review is to evaluate the effects of SMT and diaphragmatic release as a manipulative therapy (MT) on lung function, exercise capacity, symptoms, and HRQOL in people with COPD. This review was registered with PROSPERO (number: CRD42017075547).

Materials and Methods

Search strategy

This review is reported according to the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines.²⁰ A comprehensive search of the electronic databases MEDLINE, SPORTDiscus, CINAHL, EMBASE, Physiotherapy Evidence Database (PEDro), Cochrane, and PubMed was undertaken until November 2017. The search strategy used a modified PICO format (Supplementary Table S1; Supplementary Data is available online at www.liebertpub.com/acm) and was adapted for each database. Citation tracking was completed through Google Scholar and Web of Science, and manual reference list searches of relevant articles were also conducted.

Inclusion criteria

Following the removal of duplicates, two investigators (J.G. and G.M.) independently reviewed titles and abstracts according to the inclusion criteria. Full texts of potentially relevant articles were retrieved for independent assessment, with any discrepancy resolved by discussion. The selection criteria for this review are outlined in Table 1. Studies were included if the study design allowed the observed differences to be attributed to the presence of MT in one of the groups. Studies were excluded if they applied MT by instruments or devices, were published in a language other than English, or could only be sourced in abstract form.

Table 1.

Inclusion Criteria

Participants	Diagnosis of moderate to severe COPD, confirmed by respiratory physician or spirometry (FEV₁/FVC <70)¹
	No history of exacerbation of COPD within the previous 6 weeks
	Aged greater than 45 years
Intervention	MT undertaken in an outpatient setting, the treatment of which could include SMT, diaphragmatic release therapy, and osteopathic MT Treatment delivered hand-on by a skilled practitioner/clinician
Comparison	Randomized controlled trials or cross-over trials.
Outcomes	Spirometry measures (e.g., FEV₁ and FVC) and lung volumes (e.g., RV, TLC, and VC)
	Functional exercise capacity
	Symptoms, including psychological symptoms and quality of life. Validated and unvalidated questionnaires may be used. The time frame for these outcomes were short term (0–4 weeks) and medium term (16–24 weeks)

COPD, chronic obstructive pulmonary disease; FEV₁, forced expiratory volume in 1 sec; FVC, forced vital capacity; MT, manipulation therapy; SMT, spinal manipulation therapy; RV, residual volume; TLC, total lung capacity; VC, vital capacity.

Data extraction, analysis, and quality appraisal

Data were extracted from included studies using a standardized template. Information was extracted relating to participant demographics, interventions, and outcomes (spirometry measures [forced expiratory volume in 1 sec (FEV₁) and forced vital capacity (FVC)] for the primary outcome, and functional exercise capacity, symptoms, and HRQOL for secondary outcomes). Two investigators (J.G. and G.M.) independently assessed the internal validity of all studies using the PEDro scale,^21,22 with any discrepancies in scores discussed between investigators to reach a consensus. A PEDro score of ≥7/10 has previously been considered high-quality evidence with minimal risk of bias²³; hence studies with this score or greater were included.

Outcomes measured using the same validated tests were analyzed using mean differences (MD), standard deviations (SD), and 95% confidence intervals (CI).²⁴ Where standard errors (SE) were listed rather than SD, data were converted to SD using the formula SD = SE × √N.²⁴ Due to differences between control interventions across studies, meta-analysis was not possible in this review²⁵; hence results were reported narratively. Post-hoc power calculations were performed using a statistical power calculator²⁶ for the primary outcome (spirometry) to determine if the study had adequate power to detect between-group changes.

Results

Study selection

A comprehensive database search yielded 712 articles (excluding duplicates). Of these, 20 full-text articles were assessed with four meeting all selection criteria. Results of the search strategy are presented in Figure 1.

FIG. 1.

Study flow from identification to inclusion of final studies.

Participants and interventions

The four included studies involved a total of 68 participants, of whom 59% were male, with a mean age of 64 years, and confirmed diagnosis of moderate to severe COPD. Spinal manipulation was compared to a variety of interventions; a full description of all interventions is outlined in Table 2. Engel et al.¹⁸ compared the short-term effects (4 weeks) of 15–20 min of MT and soft tissue (ST) therapy to ST therapy only. A later study by Engel et al.²⁷ compared the medium-term effects (with treatment applied over 8 weeks) of PR combined with MT and ST therapy versus PR combined with ST therapy alone. Diaphragm release techniques applied over 2 weeks were compared to a sham therapy in one study,¹⁹ while another study investigated a 4-week osteopathic manipulative program applied in conjunction with PR compared to PR combined with sham manipulation.²⁸

Table 2.

Characteristics of Included Studies

Studies	Participants mean age, gender%	Interventions	Outcome measures	Between-group differences
Engel et al. (2013)¹⁸	56 years, 60% male	ST therapy group: consisted of 15–20 min of gentle massage to the muscles of the posterior chest wall. ST therapy and MT group: Spinal manipulation consisted of 15–20 min of HVLA joint manipulation of the thoracic intervertebral, costovertebral, and costotransverse joints. A total of eight intervention sessions over a 4-week period, two sessions per week for each group.	6MWT FEV₁, FVC CRQ	There was no difference in FEV₁ (MD between groups 0.05 L [95% CI −0.11 to 0.20 L; α = 84.2] or FVC 0.02 L [95% CI −0.15 to 0.19 L; α = 79.4]). The 6MWD improved by 120 m (26.3) more with MT and ST therapy compared to ST therapy alone (p < 0.0001). Dyspnea reduced more with MT and ST therapy (0.64 points [0.22], p = 0.01) compared to ST therapy alone, but there was no effect on fatigue, emotional function, or mastery.
Zanotti et al. (2012)²⁸	64 years, 75% male	PR + MT group: anamnesis, physical examination of thoracic outlet, spine, rib cage, and thoracic and pelvic diaphragm, and cranial and craniosacral evaluation, with treatment of joint restrictions. Treatment was applied weekly for 4 weeks, for 45 min. PR consisted of exercise training, with UL and LL cycle ergometer training, 6 days per week for 4 weeks with educational support, psychological counseling, and nutritional intervention. PR + sham MT group: exercise training, with UL and LL cycle ergometer training, 6 days per week for 4 weeks with educational support, psychological counseling, and nutritional intervention.	6MWT FEV₁, FVC, RV, VC	No significant between-group change in FEV₁ (MD 0.13 L [95% CI −0.66 to 0.90 L; α = 35.0] or FVC 0.05 L [95% CI −0.01 to 0.11 L; α = 8.8]) at 4 weeks. There was a greater reduction in RV with PR and MT (MD −0.44 L [95% CI −0.26 to −0.62 L]), but no between-group difference in VC (0.09 L [95% CI −0.71 to 0.89 L]). Greater improvement in 6MWD by 49 m (95% CI 17 to 80 m) in the PR and MT group compared to the PR and sham group.
Rocha et al. (2015)¹⁹	71 years, 74% male	Diaphragmatic release technique group: participant lays supine and therapist makes manual contact to the underside of the 7th to 10th rib. Therapist gently pulls the points of contact with both hands in the direction of the head and slightly laterally. During exhalation, the therapist progressively deepens contact. Maneuver performed in two sets of 10 breaths with a 1-minute interval between them. Sham group: manual contact, duration, and positioning were the same as the diaphragmatic release group; however, only light touch was maintained without exerting pressure or traction. Both groups received six treatments on nonconsecutive days within a 2-week period.	6MWT	Diaphragmatic release group improved on the 6MWD by 22 m (95% CI 11 to 32 m) more than the sham group.
Engel et al. (2016)²⁷	66 years, 50% male	PR + ST therapy group: soft tissue therapy consisted of 20 min of gentle massage to the muscles of the posterior chest wall. PR + ST therapy + MT: Spinal manipulation consisted of a HVLA joint manipulation of the thoracic intervertebral, costovertebral, and costotransverse joints. Two sessions per week for 8 weeks of ST therapy and SMT were provided during 8 weeks of PR.	6MWT FEV₁, FVC SGRQ, HADS	No significant difference between groups in FEV₁ at 16 weeks (MD of −0.06 L [95% CI −0.42 to 0.29 L; α = 19.0]) or 24 weeks (MD 0.07 [95% CI −0.09 to 0.23 L; α = 19.0]). No significant difference between groups in FVC at 16 weeks (0.001 L [95% CI −0.14 to 0.15 L; α = 9.8]) or 24 weeks (0.24 L [95% CI −0.23 to 0.71 L; α = 9.8]). Significant change in 6MWD in favor of MT (between-group difference of 48 m [95% CI 9 to 88 m]). There was no difference in SGRQ total score or HADS anxiety or depression subscores between groups.

α, alpha (power); 6MWD, 6-min walk distance; 6MWT, 6-min walk test; CI, confidence intervals; CRQ, chronic respiratory questionnaire; HADS, hospital anxiety and depression scale; HVLA, high-velocity low amplitude; LL, lower limb; MD, mean difference; PR, pulmonary rehabilitation; RV, residual volume; SGRQ, St George's Respiratory Questionnaire; ST, soft tissue; UL, upper limb.

Quality assessment

The quality assessment for all studies is outlined in Table 3, with a mean score of 8/10. All studies used computerized random number generation, with allocation concealment consistently applied. Three studies blinded participants.^19,27,28 Outcome measures were not obtained for >85% of participants in one study, which may contribute to attrition bias,¹⁸ although all studies applied intention-to-treat analyses.

Table 3.

Summary of Methodological Quality of Evidence Using the PEDro Scale

	Criterion 2	Criterion 3	Criterion 4	Criterion 5	Criterion 6	Criterion 7	Criterion 8	Criterion 9	Criterion 10	Total
Engel et al. (2013)¹⁸	Yes	Yes	No	No	No	Yes	Yes	Yes	Yes	7
Zanotti 2012²⁸	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	9
Rocha 2015¹⁹	Yes	Yes	Yes	No	No	Yes	No	Yes	Yes	7
Engel et al. (2016)²⁷	Yes	Yes	yes	yes	No	Yes	Yes	Yes	Yes	9

PEDro, Physiotherapy Evidence Database.

Primary outcome: lung function

Three studies examined the effects of MT on spirometry;^18,27,28 one study explored the impact on static lung volumes.²⁸ MT (either in isolation or when combined with PR) was no more effective than ST therapy or sham therapy for improving FEV₁ or FVC in participants with moderate to severe COPD at short- or medium-term follow-ups (Table 2).^18,27,28 MT involving osteopathic techniques plus PR had a greater reduction in residual volume (MD −0.44 L (95% CI −0.26 to −0.26) compared to PR with a sham MT treatment, but there was no effect on vital capacity.²⁸

Secondary outcomes: functional exercise capacity, symptoms, and HRQOL

All four included studies investigated the effect of MT on functional exercise capacity as measured by the 6-min walk test (6MWT). MT (using osteopathic techniques) combined with PR was significantly more effective than sham MT with PR for improving participants' performance in a 6-min walk distance (6MWD) following 4 weeks of treatment (MD 49 m: 95% CI 17 to 80 m).²⁸ Similarly, MT (using HVLA techniques) combined with PR and ST therapy improved the 6MWD by 48 m (95% CI 9 to 88 m) more at 16 weeks and 58 m (95% CI 5 to 112 m) more at 24 weeks compared to PR and ST therapy alone.²⁷ When looking at manual therapies without PR, MT combined with ST therapy was more effective than ST therapy alone for improving the 6MWD after 4 weeks (MD = 120 m: 95% CI 58 to 182 m),¹⁸ while diaphragmatic release techniques were more effective than sham light touch for improving the 6MWD (MD = 22 m: 95% CI 11 to 32 m).¹⁹ Two studies examined the effect on anxiety, depression, and HRQOL.^18,27 While dyspnea levels reduced with the combination of MT and ST therapy compared to ST therapy alone, there was no effect on fatigue, emotional function, or mastery.¹⁸ Similarly, there was no impact on anxiety, depression, or HRQOL measured by the St George's Respiratory Questionnaire total score.²⁷

Discussion

This systematic review included four studies investigating the effectiveness of MT on improving lung function, functional exercise capacity, symptoms, and HRQOL in people with moderate to severe COPD. High-quality evidence showed that MT positively affects functional exercise capacity compared to other interventions in both the short and medium term. However, MT offered no additional benefit for improving lung function. The impact of MT as provided in the included studies on symptoms was minimal, with a modest reduction in dyspnea and no change in psychological symptoms or HRQOL.

MT, which included osteopathic approaches and HVLA treatment, appears to be effective at achieving a clinically significant improvement in exercise performance. Three studies found a between-group difference greater than the minimal important difference for the 6MWT (between 25 and 33 m)²⁹ immediately following treatment.^18,27,28 To achieve a clinically significant improvement, the length of time for which the treatment is applied may be important, with Rocha et al.¹⁹ demonstrating a change in 6MWD of only 22 m after 2 weeks of treatment. In contrast, greater changes (48 and 49 m) were noted with treatment of 4 weeks or more.^18,27 In addition, the positive findings from the studies applying a longer intervention and combining MT with PR, suggest a synergistic effect of treatment and a possible ancillary role for MT in PR for some individuals with COPD. Despite the different MT approaches between studies, this review provides suggestions for effective combinations of treatment methods.

The contrasting effects of MT on lung function between studies included in this review are consistent with previous findings. Heneghan et al.¹⁶ reported decreased FVC in individuals with COPD when spinal manipulation was combined with other techniques, including proprioceptive neuromuscular facilitation technique, trager psychophysical integration, or neuromuscular release massage therapy. In contrast, Wearing et al.¹⁷ found improvements in both FEV₁ and FVC when combining spinal manipulation with exercise. A recent study demonstrated small improvements in pulmonary function of healthy subjects after HVLA thoracic spinal manipulation,³⁰ and theorized that larger changes could be seen in people with COPD. However, a single MT offered no improvement in lung function.³¹ The impact of MT on respiratory function may be influenced by the type of MT applied. The conflicting findings in this review may also be related to the power of the included studies, with only one study sufficiently powered for this outcome.⁹ Despite a lack of power, Engel et al.²⁷ demonstrated an improvement of FVC greater than the MCID of 200 mL³² at 24 weeks following MT, although the between-group difference was nonsignificant. To clarify the impact of MT on respiratory function and determine the degree of clinical importance, further research is warranted in studies with larger sample sizes.

The potential mechanisms of the improved functional exercise capacity following MT are unclear. It has been proposed that MT improves the mechanical impairments of the chest wall by improving thoracic joint mobility and reducing chest wall rigidity in individuals with COPD.^17,33 Accompanying this suggestion is that improved lung capacity following MT may reduce dyspnea, allowing an individual to exercise for longer or walk faster. However, this is not supported by findings of significant changes in lung function following MT and more research examining the mechanism of MT and its influence on 6MWD is needed. It is possible that a placebo effect is present with MT and patient-perceived benefits translate into greater 6MWDs, despite no positive change in respiratory function. Noll et al.³⁴ have previously demonstrated that respiratory function worsened in patients with COPD immediately following MT, but that self-reported patient dyspnea scores improved. Since dyspnea is often the major limiting factor in exercise for individuals with COPD,³⁵ a perceived reduction in this symptom may increase exercise time. This may account for improvements in 6MWD evident in this review and is supported by the reduction in dyspnea in one study.¹⁸ Further research is required to determine this link.

The lack of effect on psychological symptoms is not unexpected. The physiologic basis of MT is not designed to target these symptoms. Although there was a reduction in dyspnea reported in one study,¹⁸ this was not a consistent finding. More detailed analysis of the effect of MT on all components of dyspnea, including the sensory and affective domains, would be of benefit.

There are strengths and limitations to this review. The participants included are largely representative in terms of lung function of individuals with moderate to severe COPD,³⁵ which increases the external validity of these findings. Only studies with a high PEDro score (≥7/10) were included, limiting potential methodological biases. The lack of blinding of participants to treatment groups may impact on the approach to treatment or performance in outcome measure assessment.³⁶ A major limitation of the studies involved in this review was insufficient information describing the exact MT protocol used. The heterogeneity between treatment techniques prohibited meta-analysis, which limits the ability to make definitive conclusions about the effectiveness of MT in this patient population, particularly in the measures of lung function.

Conclusions

This review demonstrated that MT, either when combined with PR or as a stand-alone treatment, is more effective than ST therapy or sham MT for improving functional exercise capacity in people with moderate to severe COPD, but appears to have little or no effect on lung function, symptoms, or HRQOL. Further research is required to determine the optimal components or approaches to MT and to identify and clarify the physiologic effect of MT in this patient population, and its influence on outcomes that are important to patients.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

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