AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS CLIENT RESPONSES Onset When did you first notice the cough? After I had a cold last month. Timing How often do you cough? Every day. Exacerbating factors What makes it worse? When I run around and at night. Relieving factors What makes it better? When I stay inside and during the day. Examination and inspection Physical examination reveals bilateral tenderness of cervical lymph nodes.

TABLE 6.2 CONTEXT

Analogy: Flesh of the apple	Context: Put the presenting complaint into context to understand the disease
AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS	CLIENT RESPONSES
Family health
To Jake’s mum: Is there a family history of asthma?	Jake’s cousin has asthma.
Allergies and irritants	Jake’s mum answers:
Are there symptoms of sneezing or nose discharge, conjunctivitis and itching on the roof of the mouth with the cough? (allergies)	No, not much in terms of sneezing or runny nose or eye symptoms.
Infection and inflammation	Jake’s mum answers:
Is the cough ever worse in the morning? (PND, chronic bronchitis)	It seems to be getting worse during the night, but he doesn’t cough more in the morning.
Stress and neurological disease	Jake’s mum answers:
So if I understand correctly, the cough is disturbing sleep and does not improve at night? (may rule out psychogenic, habit cough, Tourette’s syndrome)	Yes, that’s right, it seems to definitely worsen during the night but I’m not sure if that’s because of how cold his room gets at night sometimes.
Eating habits and energy	Jake’s mum answers:
Tell me about Jake’s diet and his energy levels.	He eats whatever I give him, but doesn’t like vegetables very much. He has Weet-Bix and milk for breakfast and usually a cheese sandwich for lunch. I send fruit to school every day but he usually brings it home. He would eat McDonald’s every day if we let him, but we don’t.
	He is usually full of energy, but he seems to be a bit lethargic recently.

TABLE 6.3 CORE

Analogy: Core of the apple with the seed of ill health	Core: Holistic assessment to understand the client
AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS	CLIENT RESPONSES
Emotional health
To Jake’s mother:
Do you think Jake might be a bit stressed? Can you tell me about that?	There has been a bit of conflict between Jake’s dad and myself. I would like to live closer to my family, but he really loves it where we are and wants to stay.
Daily activities
To Jake:
Tell me what you do every day.	I go to school and when I get home I muck around with my friends or watch TV.
Family and friends
To Jake:
Tell me about your friends and family.	Tim and Ryan live up the road so we hang out a lot. My cousins live in the city so I see them sometimes on the weekend or in the holidays.
Action needed to heal
To Jake:
I know you’d like to get rid of your cough and have more energy again. Do you think you’d be willing to take some medicine and do some things I suggest to help you get better?	Depends if I like it.

TABLE 6.4 JAKE’S SIGNS AND SYMPTOMS [1–3]

Pulse	100 bpm (normal pulse for a child is 80–120 bpm)
Blood pressure	110/77 sitting with child cuff
Temperature	37°C
Respiratory rate	14 resp/min (15–30 resp/min is usual for a child)
Body mass index	20 (85th percentile for an 11-year-old boy)
Face	Red
Physical examination	Cervical nodes small and tender on both right and left sides
Urinalysis	No abnormality detected (NAD)

Results of medical investigations

No investigations have been carried out.

TABLE 6.5 UNLIKELY DIAGNOSTIC CONSIDERATIONS [2–4, 63]

CONDITIONS AND CAUSES	WHY UNLIKELY
INFECTION AND INFLAMMATION
Acute viral upper respiratory tract infection	No fever, cough has been present for more than 2 weeks
Acute bronchitis	No fever, cough has been present for more than 2 weeks
Tuberculosis	No fever, cough has been present for more than 2 weeks
Pneumonia	No fever, cough has been present for more than 2 weeks

Case analysis

TABLE 6.6 POSSIBLE DIFFERENTIAL DIAGNOSIS

Not ruled out by tests/investigations already done [2, 4, 5, 10–13, 63, 64, 66–68, 76, 77]
CONDITION	WHY POSSIBLE	WHY UNLIKELY
ALLERGIES AND IRRITANTS
Chronic allergies, irritants [64, 65]	Lives in the country, could be near irritants and pollutants such as pollens, dust and farming practices or chemicals that could trigger allergies or bronchial irritation; Jake may be exposed to chlorine and swimming pools	No history of hay fever, sinus or seasonal allergies
CANCER AND HEART DISEASE
Carcinoma: leukaemia, carcinoma of oesophagus, larynx, trachea, bronchi, alveoli, pleura	Persistent cough	Rare
TRAUMA AND PRE-EXISTING ILLNESS
Causal factor: Trauma/physical abuse: from rib fracture, laceration, haemorrhage, inhalation of foreign object	Persistent cough, stress at home	No signs or symptoms of associated body pain or trauma as yet
FUNCTIONAL DISEASE
Cystic fibrosis	Can present in school-aged children, breathlessness, recurrent chest infections	No sign of sinusitis, mucus in bowel motions, blood in sputum
Gastro-oesophageal reflux	Common cause of persistent recurrent cough; can be worse after eating chocolate or caffeinated foods/drink can be exercise induced	Usually occurs in adults and presents with a non-productive cough; usually worse on waking and after eating
INFECTION AND INFLAMMATION
Asthma: postviral	Children with recurrent cough are often asthmatic; Jake’s recent upper respiratory tract infection was most probably viral (antibiotics did not completely resolve it); family history of asthma; productive cough that is persistent and subacute with clear thick mucus; cough is worse at night, in the cold and on exertion; stressful time at home with parents fighting; shortness of breath is associated with the cough in cold weather
Chronic bronchitis: viral, bacterial, allergen based	Jake’s cough has lasted longer than 3 weeks; productive sputum, recurrent episodes, worse with exercise, lymph nodes raised; often due to dry air in winter months in school-aged children; persistent cough irritated by nonspecific bronchial irritants; shortness of breath on exertion	No exposure to cigarette smoke in the household; Jake’s cough does not produce yellow mucus; he doesn’t have a headache, fever, chills or abdominal pain; usually more likely for chronic bronchitis to develop in adults; often cough is worse in the morning
Causal factor: Recurrent viral upper respiratory tract infections	Viruses are the most common cause of coughs in children who are in contact with other children; can exacerbate asthma symptoms	No current fever or sign of viral infection
Parasites or fungi in alveoli	Cause inflammatory cough	Rare
Enlarged adenoids	Common cause of persistent cough in children	No mention of sinus or throat concerns in the case history
STRESS AND NEUROLOGICAL DISEASE
Causal factor: Psychogenic cough	Stress at home from parents arguing	Jakes cough does not usually improve during the night or with sleep

TABLE 6.7 DECISION TABLE FOR REFERRAL [2, 5, 8, 9]

Complaint	Context	Core
Referral for presenting complaint	Referral for all associated physical, dietary and lifestyle concerns	Referral for contributing emotional, mental, spiritual, metaphysical, lifestyle and constitutional factors
REFERRAL FLAGS	REFERRAL FLAGS	REFERRAL FLAGS
• Persistent cough that is worse at night and after exercise

• Recent upper respiratory tract infection treated with antibiotics

• Possible underlying allergies or intolerances

• Lowered immunity

Nil ISSUES OF SIGNIFICANCE ISSUES OF SIGNIFICANCE ISSUES OF SIGNIFICANCE Nil

• Inadequate nutritional status (does not always eat vegetables)

• Recent use of antibiotics may have negatively affected intestinal microflora

• Tendency to anxiety

• Stress and anxiety from hearing parents arguing

REFERRAL REFERRAL REFERRAL

• Referral for medical assessment and diagnosis and management plan [70, 76]

• Dietary assessment

• Food allergy and intolerance assessment

• Massage for relaxation

• Counsellor specialising in children’s psychology to assess anxiety levels

TABLE 6.8 FURTHER INVESTIGATIONS THAT MAY BE NECESSARY [1, 2, 4, 5, 10–13, 75]

TEST/INVESTIGATION	REASON FOR TEST/INVESTIGATION
FIRST-LINE INVESTIGATIONS:
Ear, nose, throat physical examination	Infection and allergic signs
Chest examination: auscultation, percussion	Signs of asthma, obstruction, infection, foreign body, heart failure
Sputum test: histology, microbiology	Detect presence of eosinophils (sign for asthma), eliminate bronchitis and pneumonia, TB, fungal origin
Lung function tests: forced expiratory volume (FEV), peak expiratory flow rate (PEF)	Will be reduced in asthma and chronic bronchitis
Exercise test	Asthma
Differential white cell count	Detection of eosinophils to confirm allergic triggers for asthma
Full blood count and IgE [74]	Infection, inflammation, anaemia, allergies
ESR/CRP	Pneumonia, infection, cancer
IF NECESSARY:
Chest x-ray	Lung abscess or tumour
Histamine/methacholine bronchial provocation test [71, 72]	Asthma
Capnometer/pulmonary gas exchange during orthostatic Tests/Nijmegen questionnaire	Hyperventilation syndrome [43–46]
Skin prick test [73]	For extrinsic allergies connected to asthma in young children
RAST [74]	To identify allergies
Food diary	To help determine any foods that may be triggering or aggravating symptoms
Sweat test	Cystic fibrosis

Confirmed diagnosis

Jake and asthma

Jake is an only child who has presented to the clinic with asthmatic symptoms following a respiratory tract infection, which was treated with antibiotics. Jake is generally a healthy and active child, although his diet appears to be lacking in a number of nutrients essential for healthy immune and lung function. Jake is also showing signs of anxiety, which may have had an effect on his immunity and respiratory health.

Asthma is a chronic inflammatory condition of the airways. Symptoms include wheezing, chest tightness, shortness of breath on expiration, a cough that is worse at night and on exertion, and production of thick clear-coloured phlegm. Onset commonly occurs in childhood and young adulthood when asthma attacks can last from hours to days. Asthma is categorised as mild, moderate or severe depending on symptom frequency and lung function tests. The condition is often initiated by a viral upper respiratory tract infection in children and may be temporary although it can often become a permanent condition. The main defining medical features of asthma include airway limitation, airway hyperresponsiveness and inflammation of the bronchi. There are both extrinsic (definite external causes such as allergies) and intrinsic (causative agents not medically identified) reasons for why asthma is triggered and develops. Precipitating factors include allergies, atmospheric and occupational pollutants [64, 65], irritants (such as cigarette smoke), medication (NSAIDs, beta-blockers), drugs, cold air, exercise, diet and emotion. Theories suggest that more exposure to allergens and illness in early years helps children boost immune response and ward off triggers for developing asthma [60, 69].

Causes of asthma include:

• elevated eosinophils in submucosa and airway exudates – these continue the inflammatory response even when the upper respiratory infection has cleared

• mucosal oedema

• production of thick mucus by airway mucosa

• increased levels of IgE – allergy.

General references used in this diagnosis: 2, 4, 10, 11, 13, 59, 61, 62, 68, 69

Prescribed medication

• Combined reliever and preventer medication

TABLE 6.9 DECISION TABLE FOR TREATMENT (ONCE DIAGNOSIS IS CONFIRMED)

COMPLAINT	CONTEXT	CORE
Treatment for the presenting complaint and symptoms	Treatment for all associated symptoms	Treatment for mental, emotional, spiritual, constitutional, lifestyle issues and metaphysical considerations
TREATMENT PRIORITY	TREATMENT PRIORITY	TREATMENT PRIORITY
• Lifestyle recommendations to reduce symptom severity and improve cardiopulmonary fitness • Recommendation for breathing exercises that may reduce the frequency and severity of asthma attacks • Lifestyle recommendations to identify and manage asthma triggers • Physical therapy suggestions to improve pulmonary function

• Lifestyle recommendation to reduce exposure to known and suspected environmental triggers

• Physical therapy recommendations to improve general health and immune function

• Dietary recommendations to increase consumption of foods that will improve Jake’s general health, nutrition and respiratory health

• Lifestyle recommendations to reduce Jake’s physical symptoms

• Recommendation for counselling and stress-management techniques to reduce stress and anxiety-related symptom aggravation

• Recommendation for Jake’s parents to talk to him regarding his anxieties about their arguing

• Dietary recommendations to identify and manage food allergies or sensitivities that may be triggering asthma and to increase consumption of foods with anti-inflammatory action

• Herbal tonic or tea with bronchospasmolytic, bronchodilatory, antimicrobial, expectorant anti-inflammatory and antiallergic actions

• Nutritional supplements to reduce inflammation and improve bronchial tone and lung function

NB: Herbal formula and nutritional supplements should be reviewed once Jake’s symptoms are under control; it is important for Jake’s condition to be collaboratively managed with his GP to ensure optimal treatment outcome

• Dietary recommendations to identify and manage food allergies or sensitivities

• Herbal tonic or tea with adaptogenic, antioxidant, immunomodulatory and tonic action to improve Jake’s vitality and immunity

• Supplemental nutrients to improve Jake’s levels of essential nutrients, reduce inflammation, allergic response, modulate immune function and restore intestinal microflora to improve general health and reduce asthma symptoms

NB: Supplements have been recommended in order of priority to help improve compliance and take financial considerations into account

• Recommendation to keep physically active to improve physical and emotional health

• Physical therapy suggestions to help reduce Jake’s stress and anxiety

• Herbal tonic or tea with anxiolytic and adaptogenic action to support Jake’s nervous system and stress response

• Nutritional support for stress and nervous system

Treatment aims

• Reduce inflammation [14], bronchial hyperreactivity [14] and bronchial smooth muscle contraction [15].

• Modulate immune-based inflammatory responses [14].

• Identify and eliminate or reduce exposure to allergies and/or sensitivities that are triggering Jake’s asthma [12, 15, 16, 50].

• Identify and reduce or eliminate underlying causative or sustaining factors such as:

• food allergies or intolerances [17, 50]

• compromised digestive function, hypochlorhydria [15], increased intestinal permeability [15, 51]

• underlying infection (possibly low-grade, unresolved infection) [15, 50]

• emotional stress [15]

• environmental triggers such as air pollution, cigarette smoke, cold dry air [16, 50].

• Improve Jake’s diet and nutritional status [17].

Lifestyle alterations/considerations

• Jake may benefit from controlled breathing exercises that emphasise slow regular breathing in which the ratio of inhalation to exhalation is 1:2 (e.g. yogic breathing) [16, 28]. Breathing exercises may reduce the frequency of asthma attacks [28]. Inhaling hot, moist air during breathing exercises can enhance the benefits [28].

• Encourage Jake to keep exercising as asthma symptoms are easier to control in people who are physically fit [28]. Improved cardiopulmonary fitness improves emotional status and decreases the intensity of wheezing attacks [33].

• If it is determined that Jake has environmental allergies (e.g. house dust mites, pets, etc.), it is important to manipulate his environment to reduce his exposure to environmental allergens [28].

• Encourage Jake to avoid or minimise his exposure to environmental triggers such as cold, dry air and airborne pollutants such as cigarette smoke, smoke from wood heaters, diesel fumes, etc. [16, 53, 54].

• Stress-management techniques, such as meditation, progressive muscle relaxation and autogenic training, can help manage stress and improve pulmonary function [28]. There is considerable evidence for a link between emotional or stress responses and asthma [32]. Helping Jake to cope with his stress and emotions may help improve his asthma symptoms [32].

• Jake needs to get an asthma-management plan from his doctor. Asthma-management plans are designed to help children and parents identify early signs of worsening asthma and intervene early with appropriate treatment strategies to prevent symptoms worsening. Written asthma-management plans are strongly associated with a reduced risk of adverse outcomes among children with asthma [34].

• Jake may benefit from counselling to help him learn helpful coping strategies to deal with his anxiety [35].

• Encourage Jake’s parents to talk to him about his anxieties, particularly relating to him overhearing them arguing. Reassurance from his parents is important.

Dietary suggestions

For compliance reasons, these are listed in order of priority. Jake may not be happy with an immediate radical change to his diet. The authors’ clinical experience has shown that gradual dietary change is more likely to be permanent than immediate radical dietary change.

• Jake should increase dietary intake of omega-3 fatty acids from cold-water fish, almonds, walnuts, pumpkin and flaxseed [28, 47] and reduce omega-6 [48] and trans-fatty acids [49]. Consumption of fresh oily fish is associated with a significantly reduced risk of asthma and improved pulmonary function [28, 47].

• Check for food sensitivities, intolerances or allergies and avoid foods that may precipitate an asthma attack [12, 15–17]. Some asthmatics experience significant improvement when excluding known reactive foods [17]. Foods most commonly found to be reactive include eggs, dairy food, wheat, fish, citrus fruits, peanuts and soya [17].

• Avoid exposure to food additives [16, 55, 56].

• Encourage Jake to consume more antioxidant-containing whole foods (vegetables, fruit, whole grains, legumes, etc.) [15, 17] and reduce consumption of refined carbohydrates and sugar. Jake needs to increase his intake of essential nutrients [17].

• Include onions and garlic in Jake’s diet. Compounds found in onions reduce leukotriene synthesis and can reduce bronchoconstriction [28].

• Avoid excessive salt intake; it may increase bronchial reactivity [14].

Physical treatment suggestions

• Acupuncture may improve Jake’s quality of life and reduce his need for bronchodilator medication [25, 37]. When combined with conventional treatment, acupuncture performed in accordance with traditional Chinese medicine principles has significant immune modulating effects [26].

• Massage therapy may be beneficial to Jake. It may help to improved his pulmonary function [27, 36] and massage may help reduce his stress and anxiety [36].

• Hydrotherapy: constitutional hydrotherapy [38–40]. Back and front contrast treatment with cold mitten friction on the trunk when symptoms begin to ease [40, 41]. A hot chest shower [41]. Smear a mustard plaster on the chest consisting of one part mustard powder to three parts flour with enough water to make a paste [42]. A steam vapouriser will assist breathing [42].

TABLE 6.10 HERBAL FORMULA (1:2 LIQUID EXTRACTS)

Made with ethanolic extract herbal liquids (alcohol removed)
HERB	FORMULA	RATIONALE
Ginkgo Ginkgo biloba 50:1 Standardised extract equivalent to 4–8 g leaf [18]	40 mL	Anti-PAF activity [18]; antioxidant [18, 19]; immunostimulant [19]; anti-inflammatory [19]; anxiolytic [19]; reduces airway hyperreactivity [19]; protective against exercise induced bronchospasm [20]
Euphorbia Euphorbia hirta

10 mL Expectorant [23, 24]; anti-asthmatic [23, 24]; traditionally used for bronchial asthma [23, 24]

Adhatoda

Adhatoda vasica

40 mL Expectorant [21]; bronchodilator [21]; anti-asthmatic [21]; protects against histamine induced bronchospasm [21]; traditionally used to treat bronchitis and asthma [22] and considered to be a sedative expectorant [22]

Baical scullcap

Scutellaria baicalensis

80 mL Antiallergic [19, 21]; antioxidant [19]; anti-inflammatory [19, 21]; antimicrobial [19, 21]; anxiolytic [19]

Licorice

Glycyrrhiza glabra

30 mL Expectorant [18, 19]; antitussive [19]; antoixidant [19]; anti-inflammatory [18, 19]; antibacterial [18, 19]; immunomodulator [19]; adaptogen [18, 19]; adrenal tonic [18, 19]; also useful to include in Jake’s formula to help improve the taste Supply: 200 mL Dose: 5 mL twice daily

TABLE 6.11 HERBAL TEA

Alternative to herbal tonic if a tea improves compliance
HERB	FORMULA	RATIONALE
Licorice root Glycyrrhiza glabra	2 parts	See above
Thyme leaf Thymus vulgarus	2 parts	Antispasmodic [18, 19]; antimicrobial [18, 19]; expectorant [18]; antitussive [19]; anti-inflammatory [19]; antioxidant [19]; traditionally used in bronchitis and asthma and upper respiratory tract inflammation [18]; approved by Commission E for the treatment of bronchitis, whooping cough and upper respiratory tract catarrh [19]
Fennel seed Foeniculum officinale	½ part	Spasmolytic [18, 23]; antimicrobial [18, 23]; expectorant [18, 23]; traditional European use for upper respiratory tract conditions in children [23]
Grindelia Grindelia camporum	1 part	Expectorant [23, 24]; antispasmodic [23, 24]; bronchospasmolytic [23]; traditionally used for asthma, bronchitis and whooping cough [23]; BHP indication to combine with licorice in asthma and bronchitis [24]

Decoction: 1 tsp per cup – 1 cup twice daily

Nutritional supplements

Listed in order of priority. Jake’s parents may only want to take one or two supplements initially due to financial reasons, or because of concerns regarding compliance.

TABLE 6.12

SUPPLEMENT AND DOSE	RATIONALE
Omega-3 fish oil 3000 mg daily in divided doses [14, 19]	Anti-inflammatory [14, 16, 19]; when taken in combination with dietary changes, improvements in asthma symptoms and lung function measurements are seen [19]
High-potency practitioner-strength probiotic supplement containing Lactobacillus GG [52] Dosage as directed by the manufacturer for a child of Jake’s age and weight

Immune system modulator [19, 37, 52]; immune stimulant [19]; important for the development and maintenance of a healthy immune system [19] and supplementation may be beneficial in atopic conditions [51]; may help prevent disruption to intestinal microflora following antibiotic therapy [31]

Vitamin C

Approx. 1500 mg daily in divided doses [14, 16]

Protects against exercise induced asthma [14, 16]; antioxidant [14, 19]; immunostimulant [14, 19]; antihistamine [19] Magnesium citrate supplement providing a daily dose of 290 mg elemental magnesium [19] Influences bronchial vasomotor tone and pulmonary vascular muscle contractility [19]; magnesium supplementation can improve asthma symptoms in children [19, 29, 57] [58], reduce bronchial reactivity [29] and reduce bronchodilator use [58]

References

[1] Douglas G., Nicol F., Robertson C. Macleod’s Clinical Examination, twelfth edn. Churchill Livingstone Elsevier; 2009.

[2] Kumar P., Clark C. Clinical Medicine, sixth edn. London: Elsevier Saunders; 2005.

[3] Talley N.J., O’Connor S. Pocket Clinical Examination, third edn. Australia: Churchill Livingstone Elsevier; 2009.

[4] Polmear A., ed. Evidence-Based Diagnosis in Primary Care. Churchill Livingstone Elsevier, Edinburgh, 2008.

[5] Collins R.D. Differential Diagnosis in Primary Care, fourth edn. Philadelphia: Lippincott Williams & Wilkins; 2008.

[6] Silverman J., Kurtz S., Draper J. Skills for Communicating with Patients, second edn. Oxford: Radcliff Publishing; 2000.

[7] Neighbour R. The Inner Consultation; how to develop an effective and intuitive consulting style. Oxon: Radcliff Publishing; 2005.

[8] Peters D., Chaitow L., Harris G., Morrison S. Integrating Complementary Therapies in Primary Care. London: Churchill Livingstone; 2002.

[9] Lloyd M., Bor R. Communication Skills For Medicine, third edn. Edinburgh: Churchill Livingstone Elsevier; 2009.

[10] Seller R.H. Differential Diagnosis of Common Complaints, fifth edn. Philadelphia: Saunders Elsevier; 2007.

[11] Jamison J. Differential Diagnosis for Primary Care, second edn. London: Churchill Livingstone Elsevier; 2006.

[12] El-Hashemy S.E. Naturopathic Standards of Primary Care. CCNM Press; 2008.

[13] Berkow R.M.D., Fletcher A.J.M.D., Beers M.H.M.D. The Meck Manual, sixteenth edn. Rathway, N.J: Merck Research Laboratories; 1993. (later edition)

[14] Jamison J. Clinical Guide to Nutrition & Dietary Supplements in Disease Management. Edinburgh: Churchill Livingstone; 2003.

[15] Pizzorno J.E., Murray M.T., Joiner-Bey H. The Clinicians Handbook of Natural Medicine, second edn. St Louis: Churchill Livingstone; 2008. p. 63

[16] Osiecki H. The Physicians Handbook of Clinical Nutrition, seventh edn. Bioconcepts; 2000.

[17] Baker J.C., Ayres J.G. Diet and asthma. Respiratory Medicine. 2000;94:925–934.

[18] Mills S., Bone K. Principles & Practice of Phytotherapy; Modern Herbal Medicine. Edinburgh. London: Churchill Livingstone; 2000.

[19] Braun L., Cohen M. Herbs & Natural Supplements: An evidence based guide, second edn. Sydney: Elsevier; 2007.

[20] Wilkens J.H., Wilkens H., Uffmann J., Bovers J., Fabel J., Frolich J.C. Effects of a PAF-antagonist (BN 52063) on bronchoconstriction and platelet activation during exercise induced asthma. British Journal of Clinical Pharmacology. 1990;29:85–91.

[21] Bone K. Clinical Applications of Chinese and Ayurvedic Herbs: Monographs for the Western Herbal Practitioners. Warwick: Phytotherapy Press; 1996.

[22] Dhuley J.N. Antitussive effect of Adhatoda vasica extract on mechanical or chemical stimulation-induced coughing in animals. Journal of Ethnopharmacology. 1999;67:361–365.

[23] Mills S., Bone K. The Essential Guide to Herbal Safety. St Louis: Churchill Livingstone; 2005.

[24] British Herbal Medicine Association. British Herbal Pharmacopoeia. BHMAA. 1983.

[25] Biernacki W., Peake M.D. Acupuncture in treatment of stable asthma. Respiratory Medicine. 1998;92:1143–1145.

[26] Joos S., Schott C., Zhou H., Daniel V., Martin E. Immunomodulatory effects of acupuncture in the treatment of allergic asthma: a randomized controlled study. J Altern Complement Med. 2000;6(6):519–525.

[27] Field T., Henteleff T., Hernandez-Reif M., Martinez E., Mavunda K., Kuhn C., Schanberg S. Children with asthma have improved pulmonary functions after massage therapy. Journal of Pediatrics. 1998;132(5):854–858.

[28] Kemper K.J., Lester M.R. Alternative asthma therapies: An evidence-based review. Contemporary Pediatrics. 1999;16(3):162–195.

[29] Gontijo-Amaral C., Ribeiro M., Gontijo L. A. Condino-Neto1, J. Ribeiro, Oral magnesium supplementation in asthmatic children: a double-blind randomized placebo controlled trial. European Journal of Clinical Nutrition. 2007;61:54–60.

[30] Higdon J. An Evidence Based Approach to Vitamins and Minerals. New York: Thieme; 2003.

[31] Madden J.A., Plummer S.F., Tang J., Garaiova I., Plummer N.T., Herbison M., Hunter J.O., et al. Effect of probiotics on preventing disruption of the intestinal microflora following antibiotic therapy: A double-blind, placebo-controlled pilot study. International Immunopharmacology. 2005;5:1091–1097.

[32] Lehrer P.M. Emotionally Triggered Asthma: A Review of Research Literature and Some Hypotheses for Self-Regulation Therapies. Applied Psychophysiology and Biofeedback. 1998;23(1):13–41.

[33] Lucas S.R., Platts-Mills T.A. Physical activity and exercise in asthma: Relevance to etiology and treatment. Journal of Allergy and Clinical Immunolog. 115(5), 2005. 928–934

[34] Lieu R.A., Quesenberry C.P., Capra A.M., Sorel M.E., Martin K.E., Mendoza G.R. Outpatient management practices associated with reduced risk of pediatric asthma hospitalization and emergency department visits. Pediatrics. 1997;100(3 pt. 1):334–341.

[35] Donovan C.L., Spence S.H. Prevention Of Childhood Anxiety Disorders. Clinical Psychology Review. 2000;20(4):509–531.

[36] Beider S., Moyer C.A. Randomized Controlled Trials of Pediatric Massage: A Review. ECAM. 2007;4(1):23–34.

[37] Blazek-O’Neill B. Complementary and Alternative Medicine in Allergy, Otitis Media, and Asthma. Current Allergy and Asthma Reports. 2005;5:313–318.

[38] Boyle W., Saine A. Lectures in Naturopathic Hydrotherapy. Eclectic Medical Publications. Oregon, 1988.

[39] Watrous L.M. Constitutional hydrotherapy: from nature cure to advanced naturopathic medicine. Journal of Naturopathic Medicine. 7(2), 1997. 72–79

[40] Blake E. Chaitow L., Blake E., Orrock P., Wallden M., Snider P., Zeff J. Naturopathic Physical Medicine: Theory and Practice for Manual Therapists and Naturopaths. Philadelphia: Churchill Livingstone Elsevier, 2008.

[41] Sinclair M. Modern Hydrotherapy for the Massage Therapist. Baltimore: Lippincott Williams & Wilkins; 2008.

[42] Buchman D.D. The complete book of water healing. New York: Contemporary Books, McGraw-Hill Companies; 2001.

[43] Malmberg L.P., Tamminen K., Sovijärvi A.R.A. Orthostatic increase of respiratory gas exchange in hyperventilation syndrome. Thorax. 2000;55(4):295–301.

[44] Hess D. Capnometry and capnography: Technical aspects, physiologic aspects, and clinical applications. Respir Care. 1990;35:557–573.

[45] O’Flaherty D. Capnometry. London: BMJ Publishing Group; 1994.

[46] Chaitow L., Blake E., Orrock P., Wallden M., Snider P., Zeff J. Natropathic Physical Medicine: Theory and Practice for Manual Therapists and Naturopaths. Philadelphia: Churchill Livingstone Elsevier; 2008.

[47] Nagakura T., Matsuda S., Shichijyo K., Subimoti H., Hata K. Dietary supplementation with fish oil rich in n-3 polyunsaturated fatty acids in children with bronchial asthma. European Respiratory Journal. 2000;16:861–865.

[48] Oddy W.H., deKlerk N.H., Kandall G.E., Mihrshahi S., Peat J.K. Ratio of omega-6 to omega-3 fatty acids and childhood asthma. Journal of Asthma. 2004;41(3):319–326.

[49] Weiland S.K., von Mutis E., Husing A., et al. Intake of trans fatty acids and prevalence of childhood asthma and allergies in Europe. Lancet. 1999;353:2040–2041.

[50] Lau S., Illi S., Sommerfeld C., Niggermann B., Bergmann R., von Mutis E., et al. Early exposure to house-dust mite and cat allergens and development of childhood asthma: a cohort study. Lancet. 2000;356:1392–1397.

[51] Kalliomäki M., Isolauri E. Role of Intestinal Flora in the Development of Allergy. Current Opinion in Allergy and Clinical Immunology. 2003;3(1):15–20.

[52] Kalliomäki M., Salminen S., Arvilommi H., Kero P., Koskinen P., Isolauri E. Probiotics in primary prevention of atopic disease: a randomised placebo-controlled trial. Lancet. 2001;357:1076–1079.

[53] D’Amato G., Liccardi G., D’Amato M., Holgate S. Environmental risk factors and allergic bronchial asthma. Clin Exp Allergy. 2005;35:1113–1124.

[54] Ring J., Eberlein-Koenig B., Behrendt H. Environmental pollution and allergy. Ann Allergy Asthma Immunol. 2001;87(6 Suppl. 3):2–6.

[55] Fugslang G., Madsen G., Halken S., Jorgensen S., Ostergaard P., Osterballe O. Adverse Reactions to food additives in children with atopic symptoms. Allergy. 1994;49(1):31–37.

[56] Hannuksela M., Haahtela T. Hypersensitivity reactions to food additives. Allergy. 1987;42:561–575.

[57] Ciarallo L., Sauer A.H., Shannon M.W. Intravenous magnesium therapy for moderate to severe pediatric asthma: Results of a randomized, placebo-controlled trial. The Journal of Pediatrics. 1996;129(6):809–814.

[58] Bede O. Efficacy of magnesium in children with bronchial asthma. European Journal of Clinical Nutrition. 2009;63:589–590.

[59] Bousquet J., et al. Asthma: from bronchoconstriction to airways inflammation and remodelling. American Journal of Respiratory and Critical Care Medicine. 2000;161:1720–1745.

[60] Christiansen S.C. Day care siblings and asthma – please sneeze on my child. N Engl J Med. 2000;343:574–575.

[61] Holgate S.T. Lessons learnt from the epidemic of asthma. Quarterly Journal of Medicine. 2004;91:247.

[62] Tattersfield A.E., et al. Asthma. Lancet. 2002;360:1313–1322.

[63] Irwin R.S., Madison J.M. The diagnosis and treatment of cough. N Engl J Med. 2000;343:1715–1721.

[64] Kelly F.J. Oxidative stress: its role in air pollution and adverse health effects. Occupational and Environmental Medicine. 2003;60:612–616.

[65] Koenig J.Q. Air pollution and asthma. Journal of Allergy and Clinical Immunology. 1999;104:717–722.

[66] Morice A. The diagnosis and management of chronic cough. Eur Respir J. 2004;24:481–492.

[67] Currie G., Gray R., McKay J. Chronic cough. BMJ. 2003;326:261.

[68] Marchant J., Masters I. S. Taylor, et.al., Evaluation and outcome of young children with chronic cough. Chest. 2006;129:1132–1141.

[69] Rees J. A.B.C. of asthma: prevalence. BMJ. 2005;331:443–445.

[70] Montnemery P., Hansson L., Lanke J., et al. Accuracy of a first diagnosis of asthma in primary healthcare. Fam Pract. 2002;19:365–368.

[71] Goldstein M., Veza B., Dunsky E., et al. Comparisons of peak diurnal expiratory flow variation, postbronchodilator FEV1 responses, and methacholine inhalation challenges in the evaluation of suspected asthma. Chest. 2001;119:1001–1010.

[72] Lewis S., Weiss S., Britton J. Airway responsiveness and peak flow variability in the diagnosis of asthma for epidemiological studies. Eur Respir J. 2001;18:921–927.

[73] Graif Y., Yigla M., Tov N., Kramer M. Value of negative aeroallergen skin-prick test result in the diagnosis of asthma in young adults. Chest. 2002;122:821–825.

[74] Eysink P., Ter Riet G., Aalberse R., et al. Accuracy of specific IgE in the prediction of asthma: development of a scoring formula for general practice. Br J Gen Pract. 2005;55:125–131.

[75] Martinez F. Development of wheezing disorders and asthma in preschool children. Pediatrics. 2002;109:362–367.

[76] Fardy H.J. A coughing child: could it be asthma? Aust Fam Physician. 2004;33(5):312–315.

[77] De Jongste J.C., Sheilds M.D. Chronic cough in children. Thorax. 2003;58:998–1003.

Otitis media

Case history

Tyler Narran is five years old. His parents have brought him to the clinic for help with a recurrent ear infection that usually develops in his right ear when acute. Tyler has been having problems with discomfort and hearing problems in both ears for the past 10 months. Tyler’s mum, Deborah, is concerned because his ENT doctor is talking about surgery to insert a grommet to release the fluid in the middle ear. She and Tyler’s dad, Jeremy, are hoping natural therapies might be able to help Tyler so he doesn’t have to have surgery.

Tyler is quiet and shy initially as he clutches his favourite teddy called ‘Woof Woof’, although he becomes relaxed and talkative as the consultation progresses. Deborah tells you that Tyler is the youngest of three children and has had problems with recurrent respiratory infections over the past year or so. Tyler’s ear problems started earlier in the year and he has had repeated courses of antibiotics, but the earaches keep coming back. They took Tyler for a hearing test two weeks ago and were told his hearing is not as good as it was the year before.

Tyler is usually a happy and active child who loves running around and playing sport at school and with his siblings and cousins. He hasn’t had quite as much energy this year since he has been having so many infections. When you ask Deborah about her pregnancy with Tyler, his birth and infancy, she tells you she had a good pregnancy and birth and she breastfed him exclusively for the first five months. When she started him on solid food he developed a rash and seemed to get some congestion in his nose. Her mother suggested she stop giving Tyler dairy and wheat. When she did his rash and congestion cleared up. Deborah tells you Tyler is a picky eater and she has to work hard to get him to eat vegetables. His favourite foods are instant noodles and grilled cheese sandwiches and, if he could, he would eat them all day every day. Tyler’s parents did not have an opportunity to discuss any of the dietary issues with their GP or ENT specialist.

When you ask Tyler how he feels about doing some new things to help him get better he seems positive, although he says he doesn’t know if he will like different food. Both Deborah and Jeremy say they will try whatever you recommend because they want Tyler to get better.

TABLE 6.13 COMPLAINT

Analogy: Skin of the apple

Complaint: Define the presenting complaint and symptoms; understand the complaint

Recurrent earache

AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS CLIENT RESPONSES

Onset

When did Tyler first start having problems with his ears?

Tyler’s mum answers:

Not quite a year ago. The earaches have been happening on and off, whenever he gets a cold.

Exacerbating factors

What makes the ears feel worse?

Tyler’s mum answers:

They seem to be worse at night and always a couple of days after he starts with a head cold.

Relieving factors

What makes the ears feel better?

Tyler’s mum answers:

Panadol seems to help and he has had antibiotics a few times, but they always come back.

Location and radiation

Where does the ear hurt and does the pain stay in one area or does it move?

Tyler points to his right ear.

Tyler’s mum explains that the pain usually occurs in his right ear but also sometimes in his left ear. She says Tyler sometimes says he has a headache in his forehead when his ear hurts.

TABLE 6.14 CONTEXT

Analogy: Flesh of the apple	Context: Put the presenting complaint into context to understand the disease
AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS	CLIENT RESPONSES
Family health Is there anyone else in the family who has had problems with their ears?	Tyler’s mum answers: Tyler’s older sister had some problems with earaches when she was younger but not as bad as Tyler gets it.
Allergies and irritants Do you experience any associated symptoms such as sneezing, nose discharge, conjunctivitis, skin rashes or itching on roof of mouth with a cough? (allergies)	Tyler’s mum answers: I don’t think so. When he was a baby he got a skin rash and when I stopped giving him wheat and dairy it went away. He doesn’t seem to have any problems with wheat and dairy now.
Obstruction and foreign body Did the ear pain developed after swimming, cleaning or from Tyler picking the ear? (otitis externa)	He did begin swimming lessons when the whole cycle of infections began, but we soon stopped them. It’s a shame because he was enjoying it.
Functional disease Has Tyler presented with any speech complications from having ear discomfort that has interfered with hearing? (chronic serous otitis media)	He doesn’t seem to hear us as well these days, which makes us yell more when we talk to him. He seems to talk less now, but not sure if that’s because he can’t hear or because he’s scared of us raising our voices!
Infection and inflammation Is there a throbbing pain in your ear that is better when you chew on food and when you swallow? (acute otitis media)	Tyler’s mum answers: A couple of weeks ago, he had an earache – that got better when he was eating. The doctor says if he gets one more acute flare up he will probably need to have surgery.
Supplements and side effects of medication Has Tyler been taking any supplements or medicine?	Tyler’s mum answers: He just had antibiotics for his last earache.
Eating habits and energy Tell me about Tyler’s diet.	Tyler’s mum answers: He has a grilled cheese sandwich or porridge and milk for breakfast. If he’s at home he usually has noodles for lunch, otherwise he gets a sandwich with cheese or polony. He doesn’t like vegetables and fruit, but I try and make him have them.

TABLE 6.15 CORE

Analogy: Core of the apple with the seed of ill health	Core: Holistic assessment to understand the client
AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS	CLIENT RESPONSES
Family and friends How do you get on with your brother and sister and your friends, Tyler?	Tyler answers: Good, sometimes Danny doesn’t let me do things when I want to.
Home life How are things at home?	Tyler’s mum answers: There’s always something happening at home. Lots of children, cousins and friends always in and out of the house. Tyler has his own friends to play but also tags along with his older sister and brother and cousins. There are the usual problems and fights that children have, but no real problems.
Action needed to heal Tyler, if I give you some medicine and ask you to eat some different food do you think you will do it?	Tyler answers: I don’t know. Does it taste bad? Tyler’s mum answers:We’ll do whatever it takes to get Tyler better.

TABLE 6.16 TYLER’S SIGNS AND SYMPTOMS [4–6]

Pulse	100 beats per minute
Blood pressure	100/60
Temperature	37.8°C
Respiratory rate	25 breaths per minute
Face	Relaxed, smiling
Body posture	Sitting, not restless, quiet, not crying, content
Percentile	75th
Weight	20 kg
Urinalysis	NAD

TABLE 6.17 RESULTS OF MEDICAL INVESTIGATIONS [1–6, 10, 12]

TEST	RESULTS
Examination of external ear and ear drum [49, 51, 52]	No excess wax, foreign objects or skin disorder in the outer ear canal; no external discharge or swelling of the outer ear; no tenderness over the mastoid process; slightly red and dull tympanic membrane that appears retracted, red blood vessels are visible and membrane appears immobile
Hearing test (Rinne and Weber): vibrating prong on external auditory meatus and mastoid process and on forehead; whispered voice test	Sound heard best in left ear; positive conduction deafness
TMJ examination	No clicking of the jaw when he opens and closes his mouth; no tenderness
Throat examination/throat swab	No swelling or redness
Nose examination/nose swab	No infection causing referred pain to ear
Chest examination: auscultation, percussion	No signs of asthma, obstruction or infection

TABLE 6.18 UNLIKELY DIAGNOSTIC CONSIDERATIONS [1–6, 10, 12, 44]

CONDITIONS AND CAUSES	WHY UNLIKELY
TRAUMA AND PRE-EXISTING ILLNESS
*Causal factor:* Traumatic perforation of tympanic ear drum	When ear is hit, slapped or from ear picking
OBSTRUCTION AND FOREIGN BODY
*Causal factor:* Impacted cerumen: can have pain and impaired hearing	External ears are clean
*Causal factor:* Foreign bodies: unilateral, vague pain and discomfort, which can then become severe	Examination revealed no foreign bodies in external ear or sign of trauma
FUNCTIONAL DISEASE
*Causal factor:* TMJ dysfunction	Usually comes and goes and worse in the morning from teeth grinding; no headache or jaw click
*Causal factor:* Dental pathology: common cause of referred pain to the ear	Recent dental check revealed no abnormalities
Gastro-oesophageal reflux: rare cause of ear pain in infants and children	No symptoms of abdominal pain or discomfort after eating
Asthma: postviral children with recurrent cough are often asthmatic; recent upper respiratory tract infection most probably viral (antibiotics did not completely resolve)	Chest examination did not reveal significant wheeze; ask more about shortness of breath and cough
*Causal factor:* Referred pain: to the ear when ear examination and hearing test is normal	Ear drum examination was not normal and conductive hearing loss is present
INFECTION AND INFLAMMATION
Otitis externa: bilateral pain more common	More common in adults, clients with diabetes, swimmer’s ear, when people have seborrheic dermatitis or psoriasis of the scalp; movement or pressure on the outer ear is not painful; there has been no discharge from the ear
Primary otalgia: chronic otitis media with effusion (middle ear infection) common in children under 8 years old; unilateral, which rules out referred pain to ear	The tympanic membrane is not perforated and no discharge present for more than 1 month
Mastoiditis: can have acute otitis media ear infection prior to mastoiditis developing by 2 weeks	Severe pain not behind the ear and no tenderness on mastoid process; no current fever or discharge from ear
Myringitis: viral, bacterial (common Streptococcus pneumoniae) mycoplasma infection aggravated by recurrent URIs, pain occurs in cycles	No bullae or vesicles on tympanic membrane and usually a diagnosis seen in adults; precipitated by cough and pneumonia; viral will present with watery rhinitis or a pink eardrum; if fever and hearing loss present, it’s more likely to be bacterial
Acute otitic barotraumas: aggravated by recurrent URIs	No recent air flights or hay fever; need to check if pain is relieved by chewing
Upper aerodigestive tract (larynx, hypopharynx, oropharynx, base of tongue) infection or malignancy	More common in adults and elderly; tumours rarely cause pain
Impetigo: can cause pain in the ear	No skin rash

TABLE 6.19 CONFIRMED DIAGNOSIS [1–3, 5, 6]

CONDITION	RATIONALE
Serous otitis media (glue ear): can be asymptomatic and aggravated by recurrent URIs and pharyngitis; common in children under 8 years old due to their short eustachian tube; develops due to eustachian tube dysfunction	Can be bilateral; slightly red and dull tympanic membrane that appears retracted, red blood vessels are visible and membrane appears immobile; sound heard best in the left ear; positive conduction hearing loss; no pain experienced at the time of consultation, common condition in children; children can present as healthy and still have glue ear
Recurrent acute otitis media: middle ear infection; more common to be viral origin, which antibiotic may not resolve	Unilateral; Tyler has had episodes of acute ear pain that resolves within 3 weeks; associated symptoms of fever, runny nose and upper respiratory tract infections; when in the acute stage the tympanic membrane is very red, cloudy, bulging and immobile; no perforation has occurred to date

Case analysis

TABLE 6.20 POSSIBLE FURTHER DIFFERENTIAL DIAGNOSIS

Not ruled out by tests/investigations already done [1–6, 10, 11]
CONDITIONS AND CAUSES	WHY POSSIBLE	WHY UNLIKELY
ALLERGIES AND IRRITANTS
Atopic eczema: the word ‘atopy’ means to react to common environmental factors; can be caused and aggravated by diet, genetic factors, heat, humidity, drying of the skin, contact with woollen clothing or animal saliva touching the skin; house dust mites are thought to be an important factor in facial eczema	Skin rash and nasal congestion as a baby when first introduced to dairy and wheat	No significant skin rash presenting at time of consultation
Food allergy: typically to cow’s milk, egg, soya, peanut, wheat and fish	Reaction of skin rash and nasal congestion to dairy and wheat	Often presents with a swelling of the lips and tongue, urticaria, skin rash, conjunctivitis, rhinitis, anaphylaxis and difficulty breathing
Coeliac disease	Can be associated with lactose intolerance; having more wheat and dairy	Ask if Tyler has experienced diarrhoea or pain in the abdomen from a change in diet
FUNCTIONAL DISEASE
*Causal factor:* Low immune function	Recurrent upper respiratory tract infections, ear infections, inadequate diet and not balanced with food groups; less energy
DEGENERATIVE AND DEFICIENCY
Anaemia	Not eating balanced diet and Tyler doesn’t have as much energy as used to
INFECTION AND INFLAMMATION
Eustachitis: inflammation of mucous membrane of eustachian tube; can be aggravated by recurrent URIs and pharyngitis	Not associated with severe earache usually; ear drum usually retracted	Check if the pain is relieved by chewing
Dermatitis herpetiformis	This condition is usually associated with gluten-sensitive enteropathy, which can be asymptomatic; rash that appeared as a baby when first ate solids	Usually associated with bullae (fluid filled palpable mass); more common to present on trunk of body

Working diagnosis

Tyler and serous otitis media (glue ear) with recurrent acute otitis media

Deborah and Jeremy have brought their five-year-old son, Tyler, to the clinic after being told he may need surgery to insert a grommet into his ear [32] to prevent recurrent ear infections. Tyler has been diagnosed with ‘glue ear’, which is beginning to affect his hearing and has precipitated several acute ear infections over the past year. Tyler is the youngest of three children and is usually a happy and active child who loves playing sports with his siblings and cousins. As the consultation progresses Tyler’s parents reveal that as a baby Tyler developed nasal congestion and a skin rash when first introduced to dairy and wheat products and when these foods were taken out of his diet the symptoms resolved. Tyler now eats these foods as they don’t seem to give him a skin rash anymore.

Tyler is experiencing two conditions of otitis media as chronic serous otitis media (glue ear) and episodes of acute otitis media (middle ear infection).

Serous otitis media (glue ear)

This is a condition where fluid accumulates in the eustachian tube in the ear causing a dysfunction in the pressure of the middle ear along with conductive hearing difficulties. Glue ear is a chronic condition where the mucus has become thick and tacky like glue. This form of chronic otitis media often has an allergic cause. Infants and children are more prone to developing this because the eustachian tube is shorter in young children and gradually grows. Glue ear usually has recurrent episodes and periods of remission but will often resolve over time. Referral for surgery to insert a ‘grommet’ may be one option to prevent ear infections and perforation of the tympanic membrane. A grommet is essentially a tube that is inserted into the tympanic membrane and takes over the role of the eustachian tube while the membrane heals (lasts from six months to two years). A child with glue ear may develop complications including hearing impairment, delayed learning and speech development, chronic blocked ears, transient earache and the predisposition to develop acute otitis media (middle ear infection).

Acute otitis media (middle ear infection)

This condition produces symptoms of severe earache, vomiting, fever, hearing loss, runny nose and is often initiated by an upper respiratory tract infection. Mucus blocks the eustachian tube and consequently infection develops leading to swelling, redness and pain in the ear. The risk of a perforated ear drum and chronic otitis media is increased with recurrent acute otitis media.

General references used in this diagnosis: 1–3, 5, 6

Confirmed diagnosis

Serous otitis media (glue ear) with recurrent acute otitis media and dairy protein allergy.

Prescribed medication

• Oral antibiotic therapy as required [46, 47]

• Oral analgesics as required

• Referral for surgery to insert a ‘grommet’

TABLE 6.21 DECISION TABLE FOR TREATMENT PRIOR TO REFERRAL

COMPLAINT	CONTEXT	CORE
Treatment for the presenting complaint and symptoms	Treatment for all associated symptoms	Treatment for mental, emotional, spiritual, constitutional, lifestyle issues and metaphysical considerations
TREATMENT PRIORITY	TREATMENT PRIORITY	TREATMENT PRIORITY
• Physical treatment recommendations to provide relief from acute symptoms and to reduce symptom recurrence • Lifestyle recommendations to provide relief from acute symptoms • Symptomatic relief with herbal ear drops • Herbal tea or tonic to reduce the accumulation of mucus and support drainage via the eustachian tube • Nutritional supplements to reduce inflammation and allergic response, which is leading to mucus accumulation in the middle ear NB: Caution should be taken when prescribing herbal or nutritional therapies to ensure Tyler is not given herbs or foods to which he may react because of allergies to herbs or foods from the same botanical family [14]	• Lifestyle recommendations to reduce Tyler’s exposure to environmental allergens and other triggers • Dietary recommendations to identify and eliminate foods to which Tyler is allergic or intolerant • Dietary recommendations and nutritional supplements to improve Tyler’s general health and immunity and reduce recurrence of upper respiratory tract infections • Herbal tea or tonic to support Tyler’s immune system and reduce the allergic response

• Encourage Tyler to participate in the process of healing and to help deal with his concerns about changing his diet

• Recommendation for reward chart or other motivation to help Tyler be more cooperative and motivated to participate in his treatment

• Recommendation to include Tyler in decisions and implementation of dietary, lifestyle and physical treatments

TABLE 6.22 DECISION TABLE FOR REFERRAL [1–6, 10–13]

COMPLAINT	CONTEXT	CORE
Referral for presenting complaint	Referral for all associated physical, dietary and lifestyle concerns	Referral for contributing emotional, mental, spiritual, metaphysical, lifestyle and constitutional factors
REFERRAL FLAGS	REFERRAL FLAGS	REFERRAL FLAGS
• Tyler’s parents have not consulted a GP or specialist and are seeking complementary therapies instead of pursuing the surgery option • It may be considered child abuse for Tyler if he was to experience recurrent and ongoing ear pain without suitable pain relief	• Possible elimination and ongoing restriction of food groups from Tyler’s diet may be unnecessary • Recurrent URIs may lead to childhood asthma	Nil
ISSUES OF SIGNIFICANCE	ISSUES OF SIGNIFICANCE	ISSUES OF SIGNIFICANCE
Nil	• Tyler developed a skin rash and nasal congestion as a baby when first introduced to wheat and dairy	• Dietary and lifestyle changes may cause Tyler stress or anxiety • Physical treatment recommendations may cause Tyler stress or anxiety • Resistance to taking herbal tea or tonic and supplements
REFERRAL DECISION	REFERRAL DECISION	REFERRAL DECISION
• Tyler needs collaborative care – his ear and hearing loss needs regular monitoring between an orthodox and a complementary practitioner • Deborah and Jeremy need education regarding hearing damage and delayed learning that can develop from ear infections that are not managed carefully [48, 50]	• Food assessment and challenge to identify food triggers • Monitor asthma and lung assessment	Nil

TABLE 6.23 FURTHER INVESTIGATIONS THAT MAY BE NECESSARY [1–6, 10, 12]

TEST/INVESTIGATION	REASON FOR TEST/INVESTIGATION
FIRST-LINE INVESTIGATIONS:
Full blood count	Infection, allergies, anaemia
Serum IgE blood test	Atopic eczema and allergic triggers for asthma
Food diary	To help determine any foods that may be triggering or aggravating symptoms
IF NECESSARY:
RAST and/or skin prick test	To determine whether Tyler has allergies to foods or environmental antigens
Radiograph of ear	Confirms otitis media diagnosis
Tympanometry/impedance audiometry [45]	Test otitis media with effusion as compliance of the eardrum is measured during changes in pressure in air canal
CT and MRI of ear	Tumours causing primary and secondary ear pain (otalgia)
Antigliadin antibody blood test	Definitive test for gluten allergy

TABLE 6.24 DECISION TABLE FOR TREATMENT (ONCE DIAGNOSIS IS CONFIRMED)

COMPLAINT	CONTEXT	CORE
Treatment for the presenting complaint and symptoms	Treatment for all associated symptoms	Treatment for mental, emotional, spiritual, constitutional, lifestyle issues and metaphysical considerations
TREATMENT PRIORITY	TREATMENT PRIORITY	TREATMENT PRIORITY
• Continue with lifestyle and physical treatment recommendations as required for relief from symptoms and to reduce symptom recurrence • Continue with use of herbal ear drops for symptomatic relief as required • Continue with herbal tea or tonic • Continue with nutritional supplements NB: Tyler’s case should be collaboratively managed with his medical practitioners to ensure his treatment program is effective and appropriate; his case should be reviewed in 2–3 weeks and again at 6–8 weeks to assess the effectiveness of the program	• Continue with lifestyle recommendations to reduce Tyler’s exposure to environmental triggers • Continue with dietary recommendations to eliminate allergic or intolerant foods • Continue with dietary recommendations and nutritional supplements to improve Tyler’s general health and immunity and reduce recurrence of upper respiratory tract infections • Continue with herbal tea or tonic to support Tyler’s immune system and reduce the allergic response	• Continue to encourage Tyler to participate in the process of healing and to be involved in decisions and the implementation of the dietary and lifestyle change • Continue with motivational and reward activities to encourage Tyler’s continued participation in the process

Lifestyle alterations/considerations

• Encourage Tyler’s parents to ensure he is not exposed to cigarette smoke [14, 15] and other airborne environmental irritants such as smoke from wood fires [20].

• Tyler’s parents should be aware that waiting for 24 hours before instituting antibiotic therapy when Tyler has an acute aggravation of otitis media is advisable [16, 18]. If his symptoms are resolving after 24 hours, antibiotic therapy may not be necessary [15, 16, 18].

• Tyler may benefit from the use of homeopathic medicines to manage acute episodes of otitis media [14, 17].

• Tyler may benefit from chewing Xylitol chewing gum. Xylitol may reduce the incidence of acute episodes of otitis media [15, 19].

• It is likely that Tyler has food and/or environmental allergies [14, 15, 22–24]. If allergy tests indicate environmental allergies, Tyler’s parents should reduce his exposure through the use of mould- and dust-reducing cleaning techniques such as a HEPA filter vacuum cleaner and damp dusting, etc. [20, 21]. Even if Tyler does not test positive to environmental allergens, they should ensure their home environment is healthy and free from mould [20].

• Tyler may benefit from the use of a room humidifier [15].

• In order to help Tyler cooperate with the recommended dietary, lifestyle and treatment measures, it may be helpful to use a reward chart or similar motivation to help improve compliance.

• Deborah and Jeremy should discuss Tyler’s treatment recommendations with him and involve him in the selection and preparation of recommended foods as well as the preparation and administration of recommended herbal and nutritional products. Tyler is more likely to be compliant if he feels involved in the process.

• Where practical, Deborah and Jeremy should include Tyler in decisions about trying particular physical therapies and become actively involved in implementing lifestyle changes and some physical therapies. By making Tyler feel involved in the process he is less likely to feel anxious and more likely to be compliant.

Dietary suggestions

• Encourage food allergies to be tested for and managed appropriately [14, 15, 22–24]. Commonly implicated foods include dairy products, wheat, eggs, soy, corn, oranges, strawberries and peanuts [14, 15]. The use of an elimination and rotation diet should be recommended [14, 15, 23, 24].

• Encourage Tyler to eat plenty of fresh fruit and vegetables, whole grains, beans and legumes, lean meat and fish to improve his intake of essential nutrients [14, 42].

• Increasing consumption of bioflavanoid-rich foods can help reduce allergic and inflammatory responses and consequent mucus production [14, 26].

• Encourage Tyler to minimise consumption of concentrated simple carbohydrates such as sugar, honey, dried fruit and concentrated fruit juice as excessive consumption may have a negative effect on his immune system [15, 43].

• Encourage Tyler to avoid consuming potentially mucus-forming foods such as wheat, dairy and orange juice [14].

Physical treatment suggestions

• Tyler may find benefit from local application of heat to the affected ear in acute exacerbations of otitis media [15].

• Hydrotherapy: hot salt bag application to affected ear to draw out catarrhal blockage and relieve pain [36].

• Hot leg bath, hot foot bath, hot foot wrappings to bring heat away from ear down to feet [36].

• Hot moist cloths on the mastoid bone applied simultaneously with an ice bag placed over the carotid artery on the same side as the ear pain (up to 30 minutes). Follow this with cold mitten friction on the trunk and limbs [36].

• A cold throat compress on the throat to draw heat away from the ear [36, 40].

• Constitutional hydrotherapy to strengthen Tyler’s immune system and tonify his lungs [37–39].

• For recurrent chest infections: back and front contrast treatment with cold mitten friction on the trunk when symptoms begin to ease [39, 41]. Hot chest shower [41]. Smear a mustard plaster over the chest made with one part mustard powder to three parts flour and enough water to make a paste [36]. A steam vapouriser will assist breathing [36].

• Laser acupuncture or acupressure may be beneficial to Tyler [14].

• Blowing into Tyler’s affected ear with hot air from a hair dryer directed through a straw may help reduce middle ear pressure and promote drainage [15].

TABLE 6.25 HERBAL EAR DROP FORMULA; OLIVE OIL INFUSION

HERB	FORMULA	RATIONALE
Garlic oil	1 part	Anti-inflammatory [26]; antimicrobial [26, 30]
Allium sativum
Mullein Verbascum thapsus (infused oil)	4 parts	Demulcent [26, 30]; emollient [26]; antimicrobial [26]; anticatarrhal [30]
Calendula flowers Calendula officinalis (infused oil)	2 parts	Antimicrobial [26, 30]; anti-inflammatory [26, 30]
St John’s wort Hypericum perforatum (infused oil)	2 parts	Antimicrobial [26, 27]; anti-inflammatory [26]; analgesic [26]
Lavender flowers Lavandula angustifolia (essential oil)	½ part	Antimicrobial [26]

5 drops in the affected ear 3 times daily [15]

These 5 herbs administered as an eardrop preparation are effective in relieving the symptoms of otitis media [19, 25, 26]

TABLE 6.26 HERBAL TEA

Alternative to herbal liquid tonic if there are compliance problems
HERB	FORMULA	RATIONALE
Elder flower Sambucus nigra	2 parts	Anticatarrhal [30]; anti-inflammatory [33]; immune stimulator with benefit in treating otitis media [14]
Eyebright Euphrasia officinalis	2 parts	Anticatarrhal [26, 28, 30]; astringent [26, 28, 30]; anti-inflammatory [26, 30]; mucous membrane tonic [30]; reduces upper respiratory tract secretions [26]
Echinacea Echinacea purpurea	2 parts	Immunomodulator [26, 27]; immunostimulant [26, 27]; anti-inflammatory [26, 27]; lymphatic [27]; beneficial for upper respiratory tract infections [26, 27, 34]
Chamomile Matricaria recutita	1 part	Anti-inflammatory [14, 26, 27]; antimicrobial [14, 26, 27]; immunostimulant [26]
Licorice root powder Glycyrrhiza glabra	½ part	Anti-inflammatory [26, 27]; antimicrobial [26, 27]; immunomodulator [26, 27]; mucoprotective [27]; expectorant [26, 27]; beneficial in upper respiratory tract infections [26, 27]; also helpful as a sweet flavouring agent [26]

Infusion: 1 tsp per cup – 2 cups daily

TABLE 6.27 HERBAL FORMULA (1:2 LIQUID EXTRACTS)

Made with ethanolic extract herbal liquids (alcohol removed)
HERB	FORMULA	RATIONALE
Echinacea	25 mL	See above
Echinacea purpurea
Eyebright	20 mL	See above
Euphrasia officinalis
Elder flower	15 mL	See above
Sambucus nigra
Licorice root	10 mL	See above
Glycyrrhiza glabra
AlbiziaAlbizia lebbek	30 mL	Antiallergic [26, 31]; stabilises mast cells [26, 31]; antimicrobial [26, 31]; traditionally used for respiratory diseases [31]
Supply:	100 mL	Dose: 2 mL 3 times daily

TABLE 6.28 NUTRITIONAL SUPPLEMENTS

SUPPLEMENT AND DOSE	RATIONALE
High-potency practitioner-strength probiotic supplement containing a range of human strain organisms including Lactobacillus GG [26]	Immune system modulator [26]; immune stimulant [26]; important for the development and maintenance of a healthy immune system [26]; may help prevent disruption to intestinal microflora following antibiotic therapy [35]
High-potency practitioner-strength children’s multivitamin and mineral supplement containing therapeutic doses of essential micronutrients Dose: as directed by the manufacturer for a child of Tyler’s weight and age

Poor nutritional status is associated with increased risk of lowered immunity and infection [42, 43]; Tyler’s current diet is nutritionally deficient and supplementation will help improve his nutritional status

Cod liver oil

Dose: approx. 3 mL to provide no more than 2500 IU of vitamin A daily [26, 29]

Vitamin A, D and omega-3 supplement; vitamin A is essential for immune function and maintenance of epithelial tissue [26, 29] and is beneficial in treating upper respiratory tract infections [26, 29]; omega-3 fatty acids are anti-inflammatory [26, 29, 32] Vitamin C and bioflavanoid complex providing 250 mg vitamin C and 250 mg bioflavanoids (containing quercetin) 3 times daily [15] Vitamin C is antihistaminic [26, 29, 32]; immunostimulant [26, 29, 32] and an antioxidant [26, 29, 32]; quercetin is antiallergic [26, 29], antioxidant [26, 29, 32]; immunomodulator [26]; anti-inflammatory [26, 29, 32]; quercetin inhibits inflammatory enzymes, prostaglandins and leukotrienes [26], stabilises mast cells [26] and inhibits mast cell release of histamine [29]

References

[1] Seller R.H. Differential Diagnosis of Common Complaints, fifth edn. Philadelphia: Saunders Elsevier; 2007.

[2] Polmear A., ed. Evidence-Based Diagnosis in Primary Care. Churchill Livingstone Elsevier, 2008. 274–283

[3] Jamison J. Differential Diagnosis for Primary Care, second edn. London: Churchill Livingstone Elsevier; 2006.

[4] Talley N.J., O’Connor S. Pocket Clinical Examination, third edn. Australia: Churchill Livingstone Elsevier; 2009.

[5] Douglas G., Nicol F., Robertson C. Macleod’s Clinical Examination, twelfth edn. Churchill Livingstone Elsevier; 2009.

[6] Kumar P., Clark C. Clinical Medicine, sixth edn. London: Elsevier Saunders; 2005.

[7] Silverman J., Kurtz S., Draper J. Skills for Communicating with Patients, second ed. Oxford: Radcliff Publishing; 2000.

[8] Neighbour R. The Inner Consultation; how to develop an effective and intuitive consulting style. Oxon: Radcliff Publishing; 2005.

[9] Lloyd M., Bor R. Communication Skills For Medicine, third edn. Edinburgh: Churchill Livingstone Elsevier; 2009.

[10] Collins R.D. Differential Diagnosis in Primary Care, fourth edn. Philadelphia: Lippincott Williams & Wilkins; 2008.

[11] Berkow R.M.D., Fletcher A.J.M.D., Beers M.H.M.D. The Merck Manual, sixteenth edn. Rathway, N.J: Merck Research Laboratories; 1993 (later edition.

[12] Pagna K.D., Pagna T.J. Mosby’s Diagnostic and Laboratory Test reference, third edn. USA: Mosby; 1997 (later edition.

[13] D. Peters, L. Chaitow, G. Harris, S. Morrison, Integrating Complementary Therapies in Primary Care. London: Churchill Livingstone, 2002.

[14] El-Hashemy S. Naturopathic Standards of Primary Care. Toronto: CCNM Press Inc; 2007.

[15] J.E. Pizzorno, M.T. Murray, H. Joiner-Bey, The Clinicians Handbook of Natural Medicine, second edn, Churchill Livingstone, St Louis, 2008.

[16] Little P., Gould C., Williamson I., Moore M., Warner G., Dunleavey J. Pragmatic randomised controlled trial of two prescribing strategies for childhood acute otitis media. British Medical Journal. 2001;322:336–342.

[17] Jacobs J., Springer D.A., Crothers D. Homeopathic treatment of acute otitis media in children: a preliminary randomized placebo-controlled trial. Pediatric Infectious Disease Journal. 2001;29(2):177–183.

[18] Spiro D.M., Tay K.Y., Arnold D.H., Dziura J.D., Baker M.D., Shapiro E.D. Wait-and-See Prescription for the Treatment of Acute Otitis Media: A Randomized Controlled Trial. Journal of the American Medical Association. 2006;296:1235–1241.

[19] Blazek-O’Neill B. Complementary and Alternative Medicine in Allergy, Otitis Media, and Asthma. Current Allergy and Asthma Reports. 2005;5:313–318.

[20] Kilpeläinen M., Terho E.O., Helenius H., Koskenvuo M. Home dampness, current allergic diseases, and respiratory infections among young adults. Thorax. 2001;56:462–467.

[21] Dykewicz M.S. Rhinitis and sinusitis. Journal of Allergy and Clinical Immunology. 2003;111(Suppl. 2):S520–S529.

[22] Alles R., Parikh A., Hawk L., Darby Y., Romero J.N., Scadding G. The prevalence of atopic disorders in children with chronic otitis media with effusion. Pediatric Allergy and Immunology. 2001;12(2):102–106.

[23] Nsouli T.M., Nsouli S.M., Linde R.E., O’Mara F., Scanlon R.T., Bellanti J.A. Role of food allergy in serous otitis media. Annals of Allergy. 1994;73(3):215–219.

[24] Arroyave C.M. Recurrent otitis media with effusion and food allergy in pediatric patients (article in Spanish). Rev. Alerg Mex. 2001;48(5):141–144.

[25] Sarrell E.M., Choen H.A., Kahan E. Naturopathic Treatment for Ear Pain in Children. Pediatrics. 2003;111:e574–e579.

[26] Braun L., Cohen M. Herbs & Natural Supplements: An evidence based guide, second edn. Sydney: Elsevier; 2007.

[27] Mills S., Bone K. Principles & Practice of Phytotherapy; Modern Herbal Medicine. Edinburgh : London: Churchill Livingstone; 2000.

[28] British Herbal Medicine Association. British Herbal Pharmacopoeia. BHMAA. 1983.

[29] Osiecki H. The Nutrient Bible, seventh edn. Eagle Farm: BioConcepts Publishing; 2008.

[30] Mills S., Bone K. The Essential Guide to Herbal Safety. St Louis: Churchill Livingstone; 2005.

[31] Bone K. Clinical Applications of Chinese and Ayurvedic Herbs: Monographs for the Western Herbal Practitioners. Warwick: Phytotherapy Press; 1996.

[32] Jamison J. Clinical Guide to Nutrition & Dietary Supplements in Disease Management. Edinburgh: Churchill Livingstone; 2003.

[33] Harokopakis E., Albzreh M.H., Haase E.M., Scannapieco F.A., Hajishengallis G. Inhibition of proinflammatory activities of major periodontal pathogens by aqueous extracts from elder flower (Sambucus nigra). Journal of Periodontology. 2006;77(2):271–279.

[34] Goel V., Lovlin R., Chang C., Slama J.V., Barton R., Gahler R., Bauer R., et al. A proprietary extract from the echinacea plant (Echinacea purpurea) enhances systemic immune response during a common cold. Phytotherapy Research. 2005;19(8):689–694.

[35] Madden J.A., Plummer S.F., Tang J., Garaiova I., Plummer N.T., Herbison M., Hunter J.O., et al. Effect of probiotics on preventing disruption of the intestinal microflora following antibiotic therapy: A double-blind, placebo-controlled pilot study. International Immunopharmacology. 2005;5:1091–1097.

[36] Buchman D.D. The complete book of water healing. New York: Contemporary Books, McGraw-Hill Companies; 2001.

[37] Boyle W., Saine A. Lectures in Naturopathic Hydrotherapy. Eclectic Medical Publications. Oregon, 1988.

[38] Watrous L.M. Constitutional hydrotherapy: from nature cure to advanced naturopathic medicine. Journal of Naturopathic Medicine. 1997;7(2):72–79.

[39] Blake E. Chaitow L., Blake E., Orrock P., Wallden M., Snider P., Zeff, Naturopathic Physical Medicine J. Theory and Practice for Manual Therapists and Naturopaths. Philadelphia: Churchill Livingstone Elsevier, 2008.

[40] Chaitow L. Hydrotherapy, water therapy for health and beauty. Dorset: Element; 1999.

[41] Sinclair M. Modern Hydrotherapy for the Massage Therapist. Baltimore: Lippincott Williams & Wilkins; 2008.

[42] Scrimshaw N.S., SanGiovanni J.P. Synergism of nutrition, infection and immunity: an overview. The American Journal of Clinical Nutrition. 1997;66:464S–477S.

[43] Chandra R.A. Nutrition and the immune system. Proceedings of the Nutrition Society. 1993;52:77–84.

[44] Leung A.K., Fong J.H., Leong A.G. Otalgia in children. J Natl Med Assoc. 2000;92(5):254–260.

[45] Blomgren K., Pitkaranta A. Current challenges in diagnosis of acute otitis media. International Journal of Pediatric Otorhinolaryngol. 2005;69(3):295–299.

[46] Glasziou P., Del Mar C., Sanders S., Haymen M. Antibiotics for acute otitis media in children. The Cochrane Database of Systematic Reviews. 2004. (Issue 1. Art No: CD000219. DOI:10.1002/14651858. CD000219.pub2)

[47] Burke P., Bain J., Robinson D. Acute red ear in children: controlled trial of non-antibiotic treatment in general practice. BMJ. 1991;303:558–562.

[48] Asher E., Leibovitz E., Press J., et al. Accuracy of acute otitis media diagnosis in community and hospital settings. Acta Paediatr. 2005;94:423–428.

[49] Heikkinen T., Ruuskanen O. Signs and symptoms predicting acute otitis media. Arch Pediatr Adolesc Med. 1995;149:26–29.

[50] Niemela M., Uhari M., Jounio-Ervasti K., et al. Lack of specific symptomatology in children with acute otitis media. Paediatr Infect Dis J. 1994;13:765–768.

[51] Karma P., Penttila M., Siplia M., et al. Otoscopic diagnosis of middle ear effusions in acute and non-acute otitis media. I. The value of different otoscopic findings. Int J Pediatr Otorhinolaryngol. 1989;17:37–49.

[52] Rothman R., Owens T., Simel D. Does this child have acute otitis media? JAMA. 2003;290:1633–1640.

Chronic bronchitis

Case history

Tara Pietrowski is 31 years old and has come to the clinic for help with a cough she has had for the past three months. Tara is in the middle of an around Australia road trip with her husband, something they have been planning for a number of years. They had both hoped they would have children by now but, despite trying for four years, Tara has never fallen pregnant. Two years ago they made the decision that if Tara wasn’t pregnant by the beginning of this year they would take time off and go travelling.

Tara tells you they started travelling six months ago, and since then she feels as if she has been sick most of the time. Tara has been having what she thinks are recurrent upper respiratory tract infections for almost the whole time they have been away, with a cough that is worse in the morning. When the cough is particularly bad Tara coughs up yellow-green sputum, particularly in the mornings. The cough can disturb Tara’s sleep.

Tara has experienced this type of thing in the past and as recently as last year during winter. In her late teens and early 20s she experienced frequent episodes of the cough. Whenever she gets run down or sick, it seems to go straight to her chest and she gets a cough that can take months to resolve. Tara thinks she is finding exercise more difficult in recent years because of shortness of breath, although she has never been diagnosed with asthma. Tara remembers that she used to cough a lot as a child and her mother said she was just like her grandfather, coughing away and spreading germs!

Tara gave up smoking for four years while she was trying to get pregnant and says she felt really good during that time. She started smoking again when they started travelling, partly because she couldn’t see the point in not smoking since she had lost faith that she will ever become pregnant and also because she enjoys smoking and the positive effect it has on her mood.

Tara and her husband have been eating a wide range of different food, depending on where they are and what is available. She loves food and will eat just about anything. Tara’s weight has increased by a couple of kilograms since they began travelling, which she attributes to spending less time exercising and more time sitting down and looking out the window of their kombivan. Tara feels she is in a significant point of change in her life, and is excited about the possibilities although she is a little confused about what is ahead for her and her husband. What she does want right now is something natural to help her stop coughing!

TABLE 6.29 COMPLAINT

Analogy: Skin of the apple

Complaint: Define the presenting complaint and symptoms; understand the complaint

Chronic cough

AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS CLIENT RESPONSES Onset When did you notice the cough? About five months ago, we had been travelling for about a month and I got sick and started coughing. I’ve been coughing on and off since then. Understanding the cause (client) What do you think is causing your cough? I think it’s caused by colds. Whenever I get sick I start coughing almost straight away. Exacerbating factors What makes the cough worse? Cold air. It seems to be worse first thing in the morning and sometimes at night when I’m in bed. Relieving factors What makes it better? Being well and the warmer weather. It’s not as bad during the day. Examination and inspection Tara’s breathing is audible and wheezy. You notice her elevating her shoulders slightly when she breathes in. Her cough sounds rattly. She looks pale and clammy.

TABLE 6.30 CONTEXT

Analogy: Flesh of the apple	Context: Put the presenting complaint into context to understand the disease
Family health
Is there anyone else in your family who has had problems with their lungs?	My mum says my grandfather was always coughing. He ended up with emphysema.
Allergies and irritants
Are there particular days in the week your cough is worse? (exposure to possible allergen)	Not that I know of.
Recreational drug use
How many cigarettes are you smoking daily? How much alcohol are you drinking a week?

Probably about 15 or 20.

It depends on where we are, but I think on average about 5 or 6 drinks each week.

Functional disease Do you experience a sour taste in the mouth and heartburn with the cough? (gastro-oesophageal reflux) Not really, but I do get a sore chest from so much coughing. Infection and inflammation

How often have you been sick in the last six months?

Have you noticed the purulent sputum associated with the cough is foul smelling? (lung abscess)

It feels like almost all the time. I feel like I have a cold or the flu every two or three weeks and then I cough for a couple of weeks before the next one comes along.

Certainly get a lot of mucus, but it is not too bad smelling.

Supplements and side effects of medication Are you taking any supplements or medicines? I’m taking a multivitamin to try and help my immune system. I’ve had a couple of courses of antibiotics. Endocrine/reproductive
Tell me about your menstrual cycle. Tara describes a 28–30 day cycle, with a 5–7 day bleed which is heaviest on days 1–3. She doesn’t experience any pain, but gets a little anxious and irritable in the week before her period. Stress and neurological disease You mentioned your cough is worse in the mornings, does it ever stop altogether during the night? (psychogenic, habit cough, Tourette’s syndrome) I cough during the night too. But when I get up I can have some really major coughing fits with a lot of mucus. Eating habits and energy Tell me about your diet and energy levels. We eat whatever we can get hold of; it depends on where we are and what’s available. I try to get fresh fruit and vegetables, but they can be hard to get in some places. We mostly eat out of cans at the moment.

TABLE 6.31 CORE

Analogy: Core of the apple with the seed of ill health	Core: Holistic assessment to understand the client
AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS	CLIENT RESPONSES
Emotional health
How do you feel about your problems conceiving?	When I think we might never have a baby I can get quite sad.
Family and friends
Are you staying in contact with family and friends while you’re travelling?	We send postcards and call them. We’ve got some friends house-sitting for us at the moment.
Action needed to heal
Are you willing to make dietary and lifestyle changes if I recommend them?	Yes, I really want to get better. I know you’re going to tell me to stop smoking.
Long-term goals
Where do you see yourself in five years?	I’d like to see myself with one or two children, but maybe I’ll be doing something completely different.

TABLE 6.32 TARA’S SIGNS AND SYMPTOMS [1–3]

Pulse	80 bpm
Blood pressure	130/70
Temperature	37.4°C
Respiratory rate	18 resp/min; elevation of shoulders on inspiration
Cough sound	Noisy breathing reduced by coughing
Body mass index	23
Waist circumference	77.6 cm
Face	Pale
Fingers	Tobacco stained
Urinalysis	No abnormality detected (NAD)

Results of medical investigations

No tests have been carried out.

TABLE 6.33 UNLIKELY DIAGNOSTIC CONSIDERATIONS [3–7]

CONDITIONS AND CAUSES	WHY UNLIKELY
CANCER AND HEART DISEASE
Heart failure: persistent chronic cough can be the first symptom of heart failure; shortness of breath; history of smoking	No tachycardia or hypertension; usually occurs in older age groups; often presents with a nocturnal cough; Tara has not reported chest pain on exertion
OBSTRUCTION AND FOREIGN BODY
Pulmonary embolism: can lodge in large pulmonary artery, medium-sized artery, terminal arteries; differing severity of symptoms depending on where it lodges and the size of the emboli; persistent cough can be an early symptom; small emboli may cause gradual progression of shortness of breath	Usually accompanied by a dry cough and with sudden onset of symptoms of fever, chest pain and tachycardia
INFECTION AND INFLAMMATION
Acute bronchitis [59]	No significant fever
Pneumonia [60]	No significant fever
Acute legionnaire’s disease	No significant fever
Acute tuberculosis	No significant fever
AUTOIMMUNE DISEASE
Autoimmune disease e.g. Wegener’s granulomatosis; persistent cough from lesions in the upper respiratory tract	Usually begins with severe nasal symptoms before a cough and then chest pain; Tara has not reported any kidney-related symptoms; urinalysis clear of abnormalities

Case analysis

TABLE 6.34 POSSIBLE DIFFERENTIAL DIAGNOSIS

Not ruled out by tests/investigations already done [1, 3–9, 55]
CONDITION	WHY POSSIBLE	WHY UNLIKELY
ALLERGIES AND IRRITANTS
*Causal factor:* Chronic allergies [58]	Recurrent cough, travelling, potential exposure to irritants	Tara has not reported any significant nasal symptoms; her eyes are not red and do not have dark circles underneath
*Causal factor:* Smoker’s cough [55, 56, 62, 71]	Chronic cough; worse in the morning; smoking again over the past 6 months; history of smoking	Usually minimum sputum production
CANCER AND HEART DISEASE
Bronchial carcinoma [68, 72]	Cough, recurrent chest infection, immune compromised; history of cigarette smoking; shortness of breath	No weight loss, Tara has not reported blood in her sputum, no chest pain; no additional bone pain indicating metastases; no signs of nail clubbing; usually presents with reduced breath sounds
OBSTRUCTION AND FOREIGN BODY
Chronic obstructive pulmonary disease (COPD): chronic bronchitis, emphysema, chronic asthma, mixed; a condition of airway limitation that is not fully reversible [55, 74]	Chronic cough present for more than 3 months; cigarette smoking is a major risk factor; long history of chest infections; shortness of breath; family history of chronic cough (grandfather)	Usually in elderly age group, more often in men
FUNCTIONAL DISEASE
*Causal factor:* Vocal cord dysfunction/vocal cord polyps	Persistent chronic cough	Tara has not reported any changes in her voice or any difficulty eating; no blood in the sputum reported
Gastro-oesophageal reflux (GORD) [54]	Common cause of persistent recurrent cough; can be worse after eating chocolate or caffeine foods/drink; worse in the morning or during the night	Usually non-productive cough; no heartburn reported
*Causal factor:* Postnasal drip (PND) [54]	Persistent chronic cough; worse in the morning; cough can disturb sleep	Tara has not reported any nasal symptoms
DEGENERATIVE AND DEFICIENCY
Emphysema	Chronic cough present for more than 3 months; cigarette smoking is a major risk factor; history of chest infections; shortness of breath	Tara doesn’t have the typical signs of emphysema: pink appearance to skin, weight loss, pursed lips, barrel chest, decreased breath sounds; no severe breathlessness reported
INFECTION AND INFLAMMATION
Asthma [65]	Recurrent cough, recent infection, long-term history of chest infections, history of smoking; shortness of breath; can develop into chronic asthmatic bronchitis	Exercise intolerance occurs more often during acute episodes of asthma and is better between episodes of asthma; usually asthma has no mucus or if present will be clear thick mucus rather than yellow-green mucus; no history of allergy reported; no wheeze reported; only appears pale/blue in skin appearance in stages of attack
Chronic bronchitis	Recurrent episodes of cough, productive cough for 3 months, smokes cigarettes, long history of chest infections; had similar cough within the past 2 years; gradual exercise intolerance with shortness of breath; most common cause of chronic cough in adults; can be accompanied by bacterial infection producing yellow/green mucus; signs of chronic bronchitis: pale /blue appearance to skin, productive cough, purulent sputum, noisy breathing reduced by coughing
Chronic sinusitis/rhinitis	Persistent chronic cough; cough can disturb sleep; shortness of breath	Tara has not reported any nasal symptoms
*Causal factor:* Recurrent upper respiratory tract infections: secondary bacterial infection causing chronic bronchitis [69, 71, 73]	Persistent cough; can exacerbate asthma symptoms; presence of yellow-green mucus	No fever at present
*Causal factor:* Postviral cough	Persistent cough; recent recurrent upper respiratory tract infections	Usually presents as a dry cough
STRESS AND NEUROLOGICAL DISEASE
*Causal factor:* Emotional stress psychogenic cough	Not being able to fall pregnant; stress and grief; persistent cough, shortness of breath	Does not usually disturb sleep; does not usually present with a productive cough accompanied by yellow-green mucus showing signs of bacterial infection

TABLE 6.35 DECISION TABLE FOR REFERRAL [3–8, 12]

COMPLAINT	CONTEXT	CORE
Referral for presenting complaint	Referral for all associated physical, dietary and lifestyle concerns	Referral for contributing emotional, mental, spiritual, metaphysical, lifestyle and constitutional factors
REFERRAL FLAGS	REFERRAL FLAGS	REFERRAL FLAGS
• Persistent productive cough lasting for more than 3 months

• Cigarette smoking

• Family history of respiratory problems (grandfather)

• Recurrent respiratory infections/low immunity

• History of chronic respiratory tract infections

• Unexplained infertility

• Grief and loss associated with fertility problems

ISSUES OF SIGNIFICANCE ISSUES OF SIGNIFICANCE ISSUES OF SIGNIFICANCE

• Lack of oxygen due to chronic cough

• Diet is often unbalanced due to availability of food while travelling

• Reduced levels of physical activity

• Increase in respiratory infections associated with Tara’s decision to give up trying to have a baby

REFERRAL DECISION REFERRAL DECISION REFERRAL DECISION

• Tara must be referred for medical assessment and management of lung disease [63]

• Dietary assessment

• Assessment for depression and emotional status

TABLE 6.36 FURTHER INVESTIGATIONS THAT MAY BE NECESSARY [1, 2, 4–9]

TEST/INVESTIGATION	REASON FOR TEST/INVESTIGATION
FIRST-LINE INVESTIGATIONS:
Ear, nose, throat physical examination	Infection and allergic signs
Chest examination: auscultation, percussion	Signs of asthma, obstruction, infection, foreign body, heart failure
Full blood count	Haemoglobin level may be elevated in bronchitis; the main function of haemoglobin for red cells is to carry oxygen to the tissues and return CO₂ to the lungs; white cell count high in infection
Differential white cell count	Detection of eosinophils to confirm allergic triggers for cough
CRP (C-reactive protein)	Infection, cancer, inflammation raised in chronic bronchitis
Sputum test: histology, microbiology	Detect presence of eosinophils, eliminate bronchitis, pneumonia, TB
Peak expiratory flow rate (PEFR) test: used often to monitor progression of disease [64, 66]	Will be reduced in chronic bronchitis, asthma
Spirometry-FEV (forced expiratory volume), FVC (forced vital capacity): test best used for assessment of airflow limitation [64, 66]	Will be reduced in chronic bronchitis, COPD, asthma
Total lung capacity (TLC) [66]	May be normal or increased in chronic bronchitis as will alleviate asthma symptoms more effectively
Hyperresonance reactivity test: salbutamol	Distinguish between asthma and chronic bronchitis
Blood gases: CO₂ gas transfer	Reduced in emphysema
Chest x-ray [60]	Detect presence of bronchitis and pneumonia; chronic bronchitis may show over inflation of lungs with low and flattened diaphragm; hypertranslucent lung fields; rule out bronchial carcinoma, TB, pneumonia, legionnaires’ disease
IF NECESSARY:
Skin prick test	For extrinsic allergies
Antineutrophil cytoplasmic antibody (ANCA)	Wegener’s granulomatosis and autoimmune disease affecting lungs
IgM and IgG antibodies	Mycoplasma infection, viral respiratory tract infection

Confirmed diagnosis

Tara and chronic bronchitis

Tara is a 31-year-old woman who has come to your clinic for help with a recurrent cough she has been having problems with since she started travelling around Australia with her husband; Tara has a longstanding history of chest infections and cigarette smoking. Over the past four years she and her husband have been trying to fall pregnant. When their attempts to have a child did not succeed, they decided to travel extensively around Australia. Recently Tara began smoking again after having given up for several years while she was trying to fall pregnant. Tara would like relief from her persistent cough, which has developed into chronic bronchitis.

The condition ‘chronic bronchitis’ is categorised under the term ‘chronic obstructive pulmonary disease’ (COPD) along with chronic asthma and emphysema. All syndromes are involved in the destruction of lung and airflow capability that is not fully reversible. Although the three syndromes are linked together because they can often overlap and coexist with one another, there are some differentiating features between each syndrome. Chronic bronchitis specifically has a productive cough with sputum that is experienced most days for at least three months of the year for more than one year. There are often recurrent episodes, a long history of chest infections and cigarette smoking in the health history [55, 62, 71]. The most consistent pathological finding in chronic bronchitis is hypertrophy of the mucus-secreting glands of the bronchial tree. The number of mucus-secreting glands is increased, which leads to increased mucus production and expectoration. In more advanced cases the bronchi can become inflamed leading to ulceration and narrowing of the airways.

The characteristic symptoms of chronic bronchitis are cough with productive sputum, wheeze, breathlessness and often a smoker’s cough. Frequent infections with every cold ‘going to the chest’ and breathlessness are other common characteristics. Airway limitation is a long-term consequence of chronic bronchitis [67].

General references used in this diagnosis: 3–7, 57, 62, 67, 69, 73, 74, 76, 77

Prescribed medication

• Antibiotics [61]

• Inhaled bronchodilator and corticosteroid [70, 75]

TABLE 6.37 DECISION TABLE FOR TREATMENT (ONCE DIAGNOSIS IS CONFIRMED)

COMPLAINT	CONTEXT	CORE
Treatment for the presenting complaint and symptoms	Treatment for all associated symptoms	Treatment for mental, emotional, spiritual, constitutional, lifestyle issues and metaphysical considerations
TREATMENT PRIORITY	TREATMENT PRIORITY	TREATMENT PRIORITY
• Lifestyle recommendations to reduce congestion and improve clearance of mucus from Tara’s lungs • Recommendation for Tara to quit smoking • Lifestyle recommendations to avoid exposure to air pollution, increase exercise and do breathing exercises to improve Tara’s respiratory function • Physical therapy recommendations to reduce congestion and improve clearance of mucus from Tara’s lungs • Physical therapy recommendations to improve respiratory function • Herbal tonic or tea with immunostimulant, antimicrobial, expectorant and anti-inflammatory action • Nutritional supplements to enhance immune function and support respiratory health NB: Vitamin A at high dose should not be taken long term [36] but only for the duration of the current infection and then reduced [8]; Tara’s case should be collaboratively managed with conventional medical practitioners to ensure optimal management and treatment outcomes [61]	• Lifestyle recommendations to quit smoking and reduce exposure to air pollution and other environmental triggers to improve respiratory function and reduce the incidence of infection • Lifestyle recommendations to improve general health, fitness and respiratory health • Lifestyle recommendations to avoid or minimise triggers or aggravating factors • Physical therapy suggestions to enhance respiratory health • Dietary recommendations to improve general health, immunity and nutritional status • Dietary recommendations to identify and manage any food allergies or sensitivities • Herbal tonic or tea with immunostimulant, antioxidant, adaptogenic and tonic action to enhance general health and wellbeing • Nutritional supplements to enhance general health, wellbeing and respiratory health

• Lifestyle and physical therapy recommendations to improve Tara’s emotional health

• Lifestyle and dietary recommendations to improve the chances of a successful pregnancy

• Recommendation to investigate the underlying causes of infertility

• Dietary recommendation to drink herbal teas with nervine action instead of coffee

• Herbal tea formula with nervine action

• Dietary recommendations to improve intake of essential nutrients to improve general health and respiratory function as well as fertility

• Dietary supplements to improve general health

NB: Tara’s vitamin and mineral levels should be monitored to ensure she stays within normal range; recommendation to use beta carotene instead of vitamin A in the longer term to avoid toxicity and any adverse affects of vitamin A supplementation on a future pregnancy [36]

Treatment aims

• Get Tara to quit smoking [8, 14, 16, 23, 37, 38].

• Eliminate Tara’s current bronchial infection [14, 38].

• Enhance Tara’s immunity to reduce the incidence of infection [8, 14, 16].

• Improve Tara’s lung function [8, 15, 16, 38].

• Reduce hypersecretion of mucus and support drainage of secretions from the respiratory tract [14, 38].

• Improve Tara’s symptoms, quality of life and prevent or minimise progression of the condition and further lung damage [16, 38].

• Reduce oxidative stress [16, 52, 53].

• Identify and manage allergies that may be contributing to the problem [8, 14, 16].

• Improve Tara’s diet and nutritional status [8, 14, 16, 38].

• Improve Tara’s lifestyle, diet, general health, fitness and vitality with the long-term goal of achieving and maintaining a healthy pregnancy [24–26].

Lifestyle alterations/considerations

• Tara must quit smoking [8, 14, 16, 23, 37, 38]; it has a negative effect on Tara’s respiratory [8, 23, 37, 38] and reproductive health [24].

• Encourage Tara to avoid exposure to air pollution wherever possible [38, 40].

• Twelve drops of eucalyptus oil in boiling water as a steam inhalation or five drops in a nebuliser can help alleviate symptoms of congestion [18]. Eucalyptus has antitussive, antimicrobial, decongestant and anti-inflammatory properties [18].

• Tara may find taking hot showers or baths soothes bronchial irritation [8].

• Breathing exercises, such as active expiration, slow and deep breathing and diaphragmatic breathing, may improve Tara’s respiratory function and increase the strength of her respiratory muscles [27, 38].

• Tara may find applying liniments containing menthol or peppermint to her chest can help soothe her cough and enhance expectoration [18, 19].

• ‘Bottle blowing’ may help Tara improve the clearance of infected secretions, decrease the impairment of pulmonary function and increase total lung capacity [14]. This technique involves blowing through a plastic tube inserted into a bottle containing 10 cm water to create bubbles. The recommended frequency is 20 times on 10 occasions daily [14].

• Regular exercise will help improve Tara’s respiratory health [15, 23, 38].

• Educating Tara about her condition and ways to manage and reduce symptoms is important to ensure her compliance to treatment and to reduce progression [23, 38]. A specific respiratory rehabilitation program may be of particular benefit to her [23, 38].

• Tara and her husband may want to seek medical investigations into the reasons for their unexplained infertility.

• Because Tara is still travelling it is unlikely she will attend the clinic on more than a couple of occasions. Treatment protocols and referrals must be provided in written form so other complementary therapists and medical practitioners can be informed of the treatments you have recommended.

Dietary suggestions

• Encourage Tara to increase consumption of nutrient-dense, antioxidant and flavanoid-rich whole foods: vegetables, fish, fresh fruit, whole grains, nuts and seeds, etc. They have a positive effect on respiratory health [16, 28, 29, 31, 32, 53]. High intake of vegetables and fruit is associated with enhanced ventilatory function, which reduces the risk of COPD [39] while low intake of vegetables (particularly cruciferous vegetables) and fruit is a risk factor for COPD [39].

• Encourage Tara to increase her intake of dietary fibre from vegetables, legumes, whole grains and fruit [16, 39].

• Encourage Tara to reduce or eliminate consumption of alcohol. Alcohol consumption is a risk factor for COPD [16, 28, 38].

• Encourage Tara to increase consumption of foods rich in omega-3 fatty acids and reduce consumption of omega-6 fatty acids [29]. Increased consumption of omega-3 fatty acids has been associated with improved lung function in COPD [30] and reduced risk for COPD [40].

• Encourage Tara to significantly reduce or eliminate consumption of refined carbohydrates, red meat, processed meat and fried foods [16, 31].

• Identify and eliminate food allergens or sensitivities and have Tara follow a hypoallergenic diet for two to three weeks [8]. Dairy products and wheat should be eliminated during this time [8].

• Encourage Tara to increase her fluid consumption [8, 16]. Vegetable broths, chicken soup and ginger tea with honey and lemon are good choices [8]. Herbal teas with a nervine and relaxation action such as passionflower [18, 20] or chamomile [18, 19] would also be a good choice.

• Encourage Tara to consume 2–5 g fresh raw garlic each day [18]. It has antioxidant, antimicrobial and immune-enhancing properties [18].

Physical treatment suggestions

• Tara may find reflexology is helpful [41].

• Massage therapy may be beneficial for Tara’s emotional health [42, 43, 44].

• Acupuncture can help reduce dyspnoea [45] and may improve airway mucociliary clearance [33].

• Hydrotherapy: constitutional hydrotherapy [46–48]. Back and front contrast treatment with cold mitten friction on the trunk when symptoms begin to ease [48, 49]. Hot chest showers [49]. Smear a mustard plaster on the chest made with one part mustard powder to three parts flour and enough water to make a paste [50]. A steam vapouriser will assist breathing [50].

TABLE 6.38 HERBAL FORMULA (1:2 LIQUID EXTRACTS)

HERB	FORMULA	RATIONALE
Echinacea root Echinacea angustifolia/purpurea	50 mL	Immunostimulant [18, 19]; anti-inflammatory [18, 19]; antioxidant [18]; increases resistance to infection [19]
Thyme Thymus vulgaris	30 mL	Expectorant [18, 19]; spasmolytic [18, 19]; respiratory antiseptic [18]; traditionally used for the treatment of bronchitis [18, 19, 20]; approved for use by Commision E for treating bronchitis [18]
Mullein Verbascum thapsus	55 mL	Respiratory demulcent [18]; antimicrobial [18]; traditionally used for bronchitis [18, 20]; approved for use by Commission E for treating respiratory catarrh [18]
Astragalus Astragalus membranaceus	60 mL	Immunostimulant [18, 19, 51]; tonic [18, 19, 51]; adaptogen [19, 51]; indicated for use with chronic infections [51]
Ginger Zingiber officinalis	5 mL	Anti-inflammatory [18, 19]; antimicrobial [18, 19]; antioxidant [18, 19]; immunomodulator [18]; anxiolytic [18]; traditionally used as a warming or diaphoretic herb [19]
Supply:	200 mL	Dose: 5 mL four times daily until bronchitis has resolved

TABLE 6.39 HERBAL TEA

Alternative to herbal liquid if Tara prefers a tea
HERB	FORMULA	RATIONALE
Elecampane root Inula helenium	2 parts	Expectorant [20, 21, 22]; antibacterial [20, 21, 22]; traditionally used for bronchitis [22, 23]
Thyme herb or flower Thymus vulgaris	1½ parts	See above
Echinacea root Echinacea angustifolia/purpurea	2 parts	See above
Peppermint herb Mentha × piperita	1 part	Antimicrobial [18, 19]; antioxidant [18]; sedative [19]; traditionally used for respiratory infections [18, 19]
Ginger root Zingiber officinalis	¼ part	See above

Decoction: 1 cup four times daily

TABLE 6.40 NUTRITIONAL SUPPLEMENTS

SUPPLEMENT AND DOSE	RATIONALE
Quercetin 1500 mg daily in divided doses [16, 34]	May play a role in decreasing damage to lung tissue [16, 17]
Vitamin C 1000 mg twice daily [8]	Antioxidant [34, 35]; smokers have an increased requirement for vitamin C [34, 35]; possible link between vitamin C deficiency and COPD [38, 40]
Vitamin A 25000 IU twice daily until current infection resolves [8]; the dose should be reduced to no more than 2500 IU daily [35] thereafter or swap to a 6 mg beta carotene supplement daily [18] to ensure there are no adverse effects to the fetus from vitamin A should Tara become pregnant [36]	Antioxidant [34, 35]; deficiency is associated with low immunity [34, 35]; enhances resistance to infection [34] and maintains mucosal barrier to infection [34]
Zinc sulphate or citrate [36] 30 mg elemental zinc twice daily [8] 1 hour before or 2 hours after food [36] and taken at least 2 hours away from antibiotics and other supplements [36] 2 mg daily of copper should be included if zinc supplement is taken for more than 1 month [36] Dosage should be reviewed once the current infection resolves	Antioxidant [18]; plays an important role in immunity [36]; deficiency may be associated with low immunity [34]; and reproductive disorders [18, 34]; zinc supplementation may reduce the incidence of lower respiratory tract infections [35]
Omega-3 fish oil 4000 mg daily in divided doses [18, 36]	Anti-inflammatory [34]; may improve respiratory function in COPD [29, 30]
High-potency practitioner-strength multivitamin, mineral and antioxidant supplement providing therapeutic doses of essential micronutrients and antioxidants Dosage as per the manufacturer’s instructions	To ensure Tara’s intake of essential nutrients and antioxidants is sufficient; people with COPD often have lower intakes of essential vitamins and antioxidants [28, 29]; particularly important when Tara is unable to find fresh fruit and vegetables