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Preliminary development of a complex intervention for osteopathic management of dysfunctional breathing
Abstract
Background: Breathing retraining (BRT) is commonly used during osteopathic consultations as an adjunct to osteopathic manual therapy (OMT) for assessment and treatment of breathing-related dysfunction. Although BRT and OMT are widely recognised within osteopathy and other allied health disciplines, there are few descriptions of clinically applicable protocols in the literature. Objective: To describe the development of a dual-protocol framework (BRT and OMT) for assessment and treatment of dysfunctional breathing. Design: Development and evaluation of a complex intervention. Methods: Cyclical, iterative processes of development, feasibility and piloting, evaluation and subsequent redevelopment were applied in the design of two conceptual protocols for BRT and OMT. Results: The resulting BRT protocol consists of progressive steps of breathing practice in three body positions (neutral, flexion, extension), followed by a guide for more advanced breathing challenges that can be tailored towards the individual. The OMT protocol provides a semi-standardised assessment and treatment plan, which details body regions for assessment of somatic dysfunction and a list of techniques that can be selected according to practitioner clinical judgement, based on patient presentation and preferences, and clinical context. Conclusions: Here we present a clinically applicable guide for a complex intervention entailing assessment and management of dysfunctional or abnormal breathing. Implementation of this protocol within the clinical setting is now recommended, along with ongoing development, and further randomised clinical trials assessing its efficacy, effectiveness, and acceptability.
Background
Breathing retraining and manual therapy (MT), delivered independently or together, influence autonomic activity, and improve symptoms in patients with chronic conditions. This study evaluated the effects of breathing retraining and osteopathic MT on cardiac autonomic measures and breathing symptoms during spontaneous breathing in healthy active adults. Methods: Participants (n=18) received breathing retraining and four, weekly manual therapy sessions, randomised to start immediately, or after 6-week delay. Heart-rate (HR) variability was assessed as a 7-day average of waking 6-minute electrocardiograms, using time (logarithm of root-mean-square of successive differences; LnRMSSD) and frequency domain (logarithm of high-frequency; LnHF) measures. Recordings were taken before, one week following intervention or delay, and then following the later intervention for those with delayed starts. Changes were compared between those who received and had yet to receive the intervention, and before and after treatment for the whole cohort. Results: Following the intervention, HR-variability measuresincreased 4% overall (Effect Sizes: 1.0–1.1) for the whole cohort. Between-group analyses showed that the immediate-start group increased more than the delayed start group: LnRMSSD 0.27 (0.02–0.52; 95%CI) ln.ms, and LnHF 0.41 (-0.01–0.84) ln.ms² for immediate start; compared withLnRMSSD -0.09 (-0.29–0.11) ln.ms, and LnHF -0.19 (-0.59–0.22) ln.ms² (P=0.02–0.03 for interaction) for delayed start. Resting HR decreased following intervention in the whole cohort (Effect Size -0.8; P=0.02).
Conclusion
A 6-week osteopathic treatment consisting of breathing retraining and MT is beneficial in lowering HR-variability compared to no treatment, and may induce favourable (parasympathetic over sympathetic) autonomic modulation.
Trial Registration
[redacted for anonymous review]
Study design: Randomized clinical trial. Objective: To investigate the effect of including manual therapy (MT) in a pulmonary rehabilitation program for patients with chronic obstructive pulmonary disease (COPD). Background: The primary source of exercise limitation in people with COPD is dyspnea. The dyspnea is partly caused by changes in chest wall mechanics, with an increase in chest wall rigidity (CWR) contributing to a decrease in lung function. As MT is known to increase joint mobility, administering MT to people with COPD carries with it the potential to influence CWR and lung function. Methods: Thirty-three participants with COPD, aged between 55 and 70 years (mean565.5¡4 years), were randomly assigned to three groups: pulmonary rehabilitation (PR) only, soft tissue therapy (ST) and PR, and ST, spinal manipulative therapy (SM), and PR. Outcome measures including forced expiratory volume in the 1st second (FEV 1), forced vital capacity (FVC), 6-minute walking test (6MWT), St. George's respiratory questionnaire (SGRQ), and the hospital anxiety and depression (HAD) scale were recorded at 0, 8, 16, and 24 weeks. Results: There was a significant difference in FVC between the three groups at 24 weeks (P50.04). For the STzSMzPR group versus PR only the increase was 0.40 l (CI: 0.02, 0.79; P50.03). No major or moderate adverse events (AE) were reported following the administration of 131 ST and 272 SM interventions. Discussion: The increase in FVC is a unique finding. Although the underlying mechanisms responsible for this outcome are not yet understood, the most likely explanation is the synergistic effect resulting from the combination of interventions. These results support the call for a larger clinical trial in the use of MT for COPD.
Questions:
In people with chronic obstructive pulmonary disease, does the Manual Diaphragm Release Technique improve diaphragmatic mobility after a single treatment, or cumulatively? Does the technique also improve exercise capacity, maximal respiratory pressures, and kinematics of the chest wall and abdomen?
Design:
Randomised, controlled trial with concealed allocation, intention-to-treat analysis, and blinding of participants and assessors.
Participants:
Twenty adults aged over 60 years with clinically stable chronic obstructive pulmonary disease.
Intervention:
The experimental group received six treatments with the Manual Diaphragm Release Technique on non-consecutive days within a 2-week period. The control group received sham treatments following the same regimen.
Outcome measures:
The primary outcome was diaphragmatic mobility, which was analysed using ultrasonography. The secondary outcomes were: the 6-minute walk test; maximal respiratory pressures; and abdominal and chest wall kinematics measured by optoelectronic plethysmography. Outcomes were measured before and after the first and sixth treatments.
Results:
The Manual Diaphragm Release Technique significantly improved diaphragmatic mobility over the course of treatments, with a between-group difference in cumulative improvement of 18mm (95% CI 8 to 28). The technique also significantly improved the 6-minute walk distance over the treatment course, with a between-group difference in improvement of 22 m (95% CI 11 to 32). Maximal expiratory pressure and sniff nasal inspiratory pressure both showed significant acute benefits from the technique during the first and sixth treatments, but no cumulative benefit. Inspiratory capacity estimated by optoelectronic plethysmography showed significant cumulative benefit of 330ml (95% CI 100 to 560). The effects on other outcomes were non-significant or small.
Conclusion:
The Manual Diaphragm Release Technique improves diaphragmatic mobility, exercise capacity and inspiratory capacity in people with chronic obstructive pulmonary disease. This technique could be considered in the management of people with chronic obstructive pulmonary disease.
Trial registration:
NCT02212184. [Rocha T, Souza H, Brandão DC, Rattes C, Ribeiro L, Campos SL, Aliverti A, de Andrade AD (2015) The Manual Diaphragm Release Technique improves diaphragmatic mobility, inspiratory capacity and exercise capacity in people with chronic obstructive pulmonary disease: a randomised trial.Journal of PhysiotherapyXX: XX-XX].
Medium term effects of including manual therapy in a pulmonary rehabilitation program for chronic obstructive pulmonary disease (COPD): a randomized controlled pilot trial. Study design: Randomized clinical trial. Objective: To investigate the effect of including manual therapy (MT) in a pulmonary rehabilitation program for patients with chronic obstructive pulmonary disease (COPD). Background: The primary source of exercise limitation in people with COPD is dyspnea. The dyspnea is partly caused by changes in chest wall mechanics, with an increase in chest wall rigidity (CWR) contributing to a decrease in lung function. As MT is known to increase joint mobility, administering MT to people with COPD carries with it the potential to influence CWR and lung function. Methods: Thirty-three participants with COPD, aged between 55 and 70 years (mean565.5¡4 years), were randomly assigned to three groups: pulmonary rehabilitation (PR) only, soft tissue therapy (ST) and PR, and ST, spinal manipulative therapy (SM), and PR. Outcome measures including forced expiratory volume in the 1st second (FEV 1), forced vital capacity (FVC), 6-minute walking test (6MWT), St. George's respiratory questionnaire (SGRQ), and the hospital anxiety and depression (HAD) scale were recorded at 0, 8, 16, and 24 weeks. Results: There was a significant difference in FVC between the three groups at 24 weeks (P50.04). For the STzSMzPR group versus PR only the increase was 0.40 l (CI: 0.02, 0.79; P50.03). No major or moderate adverse events (AE) were reported following the administration of 131 ST and 272 SM interventions. Discussion: The increase in FVC is a unique finding. Although the underlying mechanisms responsible for this outcome are not yet understood, the most likely explanation is the synergistic effect resulting from the combination of interventions. These results support the call for a larger clinical trial in the use of MT for COPD.
Evaluating complex interventions is complicated. The Medical Research Council's evaluation framework (2000) brought welcome clarity to the task. Now the council has updated its guidance
The significance of respiratory influences upon cardiovascular functioning has been much neglected in the psychophysiological literature. Various phasic and nonphasic respiratory parameters manifest marked and specific effects upon numerous cardiac and circulatory events. Ventilatory patterns associated with stress responses, furthermore, bring about cardiovascular alterations indicative of dysfunction and risk, even when these ventilatory patterns are voluntarily enacted by normal individuals under nonstressful circumstances. Evidence is presented which suggests that respiratory processes may contribute significantly to cardiovascular competence and dysfunction. The implications of this theoretical approach for psychophysiological research are also discussed.
The concept of hyperventilation and the principle of a vicious circle provide an elegant explanation for the development of a wide range of somatic and psychological symptoms, the so-called hyperventilation syndrome (HVS). The model has a high degree of credibility and has led to the development of therapeutic interventions that appeared beneficial. However, recent investigations dismiss hyperventilation as an important symptom-producing mechanism. First, the hyperventilation provocation test appears to be invalid as a diagnostic test. Second, studies using ambulant monitoring of pCO2 demonstrate that the vast majority of real-life attacks are not attended by decreases in pCO2. Third, the evaluation of therapy outcome studies indicate that the beneficial effect of breathing retraining is probably not mediated by reducing the tendency to hyperventilate. We conclude that a diagnosis of HVS should be avoided.
To estimate the prevalence of dysfunctional breathing in adults with asthma treated in the community.
Postal questionnaire survey using Nijmegen questionnaire.
One general practice with 7033 patients.
All adult patients aged 17-65 with diagnosed asthma who were receiving treatment.
Score >/=23 on Nijmegen questionnaire.
227/307 patients returned completed questionnaires; 219 (71.3%) questionnaires were suitable for analysis. 63 participants scored >/=23. Those scoring >/=23 were more likely to be female than male (46/132 (35%) v 17/87 (20%), P=0.016) and were younger (mean (SD) age 44.8 (14.7) v 49.0 (13.8, (P=0.05). Patients at different treatment steps of the British Thoracic Society asthma guidelines were affected equally.
About a third of women and a fifth of men had scores suggestive of dysfunctional breathing. Although further studies are needed to confirm the validity of this screening tool and these findings, these prevalences suggest scope for therapeutic intervention and may explain the anecdotal success of the Buteyko method of treating asthma.
In this pilot study, the authors evaluated the immediate effects of osteopathic manipulative procedures compared with sham procedures on 10 subjects who were diagnosed with chronic asthma. The research followed a pretest-posttest crossover design wherein each subject served as her own control. Blinded examiners recorded respiratory excursion, peak expiratory flow rates, and subjective measures of asthma symptoms. Measurements of both upper thoracic and lower thoracic forced respiratory excursion statistically increased after osteopathic manipulative procedures compared with sham procedures. Changes in peak expiratory flow rates and asthma symptoms were not statistically significant.
The objective of this study was to explore the effect of combining manual therapy with exercise on respiratory function in normal individuals.
The study design was a randomized control trial. Forced vital capacity (FVC) and forced expiratory volume in the first second (FEV1) were measured in 20 healthy, nonsmoking individuals before and after 3 interventions: exercise only, chiropractic manual therapy only, and manual therapy followed by exercise. The participants, 18 to 28 years of age, were randomly allocated to a control and 3 intervention groups. Each participant underwent 6 sessions of interventions over a 4-week period.
The exercise only group showed a significant decrease in FVC (P = .002, generalized linear model [GLM]) and FEV1 readings (P = .0002, GLM). The manual therapy only group showed a significant increase in FVC (P = .000, GLM) and FEV1 (P = .001, GLM). The group that received both manual therapy and exercise showed increases in FVC and FEV1 immediately after manual therapy followed by an additional increase after exercise. The overall increase in this group was not statistically significant. Participants in the control group showed no change in FVC or FEV(1).
Manual therapy appears to increase the respiratory function of normal individuals. The potential for this intervention administered before exercise to permit additional tolerance within the respiratory system that could allow an extended exercise program than was previously possible is discussed.
This book is intended to help practitioners understand the causes and effects of disordered breathing and to provide strategies and protocols to help restore normal function. Fully updated throughout, this volume has been completely revised to guide the practitioner in the recognition of breathing pattern disorders and presents the latest research findings relating to the condition including a range of completely new techniques - many from an international perspective - to help restore and maintain normal functionality. Video clips on an associated website presents practical examples of the breathing techniques discussed in the book.
Background:
Dysfunctional breathing/hyperventilation syndrome (DB/HVS) is a respiratory disorder, psychologically or physiologically based, involving breathing too deeply and/or too rapidly (hyperventilation) or erratic breathing interspersed with breath-holding or sighing (DB). DB/HVS can result in significant patient morbidity and an array of symptoms including breathlessness, chest tightness, dizziness, tremor and paraesthesia. DB/HVS has an estimated prevalence of 9.5% in the general adult population, however, there is little consensus regarding the most effective management of this patient group.
Objectives:
(1) To determine whether breathing exercises in patients with DB/HVS have beneficial effects as measured by quality of life indices (2) To determine whether there are any adverse effects of breathing exercises in patients with DB/HVS SEARCH METHODS: We identified trials for consideration using both electronic and manual search strategies. We searched CENTRAL, MEDLINE, EMBASE, and four other databases. The latest search was in February 2013.
Selection criteria:
We planned to include randomised, quasi-randomised or cluster randomised controlled trials (RCTs) in which breathing exercises, or a combined intervention including breathing exercises as a key component, were compared with either no treatment or another therapy that did not include breathing exercises in patients with DB/HVS. Observational studies, case studies and studies utilising a cross-over design were not eligible for inclusion.We considered any type of breathing exercise for inclusion in this review, such as breathing control, diaphragmatic breathing, yoga breathing, Buteyko breathing, biofeedback-guided breathing modification, yawn/sigh suppression. Programs where exercises were either supervised or unsupervised were eligible as were relaxation techniques and acute-episode management, as long as it was clear that breathing exercises were a key component of the intervention.We excluded any intervention without breathing exercises or where breathing exercises were not key to the intervention.
Data collection and analysis:
Two review authors independently checked search results for eligible studies, assessed all studies that appeared to meet the selection criteria and extracted data. We used standard procedures recommended by The Cochrane Collaboration.
Main results:
We included a single RCT assessed at unclear risk of bias, which compared relaxation therapy (n = 15) versus relaxation therapy and breathing exercises (n = 15) and a no therapy control group (n = 15).Quality of life was not an outcome measure in this RCT, and no numerical data or statistical analysis were presented in this paper. A significant reduction in the frequency and severity of hyperventilation attacks in the breathing exercise group compared with the control group was reported. In addition, a significant difference in frequency and severity of hyperventilation attacks between the breathing and relaxation group was reported. However, no information could be extracted from the paper regarding the size of the treatment effects.
Authors' conclusions:
The results of this systematic review are unable to inform clinical practice, based on the inclusion of only one small, poorly reported RCT. There is no credible evidence regarding the effectiveness of breathing exercises for the clinical symptoms of DB/HVS. It is currently unknown whether these interventions offer any added value in this patient group or whether specific types of breathing exercise demonstrate superiority over others. Given that breathing exercises are frequently used to treat DB/HVS, there is an urgent need for further well designed clinical trials in this area. Future trials should conform to the CONSORT statement for standards of reporting and use appropriate, validated outcome measures. Trial reports should also ensure full disclosure of data for all important clinical outcomes.
Breathwork is an increasingly popular experiential approach to psychotherapy based on the use of a specific breathing technique,
however, claims of positive mental health outcomes rely on anecdotal clinical evidence. To ascertain the likely efficacy of
breathwork this review clarifies the approach and its theoretical assumptions and examines relevant empirical research relating
to breathing inhibition, suppression of inner experience, and possible neurological and physiological effects. Additionally,
research into mindfulness-based psychotherapy and yoga breathing-based interventions with comparable features to breathwork
are examined. Findings suggest qualified support for the key theoretical assumptions of a three component breathwork model,
referred to as Integrative Breathwork Therapy (IBT), and its possible utility in the treatment of anxiety and depression.
Further research aimed at exploring specific efficacy of this approach for these disorders may yield a useful additional treatment
option utilising a different process of change to existing treatments.
KeywordsAnxiety–Breathwork–Depression–Mindfulness–Psychotherapy–Respiration–Somatic
Dysfunctional breathing (DB) can be defined by the presence of unexplained breathing symptoms. However, validated questionnaires to comprehensively evaluate all dimensions of breathing symptoms proposed to be associated with DB have not been extensively developed. This paper discusses the development and exploration of the dimensionality of a preliminary questionnaire, the Self Evaluation of Breathing Questionnaire, whose items were derived from a popular Internet questionnaire for evaluating breathing functionality and breathing symptoms proposed in the scientific literature to be discriminative for DB.
Dysfunctional breathing, hyperventilation and vocal cord dysfunction are frequently seen in children and adults. The prevalence is unknown. There are no standardized diagnostic criteria, and for now, effective exclusion of organic disease leaves the diagnosis of dysfunctional breathing. Therapy is mainly focussed on explanation of a benign condition and reassurance. Since dysfunctional breathing is a possible chronic condition, other therapies should be evaluated. In adults physiotherapy and breathing retraining appear beneficial. In childhood there is lack of evidence, and further research is necessary in order to optimise the outcome for children with dysfunctional breathing.
Back and neck pain are extremely common reasons for patients seeking manual therapy treatment. Epidemiological evidence supports a link between breathing difficulties and back pain. Since trunk muscles perform both postural and breathing functions, it is theorized that disruption in one function can negatively impact the other. Altered breathing mechanics can change respiratory chemistry and therefore pH causing smooth muscle constriction, altered electrolyte balance and decreased tissue oxygenation. These changes can profoundly impact any body system. Increased excitability in the muscular and nervous systems may be most relevant to a manual therapist. Respiratory function can be tested via capnography which measures CO₂ at the end of exhale known as End Tidal CO₂ (ETCO₂). ETCO₂ closely reflects arterial CO₂ in people with normal cardiopulmonary function. A case series of twenty nine outpatients with neck or back pain who had plateaued with manual therapy and exercise were identified all of whom were found to have low ETCO₂. Breathing retraining improved ETCO₂, pain and function in all patients with 93% achieving at least a clinically important change in either pain or function. Screening for breathing dysfunction using capnography may improve patient outcomes in those patients where manual therapy, exercise and education do not provide full resolution of symptoms.
Anxiety disorders, particularly panic disorder (PD), are associated with respiratory abnormalities. PD consists of unexpected panic attacks (PA) with anxiety, fear and many autonomic and respiratory symptoms. There is a substantial body of literature demonstrating that stimulation of respiration is a common event in panic disorder patients during PA. A number of abnormalities in respiration, such as enhanced CO(2) sensitivity, have been detected in PD patients. As a result, some investigators advanced that there is a fundamental abnormality in the physiological mechanisms that control breathing in PD. Studies indicate that PD patients with dominant respiratory symptoms are particularly sensitive to respiratory tests compared with those who do not manifest dominant respiratory symptoms, possibly representing a distinct subtype. Accumulated evidence suggests that respiratory physiology remains normal in PD patients and that their tendency to hyperventilate and to react with panic to respiratory stimulants like CO(2) represents the triggering of a hypersensitive fear network. However, some recent evidences support the presence of subclinical abnormalities in respiration and other functions related to body homeostasis. The fear network, composed by the hippocampus, the medial prefrontal cortex, the amygdala and its brainstem projections, may be abnormally sensitive in PD patients. This theory might explain why both medication and psychosocial therapies are clearly effective. The evidence of abnormalities in several neurochemical systems might be just the expression of the complex interactions among brain circuits. Our aim was to review the relationship between respiration and panic disorder, addressing the respiratory subtype of panic disorder, the hyperventilation syndrome, the respiratory challenge tests, the current mechanistic concepts and the pharmacological implications.
Until recently, claims for the psychological benefits of physical exercise have tended to precede supportive evidence. Acutely, emotional effects of exercise remain confusing, both positive and negative effects being reported. Results of cross-sectional and longitudinal studies are more consistent in indicating that aerobic exercise training has antidepressant and anxiolytic effects and protects against harmful consequences of stress. Details of each of these effects remain unclear. Antidepressant and anxiolytic effects have been demonstrated most clearly in subclinical disorder, and clinical applications remain to be exploited. Cross-sectional studies link exercise habits to protection from harmful effects of stress on physical and mental health, but causality is not clear. Nevertheless, the pattern of evidence suggests the theory that exercise training recruits a process which confers enduring resilience to stress. This view allows the effects of exercise to be understood in terms of existing psychobiological knowledge, and it can thereby provide the theoretical base that is needed to guide future research in this area. Clinically, exercise training continues to offer clinical psychologists a vehicle for nonspecific therapeutic social and psychological processes. It also offers a specific psychological treatment that may be particularly effective for patients for whom more conventional psychological interventions are less acceptable.
Converging evidence indicates that primates have a distinct cortical image of homeostatic afferent activity that reflects all aspects of the physiological condition of all tissues of the body. This interoceptive system, associated with autonomic motor control, is distinct from the exteroceptive system (cutaneous mechanoreception and proprioception) that guides somatic motor activity. The primary interoceptive representation in the dorsal posterior insula engenders distinct highly resolved feelings from the body that include pain, temperature, itch, sensual touch, muscular and visceral sensations, vasomotor activity, hunger, thirst, and 'air hunger'. In humans, a meta-representation of the primary interoceptive activity is engendered in the right anterior insula, which seems to provide the basis for the subjective image of the material self as a feeling (sentient) entity, that is, emotional awareness.
The objectives of this study were to assess the prevalence, screening, and recognition of depression and anxiety in persons with chronic breathing disorders, including COPD.
Cross-sectional study.
The Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC).
A large sample of 1,334 persons with chronic breathing disorder diagnoses who received care at the MEDVAMC.
The prevalence of anxiety and depression was measured in a large sample of persons with a chronic breathing disorder diagnosis who received care at the MEDVAMC, using the Primary Care Evaluation of Mental Disorders (PRIME-MD) screening questions. The positive predictive value of the PRIME-MD questions was then determined. The prevalence of anxiety and depressive diagnoses in patients determined to have COPD was then measured, using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID).
Of patients screened with the PRIME-MD, 80% screened positive for depression, anxiety, or both. The predictive value of a positive phone screen for either depression or anxiety was estimated to be 80%. In the subsample of patients who had COPD and received a diagnosis using the SCID, 65% received an anxiety and/or depressive disorder diagnosis. Of those patients, only 31% were receiving treatment for depression and/or anxiety.
It is troubling that a mere 31% of COPD patients with depression or anxiety are being treated, particularly given their high prevalence in this population. Practical screening instruments may help increase the recognition of anxiety and depression in medical patients, as suggested by the excellent positive predictive value of the PRIME-MD in our study.
This paper reviews the limited literature on paroxysmal hypertension. A case report describes the clinical picture frequently seen in specialty hypertension practice, a patient with paroxysmal or intermittent hypertension who proves not to have a pheochromocytoma. The variety of diagnostic labels given to these patients is reviewed, including pseudopheochromocytoma, panic attacks, and hyperventilation syndrome. The clinical features, pathology, diagnosis, and treatment of these syndromes are outlined. It is proposed that successful management of these patients may be best achieved by collaborative care between a hypertension specialist and a psychiatrist or clinical psychologist with expertise in cognitive-behavioral panic management, stress-reduction techniques including controlled breathing, and treating health anxiety. The use of drugs effective for treatment of panic disorder can also be helpful in managing these patients.
- Jb Howell
- Behavioural Breathlessness
Howell JB. Behavioural breathlessness. Thorax 1990;45:
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Osteopathic assessment of structural changes related to BPD Recognizing and treating breathing disorders: a multidisciplinary approach
- L Chaitow
- L Chaitow
- D Bradley
- C Gilbert
Chaitow L. Osteopathic assessment of structural changes
related to BPD. In: Chaitow L, Bradley D, Gilbert C, editors.
Recognizing and treating breathing disorders: a multidisciplinary approach. 2nd ed. Amsterdam: Elsevier; 2014. p.
99e118.
A novel breathing retraining osteopathic manual therapy intervention, and its effect on cardiac autonomic activity and breathing symptoms
- J G Benjamin
Benjamin JG. A novel breathing retraining osteopathic
manual therapy intervention, and its effect on cardiac
autonomic activity and breathing symptoms. Master of
Osteopathy thesis. New Zealand: Unitec Institute of Technology; 2016.
Osteopathic treatment of thoracic and respiratory dysfunction Recognizing and treating breathing disorders: a multidisciplinary approach
- L Chaitow
- L Chaitow
- D Bradley
- C Gilbert
Chaitow L. Osteopathic treatment of thoracic and respiratory dysfunction. In: Chaitow L, Bradley D, Gilbert C,
editors. Recognizing and treating breathing disorders: a
multidisciplinary approach. 2nd ed. Amsterdam: Elsevier;
2014. p. 169e84.