3: Asthma

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Case 3 Asthma

Description of asthma

Definition

Asthma is a chronic inflammatory disease of the airways, characterised by acute exacerbations of reversible airway obstruction. The condition was formerly divided into two main types – extrinsic and intrinsic asthma. These classifications have since changed. Asthma is now separated into more specific aetiological subtypes, including, for example, allergic, exercise-induced, nocturnal, aspirin-sensitive and occupational asthma.

This distressing, often disabling, and sometimes fatal disorder affects around ten per cent of the Australian population.¹ A slightly higher prevalence rate is evident among adult women (eleven per cent) and among the 15–24 and 75 years and over age groups (eleven per cent). Higher rates of asthma are also observed among socially disadvantaged, unemployed and Indigenous populations.¹

Aetiology and pathophysiology

The aetiology of asthma is multifactorial, with genetic and familial factors playing a major part in the pathogenesis of the disease. There is some suggestion that the growing prevalence of asthma is also due to a number of environmental contacts, such as vaccination, early introduction of foods, early exposure to antibiotics and food additives,^2,³ but there are insufficient data to support these theories. Emerging evidence does indicate that exposure to infectious agents may be a risk factor; one recent longitudinal study reported significantly higher odds of asthma and respiratory wheeze among 5-year-old children who reported severe respiratory infections during infancy, particularly those with atopy.⁴ Other factors linked to the development of asthma are obesity, exposure to household allergens (e.g. dust mite, cockroaches, pets), omega 3 fatty acid intake and perinatal issues (e.g. lack of breastfeeding, poor maternal nutrition, young maternal age, prematurity, low birthweight).^3,⁵ Evidence linking nutrient deficiency (e.g. vitamin C, vitamin E) with asthma is not convincing.^6,⁷

The acute onset of asthma in susceptible individuals can be initiated by a range of allergic and non-allergic triggers, including household allergens (e.g. dust mite, cockroaches, animal dander), respiratory irritants (e.g. air pollution, cigarette smoke, perfumes, cleaning agents, sulfur dioxide), grass and tree pollens, occupational irritants (e.g. latex, solder, flour), hormonal changes, exercise, emotions (e.g. anger, anxiety, excitement), respiratory infections, cold air, aspirin and gastro-oesophageal reflux disease.^3,⁸ It is not yet established how these factors trigger respiratory distress, although the prevailing theory suggests that heightened inflammatory activity could be a precipitating factor. The predominance of T-helper cell type 2 (Th2) activity observed in asthmatics and the subsequent increase in pro-inflammatory cytokine levels, airway eosinophilia and immunoglobulin (IgE) production, all appear to promote the development of smooth muscle hypertrophy and airway remodelling.⁹ These changes lead to airway hyper-responsiveness, which, upon exposure to any one of the aforementioned triggers, causes airway inflammation, submucosal oedema, increased mucus production, bronchoconstriction, mucus plugging and respiratory distress.^3,⁹

Clinical manifestations

People with mild asthma are normally asymptomatic between exacerbations. In more severe cases of asthma, and during acute exacerbations of asthma, people typically present with dyspnoea, tachypnoea, chest tightness, cough, audible wheezing and anxiety. As airway obstruction progresses, and oxygen exchange diminishes, more serious manifestations begin to emerge, including hypoxia, cyanosis and altered consciousness, and at worst, respiratory failure and death.^3,⁸

Clinical case

23-year-old woman with exercise-induced asthma

Rapport

Adopt the practitioner strategies and behaviours highlighted in Table 2.1 (chapter 2) to improve client trust, communication and rapport, and the accuracy and comprehensiveness of the clinical assessment.

Assessment

Once measures have been put into place to build client–practitioner rapport, the clinician can begin the clinical assessment.

Health history

History of presenting condition

A 23-year-old woman presents to her CAM practitioner with concerns about relapsing asthma. The client developed mild asthma at the age of 5, that went into remission in mid-adolescence. In the past 12 months, the signs of asthma have returned, specifically, wheezing, coughing, dyspnoea and chest tightness. These symptoms, which manifest at least 2–3 times a week, are mild and short-lived, and are no more than 10–15 minutes in duration. The symptoms, relieved by salbutamol inhaler and rest, are infrequently aggravated by cold air and frequently triggered by intense exercise. The exercise-induced asthma is particularly problematic for the client as it is interfering with her ability to perform as a personal trainer. The client is deeply concerned that without adequate treatment, she may have to turn to another career.

Medical history

Lifestyle history

Diet and fluid intake
Breakfast	Wholemeal toast with low-fat cream cheese, coffee.
Morning tea	Protein bar, banana, walnuts.
Lunch	Tossed salad or wholemeal sandwich with turkey or chicken, tomato, low-fat cheese and lettuce.
Afternoon tea	150 g vanilla yoghurt.
Dinner	Egg white omelette with tomato and cheese, grilled salmon or whiting with carrots and beans, stirfry with chicken breast, carrots, capsicum and onion.
Fluid intake	1–2 cups of instant coffee a day, 7–8 cups of water a day.
Food frequency
Fruit	1–2 serves daily
Vegetables	2–3 serves daily
Dairy	2–3 serves daily
Cereals	4–5 serves daily
Red meat	1 serve a week
Chicken	6 serves a week
Fish	1 serve a week
Takeaway/fast food	0–1 times a week

Quality and duration of sleep

Continuous sleep, average duration is 6–7 hours. In winter, sleep is often broken due to cold-air induced exacerbations of asthma.

Frequency and duration of exercise

Client is very active. Drives to work, but participates in personal training activities (e.g. weights, circuit) more than 4 hours a day; recently had to cease aerobic training due to asthma. Engages in incidental exercise (e.g. cleaning, cooking, work-related walking) more than 3 hours a day and sedentary activities less than 2 hours a day.

Socioeconomic background

The client is German-born with German-born parents. She completed tertiary education 18 months ago and has since been employed as a full-time personal trainer, which she enjoys. The client lives with her supportive partner in a new home in the outer suburbs, away from arterial roads and heavy industry. She has no children, nor any firm religious or cultural beliefs.

Physical examination

Inspection

Client is able to maintain a normal conversation in a sitting and lying position without becoming short of breath. Respiratory rate (16 breaths per minute), rhythm (regular), depth and effort are unremarkable. There are no visible signs of respiratory distress (e.g. accessory muscle use), hypoxia (e.g. clubbing or cyanosis), oropharyngeal inflammation, chest deformities or scarring.

Olfaction

Mild halitosis is evident. The client denies any sinus, chest or oral infections.

Palpation

Paranasal sinuses, lymph nodes and chest wall are non-tender and unremarkable. Chest expansion is symmetrical and tactile fremitus is normal.

Percussion

All lung fields are resonant; no abnormal percussive tones were detected.

Auscultation

Vesicular breath sounds are heard equally over all lung fields. Mild late expiratory polyphonic wheeze is also evident across all lung fields. Bronchophony, aegophony and whispered pectoriloquy are absent.

Additional signs

Client is afebrile (36.7°C, per oral) and of normal weight (BMI is 21.4 kg/m², waist circumference is 67 cm).

Clinical assessment tools

The asthma control scoring system (ACSS) revealed a clinical subscore of twenty per cent (a measure of symptom frequency, physical limitation and rescue medication use), a physiological subscore of eighty per cent (a measure of peak expiratory flow rate), and an inflammatory subscore of eighty per cent (a measure of airway eosinophil count).¹⁰ This provided a mean global asthma control score of 60 per cent, signifying modest asthma control and moderate asthma severity (a higher percentage score indicates better control and reduced severity).

Diagnostics

CAM practitioners may request, perform and/or interpret findings from a range of diagnostic tests in order to add valuable data to the pool of clinical information. While several investigations are pertinent to this case (as described below), the decision to use these tests should be considered alongside factors such as cost, convenience, comfort, turnaround time, access, practitioner competence and scope of practice, and history of previous investigations.

Pathology tests

Eosinophil count

This count is a useful marker of asthma activity because activated eosinophils release histamine, which triggers bronchial smooth muscle contraction and mucus production, all of which are implicated in the pathogenesis of asthma.⁹

Immunoglobulin E (IgE)

IgE is an antibody primarily involved in allergic reactions. When IgE is cross-linked with an antigen, it stimulates the release of vasoactive substances (e.g. histamine) from basophils and mast cells. This results in smooth muscle contraction, increased vascular permeability and inflammation,¹¹ and the subsequent manifestation of symptoms such as wheeze and dyspnoea. Elevated levels of serum IgE are positively associated with the severity of asthma.¹²

Plasma or red cell fatty acid analysis

This assesses the concentration of fatty acids within the plasma or erythrocyte, including omega 3, omega 6 and omega 9 polyunsaturated fatty acids, saturated fatty acids and trans fatty acids. Given that high dietary omega 3 fatty acid intake is associated with decreased odds of developing wheeze and asthma when compared with lower omega 3 fatty acid intake,⁵ this test may help to determine whether poor omega 3 fatty acid consumption is a contributing factor in asthma.

Sputum culture and sensitivity testing

These tests may be warranted if infectious triggers of asthma are suspected, in particular, the presence of bacterial, viral or fungal infections of the respiratory tract.¹¹

Radiology tests

It is not routine practice to use medical imaging in the diagnosis of asthma. Chest X-ray and CT scans may be indicated, however, in complicated asthma, atypical presentations of asthma, and/or suspicions of more serious pathology.⁷

Functional tests

Pulmonary function tests (PFTs)

PFTs are often used to evaluate the presence and severity of asthma. The PFT can incorporate any number of different measures of lung volume and capacity, including total lung capacity, tidal volume, maximal mid-expiratory flow (MMEF), maximal volume ventilation (MVV), peak inspiratory flow rate (PIFR), forced vital capacity (FVC), forced expiratory volume in 1 second (FEV₁), and peak expiratory flow rate (PEFR). Reductions in the latter three measures are often evident in obstructive airway diseases such as asthma.¹¹

Invasive tests

Invasive procedures are not typically used in the diagnosis of asthma unless there are suspicions of serious underlying pathology.

Miscellaneous tests

Bronchial provocation tests use either direct (e.g. inhaled histamine or methacholine) or indirect (e.g. exercise, cold air hyperventilation) stimuli to trigger bronchial smooth muscle contraction in hyperresponsive airways. There is some debate as to whether the results of these tests are specific to a diagnosis of asthma.^13,¹⁴

Diagnosis

Clusters of data extracted from the health history, clinical examination and pertinent diagnostic test results point towards the following differential CAM diagnoses.

• Dyspnoea (actual), secondary to asthma, related to genetic predisposition (client has a family history of asthma), chronic inflammation (if supported by an elevated serum IgE and eosinophil count), exercise (asthma symptoms are triggered by intense exercise), cold air (asthma symptoms are aggravated by cold air), and/or low omega 3 fatty acid intake (low omega 3 fatty acid intake is associated with increased odds of developing asthma; while the client reports the consumption of approximately one serve of fish a week, dietary recall bias cannot be excluded).

• Exercise intolerance (actual), secondary to asthma, related to genetic predisposition, chronic inflammation, exercise, cold air and/or low omega 3 fatty acid intake.

Planning

The goals and expected outcomes that best serve the client’s needs and that are most relevant to the presenting case (as determined by the clinical assessment and CAM diagnoses) are as follows.

Goals

1. Client will report a reduction in acute asthmatic episodes (client is concerned about the relapsing asthma).

2. Client will experience an improvement in exercise tolerance (client has expressed concern about the asthma interfering with personal training activities).

Expected outcomes

Based on the degree of improvement reported in clinical studies that have used CAM interventions for the management of asthma,^15,¹⁶ the following are anticipated.

1. Client will demonstrate a forty per cent reduction in the baseline number of asthma attacks experienced per week in 6 weeks or by dd/mm/yyyy (measured by asthma diary and ACSS clinical assessment subscore).

2. Client will exhibit a forty per cent decrease in baseline asthma severity in 6 weeks or by dd/mm/yyyy (measured by mean global asthma control score).

3. Client will report a forty per cent increase in the baseline duration of exacerbation-free exercise per week in 3 weeks or by dd/mm/yyyy (measured by exercise diary).

Application

The range of interventions reported in the CAM literature that may be used in the treatment of asthma are appraised below.

Diet

Low-calorie diet (Level I, Strength C, Direction +)

As previously stated, there are a number of factors that elevate a person’s risk of developing asthma. A risk factor that is generally responsive to dietary change is obesity. There is, for instance, convincing evidence that high body weight at birth and/or during middle childhood increases the risk of developing asthma.¹⁷ Whether weight-reduction strategies are able to reverse this risk or improve asthma outcomes requires evidence from intervention studies. According to a Cochrane review, only one RCT has explored this hypothesis. The trial found the consumption of a low-energy diet plus education for 14 weeks to be statistically significantly superior to normal diet plus education at improving FEV₁, FVC and rescue medication use in obese people with asthma.¹⁸ Given that low-calorie diets also reduce serum levels of inflammatory markers¹⁹ suggests that the low-energy diet could have improved respiratory function via an anti-inflammatory effect.

Miscellaneous diets (Level I, Strength C, Direction o)

Dietary modification is central to the overall management of asthma in many fields of CAM. While there is adequate theoretical justification to recommend many of these dietary interventions to people with asthma, such as a low-reactive or anti-inflammatory diet, there is a paucity of evidence to support these practices. A number of systematic reviews have also found insufficient or inconclusive evidence to link fish oil supplementation,^20,²¹ dietary salt reduction²² and tartrazine avoidance²³ to improvements in asthma outcomes. A recent meta-analysis of 10 observational studies also failed to find a significant correlation between dietary intake of antioxidants (including vitamin C, vitamin E and beta-carotene) and risk of asthma.⁶ By contrast, the consumption of whole foods (e.g. apples, pears, whole milk, butter) appears to offer some protection against asthma, according to a community-based, cross-sectional study of 1601 young adults.²⁴ Several controlled trials have also found the dietary consumption of sulfur dioxide to exacerbate asthma in adults²⁵ and to significantly reduce lung function in children with asthma.²⁶ Nonetheless, these studies were small and, despite being published more than 15 years ago, have yet to be replicated using larger samples and more rigorous methodology.

Lifestyle

Buteyko breathing (Level II, Strength B, Direction + (for bronchodilatator use) and o (for respiratory function))

The Buteyko breathing technique (BBT) is a set of breathing exercises that serve to control the rate and depth of respirations. In doing so, Buteyko is believed to benefit people suffering from conditions characterised by hyperventilation, such as asthma. Five small RCTs have tested this claim,²⁷^–³¹ none of which found BBT to be effective at improving the physiological outcomes of asthma (e.g. FEV₁, PEFR). Changes in quality of life and asthma control were also inconsistent across studies. On the other hand, all studies consistently showed BBT to be statistically significantly superior to controls at reducing inhaled beta-2 agonist and corticosteroid medication use. This suggests that the inclusion of BBT within a client’s asthma management plan may help to reduce the overall cost of asthma treatment.

Relaxation therapy (Level I, Strength C, Direction + (for bronchodilatator use) and o (for respiratory function))

The relaxation response can be induced by a number of behavioural therapies, such as progressive muscle relaxation, guided imagery and autogenic training. Many RCTs and systematic reviews have examined the effect of these therapies on asthma outcomes, although the results of these studies have been inconsistent. There are conflicting findings regarding, for instance, the effect of relaxation therapy (RT) on asthma symptoms and respiratory function (e.g. FEV₁ and PEFR) in asthmatic adults.³²^–³⁵ In asthmatic children, evidence suggests that RT may be effective at improving PEFR.³⁶ A meta-analysis of two small RCTs indicates that RT may also be effective at reducing bronchodilator use,³⁵ but the small size and methodological limitations of these studies, as well as the short duration of the interventions, limits any conclusions that can be made.

Yoga (Level II, Strength B, Direction o)

Yoga is an ancient Indian practice that integrates stretching, posture, exercise and breathing with meditation. Given that these techniques are likely to bring on a relaxation response, yoga has been thought to be helpful in improving asthma symptoms, but with the exception of one controlled trial,³⁷ many RCTs have found yoga to be no more effective than controls at improving asthma symptoms, physiological parameters or quality of life.³⁸^–⁴² Still, studies using bronchial provocation tests have demonstrated significantly greater tolerance to airway provocation among people practising yoga than people receiving controls.^39,⁴¹ This suggests that yoga might be more effective in certain subtypes of asthma, although given the uncertain specificity of this test, further investigation is needed.

Nutritional supplementation

Ascorbic acid (Level 1, Strength C, Direction o)

When compared with normal subjects lower levels of vitamin C have been reported in asthmatic adults and children.^43,⁴⁴ Low vitamin C levels are also associated with poor respiratory function.⁴⁵ A meta-analysis of seven studies (n = 13,653) found no significant association between dietary intake of vitamin C and risk of asthma.⁶ Similarly, a Cochrane review of nine RCTs that involved 330 adults and children found no significant difference for the effect of orally administered vitamin C on lung function or symptoms.⁴⁶

Beta-carotene (Level III-1, Strength C, Direction +)

Beta-carotene demonstrates immunomodulatory and antioxidant activity in experimental and clinical studies.⁴⁷ While a meta-analysis of seven studies (n = 13,653) found no significant association between dietary intake of beta-carotene and risk of asthma,⁶ this does not seem to apply to supplemental beta-carotene. In a small RCT, the acute effect of beta-carotene supplementation (64 mg daily for 1 week) was compared with placebo in 37 patients with exercise-induced asthma. Exercise-induced asthma was prevented in fifty-two per cent of people receiving the beta-carotene. All people in the placebo group demonstrated a decline in lung function.¹⁶ Whether these effects can be replicated using lower doses of beta-carotene over a longer period of time is not yet certain.

Magnesium (Level II, Strength B, Direction o)

Magnesium is involved in many enzymatic reactions and physiological processes throughout the body. Hence, a deficiency of this mineral can result in a number of adverse manifestations. Low serum magnesium levels, for example, have been shown to intensify neuromuscular cell excitability, resulting in increased smooth muscle contractility. High serum levels of magnesium cause smooth muscle relaxation.⁴⁸ In addition to this bronchodilating effect, magnesium also plays a role in modulating inflammation.⁴⁹ Although these properties have influenced the use of intravenous magnesium in the emergency management of asthma, for which there is sound evidence,⁵⁰ this approach to asthma is not congruent with CAM philosophy or compatible with the scope of CAM practice. Using orally administered magnesium to prevent asthma exacerbations would be a more suitable approach. Even though several RCTs have examined the effectiveness of orally administered magnesium in children and adults with asthma (with doses ranging from 200–450 mg/day of Mg chelate, to 18.3 g/day of Mg), results have been conflicting with regards to lung function, bronchial reactivity, asthma symptoms and bronchodilator use.⁵¹^–⁵³

Omega 3 fatty acids (Level I, Strength B, Direction o)

High dietary omega 3 fatty acid intake is associated with decreased odds of developing wheeze and asthma when compared with lower omega 3 fatty acid intake.⁵ It is likely that this protective effect may be attributed, among other reasons, to the anti-inflammatory action of the fatty acids.⁵⁴ While findings from epidemiological studies are promising, a systematic review of 26 clinical studies (including 11 RCTs) found inadequate or inconclusive evidence to support the use of fish oil supplementation in the primary and secondary prevention of asthma.²⁰ Studies postdating this review⁵⁵^–⁵⁷ have also demonstrated conflicting results. There is some evidence to suggest that prenatal administration of fish oil may be effective in the primary prevention of asthma, allergic asthma⁵⁸ and asthma symptoms.⁵⁹

Pyridoxine (Level III-1, Strength C, Direction + (for medication use only))

Vitamin B₆ is a water-soluble vitamin and an important coenzyme in carbohydrate, lipid and protein metabolism. Emerging data suggest pyridoxine also may be useful in the treatment of inflammatory disorders. Clinical data indicate that, for instance, pyridoxine supplementation (300 mg twice a day for 7 days) significantly reduces thromboxane B₂ and leukotriene E₄ excretion (p<0.05) in male subjects, although the effect in females is not certain.⁶⁰ Despite the results of this small mechanistic study, evidence from two double-blind controlled clinical trials is somewhat difficult to interpret because of the small size of the studies, the lack of randomisation, different control groups, the variable dosage and duration of B₆ treatment, and the different outcomes measured. In the first study, oral pyridoxine (200 mg daily for 20 weeks) significantly reduced bronchodilator and cortisone use when compared with lower dose pyridoxine (100 mg daily).⁶¹ In the second study, oral pyridoxine (300 mg daily for 9 weeks) was found to be no more effective than placebo at improving asthma symptoms or lung function,⁶² which highlights the need for further research in this area.

Selenium (Level II, Strength B, Direction o)

Selenium is a mineral involved in the regulation of inflammation and immunity, specifically, the inhibition of nuclear factor-kappaB activation,⁶³ the enhancement of T-cell function, and B-cell activation and proliferation.⁶⁴ Selenium has also been shown to lower oxidative stress in asthmatics with selenium deficiency.⁶⁵ Despite these favourable results, findings from controlled trials have yet to support the use of this mineral in people with asthma. Two controlled clinical trials have, for instance, failed to demonstrate a statistically significant difference between patients receiving selenium (100 μg daily for 14–24 weeks) and patients receiving placebo with regards to lung function, medication use, asthma symptoms and quality of life.^66,⁶⁷ While selenium supplementation was significantly (p = 0.04) more effective than placebo at improving a composite score of these measures (excluding quality of life), the validity and reliability of this score is questionable. The effectiveness of higher doses of selenium in people with asthma is a matter for further research.

Vitamin E (Level II, Strength C, Direction o)

Tocopherols exhibit a number of actions that may target the mechanisms of asthma; for instance, the inhibition of proinflammatory cytokine release, and the reduction in monocyte adhesion to endothelial tissue.⁶⁸ Even so, observational studies have failed to find a significant correlation between dietary vitamin E intake and risk of asthma.⁶ Likewise, a 6-week double-blind RCT involving 72 adults with asthma found vitamin E supplementation (500 mg daily) to be no more effective than placebo at improving bronchial hyperresponsiveness, lung function, asthma symptom scores and bronchodilator use.⁶⁹

Quercetin

Quercetin exhibits myriad effects that are considered desirable in the management of asthma, including anti-inflammatory, immunomodulatory and antiallergic activity; however, there is insufficient clinical evidence regarding its efficacy to justify the administration of this nutrient in people with asthma.

Herbal medicine

Boswellia serrata (Level II, Strength B, Direction +)

Frankincense has long been used as an anti-inflammatory herb in Ayurvedic medicine. Data from experimental studies support this anti-inflammatory effect; the boswellic acids in frankincense gum resin have been shown to inhibit 5-lipo-oxygenase and cyclo-oxygenase activity, and the subsequent release of proinflammatory mediators.⁷⁰ While frankincense was traditionally used as a treatment for arthritis, the action of the herb suggests it may also be useful in the management of asthma. Findings from one well-designed RCT (n = 80 adults with asthma) lend support to this claim. This trial found B. serrata extract (350 mg three times a day for 6 weeks) to be significantly more effective than placebo at improving lung function, particularly FEV₁ (p<0.0001). B. serrata was also effective at reducing asthma symptoms, number of asthma attacks, eosinophilic count and erythrocyte sedimentation rate.¹⁵ Further research is now required to corroborate these findings.

Ginkgo biloba (Level III-2, Strength C, Direction +)

Maidenhair tree has demonstrable anti-inflammatory and antioxidant effects.^71,⁷² Despite these useful properties, and the long history of its use in traditional Chinese medicine, only one published study has explored the clinical efficacy of ginkgo in people with asthma. This study, which compared the effectiveness of a concentrated ginkgo leaf liquor (15 g three times a day) to placebo in 61 adults and children with asthma, found ginkgo to be significantly more effective than placebo (p<0.05) at improving FEV₁ at 8 weeks.⁷² While this outcome is promising, further research is needed to determine if standardised extracts of G. biloba exhibit similar activity to ginkgo liquor.

Picrorhiza kurroa (Level II, Strength B, Direction o)

Katuka is traditionally used in Ayurvedic medicine for the treatment of respiratory disease, particularly asthma and bronchitis. The anti-inflammatory, antioxidant, smooth muscle relaxant and immunomodulatory effects of the herb, which have been demonstrated experimentally,^73,⁷⁴ offer a pathophysiological rationale for the use of katuka in asthma. That said, the best available evidence fails to support this theory. In the only known RCT of katuka and asthma, P. kurroa root (300 mg three times a day for 14 weeks) was found to be no more effective than placebo at improving lung function (i.e. FEV₁) or asthma symptoms in 72 children and adults with asthma.⁷⁵

Tylophora indica (Level I, Strength B, Direction o)

Indian ipecac is an Ayurvedic herb traditionally prescribed for the treatment of asthma, bronchitis, allergy and respiratory complaints. The anti-inflammatory, antihistaminic and smooth muscle relaxant properties of T. indica, which are supported by a number of experimental studies,⁷⁶ are desirable for the effective management of asthma. At least five controlled clinical trials have explored the effectiveness of monopreparations of T. indica in adults and children with asthma.⁷⁷ Firm conclusions cannot be made about the effectiveness of this herb, as improvements in lung function and asthma symptoms have not been consistent across studies. This may be partly explained by differences in treatment duration (i.e. 1–12 weeks), as well as differences in the active and control preparations used. One study did find the alkaloid extract of Indian ipecac to be significantly more effective than control at reducing medication use at 12 weeks, though the relevance of this preparation to conventional CAM practice is not certain. Given that all five studies are more than 30 years old, and that the clinical efficacy of T. indica in people with asthma is still inconclusive, further research in this area is well justified.

Other herbs

Adhatoda zeylanica (adhatoda), Albizia lebbeck (albizzia), Aloe barbadensis (aloe vera), Althaea officinalis (marshmallow), Chamomilla recutita (German chamomile), Coleus forskohlii (coleus), Euphorbia hirta (euphorbia), Inula helenium (elecampane), Grindelia camporum (grindelia), Rehmannia glutinosa (rehmannia), Schisandra chinensis (schisandra), Scutellaria baicalensis (baical skullcap), Viburnum prunifolium (black haw) and Withania somnifera (ashwaganda) have all been used traditionally and/or tested under experimental conditions for their antiallergic, antimicrobial, anti-inflammatory and/or immunostimulant activity,^78,⁷⁹ but there is insufficient clinical data to support the use of these herbs in asthma.

Other

Acupuncture (Level I, Strength C, Direction o)

Acupuncture originated in China more than 4000 years ago.⁸⁰ Since then, the therapy has established a large traditional evidence base. In the case of asthma, the best available evidence indicates that acupuncture is not an effective treatment for this condition. According to a Cochrane review of 12 RCTs (n = 350), for instance, neither needle nor laser acupuncture were found to be effective at improving lung function or wellbeing in people with asthma, while changes in asthma symptoms were shown to be inconsistent across studies. Needle acupuncture did demonstrate statistically significant superiority to sham acupuncture in reducing medication usage.⁸¹ Given the range of interventions or techniques used, the lack of consideration given to contextual effects, and the differences in study design and outcomes measures, no firm conclusions can be drawn.

Chiropractic (Level II, Strength C, Direction o)

Chiropractic manipulation is generally indicated in the treatment of nervous and musculoskeletal disorders. While chiropractic is also used to treat a range of non-musculoskeletal complaints, such as asthma,^82,⁸³ there is insufficient evidence to support the use of chiropractic manipulation in asthma. Findings from three small RCTs indicate that chiropractic spinal manipulation is no more effective than sham manipulation at reducing bronchodilator use or improving PEFR, FEV₁ or FVC in children and adults with asthma.⁸⁴^–⁸⁶ As for asthma severity and quality of life, results have not been consistent across studies.

Homeopathy (Level I, Strength C, Direction o)

Homeopathy is a system of medicine that uses highly diluted and potentised remedies to influence the body’s vital force and restore balance. The therapy can be used to treat a wide range of acute and chronic complaints, including asthma. A number of trials have investigated the effectiveness of homeopathy in asthma, the results of which have been synthesised in a Cochrane review.⁸⁷ The six randomised double-blind placebo-controlled trials included in the review examined the effect of individualised and formula homeopathy in adults and children with mild to severe asthma, for a period ranging from 1 day to 12 months. Changes in lung function (e.g. FEV₁, FVC, PEFR), asthma symptoms, quality of life, frequency, duration or intensity of asthma exacerbations and medication use were not consistent across studies; thus the effectiveness of homeopathy for asthma is still uncertain. There is some concern that the outcomes of these studies might have been influenced by the concurrent administration of allopathic medication, as well as the omission of important contextual effects of homeopathic treatment (i.e. client–practitioner interaction). A more appropriate way of investigating the effectiveness of homeopathic management in future may be through whole systems research.

Massage therapy (Level II, Strength C, Direction + (for some measures of respiratory function))

Massage is the systematic manipulation of soft tissues of the body. This therapy may be helpful in reducing the symptoms of asthma, such as anxiety, wheezing and tachypnoea, by stimulating parasympathetic nervous system activity.⁸⁸ The best available evidence to date comes from two small RCTs, both of which investigated the effects of parent-administered massage (20 minutes every night for 30 days) in children. In the first study (n = 32), massage was found to be more effective than progressive muscle relaxation in reducing child anxiety,⁸⁹ although the level of significance was not clear. In the second trial (n = 44), massage was shown to be more effective than standard care in improving FEV₁ (p = 0.04) and FVC (p = 0.05), though the difference between groups was only marginally significant.⁹⁰ Reported changes in MMEF were inconsistent across studies. Whether massage is effective in adults with asthma or at reducing the frequency or severity of asthma attacks is yet to be investigated.