ASTHMA

1a - Definition of Condition

Asthma is a chronic (long-lasting) inflammatory disease of the airways. In simple words,

asthma is condition that causes occasional tightening of the air passage, which makes it
difficult breathing air in and out of the lungs (1). In those susceptible to asthma, this
inflammation causes the airways to spasm and swells periodically so that the airways
narrow. The individual then must wheeze or gasp for air. Obstruction to air flow either
resolves spontaneously or responds to a wide range of treatments, but continuing
inflammation makes the airways hyper-responsive to stimuli such as cold air, exercise, dust
mites, pollutants in the air, and even stress and anxiety.

The changes that take place in the lungs of people with asthma makes the airways (the
"breathing tubes," or bronchi and the smaller bronchioles) hyper-reactive to many different
types of stimuli that do not affect healthy lungs. In an asthma attack, the muscle tissues in
the walls of bronchi go into spasm, and the cells lining the airways swell and secrete mucus
into the airways. Both these actions cause the bronchi to become narrowed
(bronchoconstriction). As a result, an asthmatic person has to make a much greater effort to
breathe in air and to exhale it.

Cells in the bronchial walls, called mast cells, release certain substances that cause the
bronchial muscle to contract and stimulate mucus formation. These substances, which
include histamine and a group of chemicals called leukotrienes, also bring white blood cells
into the area, which is a key part of the inflammatory response. Many individuals with
asthma are prone to react to such "foreign" substances as pollen, house dust mites, or
animal dander; these substances are called allergens. On the other hand, asthma affects
many individuals who are not allergic in this way.

About two-thirds of all cases of asthma are diagnosed in people under age 18, but asthma
also may first appear during adult years. Individuals presenting with breathlessness,
wheezing, cough, and chest tightness should be considered as potential asthmatic; however,
this symptomatology is not exclusive to asthma (2). While the symptoms may be similar,
certain important aspects of asthma differ in children and adults.

1b - Aetiology

The complete causes of asthma are unknown. Heredity does seem to play a role as do
allergens and environmental factors. The genetic predisposition for the development of an
Ig E-mediated response to common aeroallergens, is the strongest identifiable predisposing
factor for developing asthma.

There are two categories of asthma: allergic or extrinsic and idiosyncratic or intrinsic.

Allergic asthma is a result of an antigen\antibody reaction on mast cells in the respiratory

tract. This reaction causes the release of inflammatory mediators from mast cells which elicit
the clinical response associated with an asthma attack.

Idiosyncratic asthma is a result of neurological imbalances in the autonomic nervous system

(ANS) in which the alpha and beta adrenergic as well as the cholinergic sites of the ANS are
not properly coordinated. If onset occurs later in life, asthma is more likely idiosyncratic. The
incidence of asthma in the population below the age of 15 years is 5% to 15%. An incidence
of 1% is found in the adult population.

1c – Clinical Features

 Wheezing
 Cough
 Cough at night or with exercise
 Shortness of breath
 Chest tightness
 Sputum production

Worldwide, asthma is estimated to affect 300 million people. Asthma is closely linked to
allergies; about 75% of people with asthma also have allergies.

Onset of asthma between the ages of 5 to 15 years usually indicates asthma with an allergic
basis. Asthma affects an estimated 4.8 million children and is the most common chronic
disease of childhood.

The incidence of asthma in the population below the age of 15 years is 5% to 15%. An
incidence of 1% is found in the adult population.

References:

1 – Mark Levy, Thrista Weller, Sean Hilton, Asthma: The at Your Finger Tips, 4th ed., 2006

2 – Margaret Varnell Clark, Asthma: A Clinician’s Guide, Jones & Bartlett Publishers, 2011

2. CLIENT ASSESSMENT

2a.

Assessment in this case will rely on subjective and objective findings using the
HOPRS methodology.

History:

A full case history, including knowledge of medications or supplements they may be

taking together with observational skills. A series of questions may include the
reason for their visit today, diseases & medication, injuries & operation, allergies.
Have they been assessed by a medical practitioner or currently under supervision (if
medicated). When did the first episode of asthma happen? What are the treatment and
management ways ever since? If this is extrinsic type of asthma what are the common
trigger factors in her life (eg, drug, food, environmental irritants).
Observation:

Commonly there are some physical signs for people with asthma, including:

 Dyspnea, Apprehension
 Pallor, Grayness
 Alar Flaring
 Coughing, Possible
 Audible Wheezing
 Shoulders Raised
 Leaning Forward
 Disended Chest, Congestion,
 Wheeze on Auscultation
 Using Accessory Respiratory Muscles
 Arms to Side, Palms Down for Support

Palpation:

We can palpate and feel skeletal abnormalities ( e.g. symmetrically chest expansion)
and tactile fremitus (due to hyperinflation). Moreover, we can palpate and feel the
5Ts change in specific group of muscles such as hypertonicity noted in SCM, levator
scapulae, upper trapezius, pecs and suboccipitals, intercostals.

ROM:

Check the ROM of neck and shoulders. All the side bending, rotation, flexion,
extension of neck and shoulders are restricted/limited.

2b. Contra-indications

 Unrealistic expectations of treatment

 Client/therapist boundary has been distorted, crossed or left unclear

 The client is under an episode of a severe asthma attack

3. Treatment Strategy

3a. Rationale

 To increase the sense of warmth through friction, as attack increases during cold
responsible for bronchospasm.
 To decrease the adhesion and tension of the accessory breathing muscles and
fascia
 To improve circulation this will reduce dryness in airways also responsible for
bronchospasm and dry cough.
 To increase the discharge of mucous in sputum, there by relieving blockage of
airways resulting in reduced breathlessness.
  Physical effects include:
Brain waves changing from alpha to theta.
Blood vessels dilate- improved circulation, slower heart rate, slower but deep
breathing rate, and decrease in blood pressure.
Pain relief.
Psychological changes include:
Anxiety and worry level lowered.
Improved relationships- less reactive to people and situations.
Enjoy restful sleep

3b. Client symptoms

Client is a 33 y/o woman diagnosed with asthma 6 months ago since she was overseas for a
quite stressed sales meeting. She still works as sales manager in an international import &
export company. She uses corticosteroids by inhaler. She has a sore and tightness in her
neck, chest and shoulder sometimes having a low energy and little stress. She has no
significant past injuries or surgery but she has allergic rhinitis (hay fever allergy). Asthma
attack also gives her low esteem especially when she’s at work or outside with friends.

3c. In assessment client stated regularly suffered from a sore and tightness in her neck,
chest and shoulder also with headache sometimes which will worsen during the acute
attack episode. Observational assessment showed that obvious upper chest breathing
pattern- early upward movement of her shoulders and neck when asthma attack occurs
which comes with audible wheezing and coughing sometimes. Further palpation
revealed tension and tightness within neck, shoulder and chest. Initial session will focus
on chest, neck and shoulders.

3d. Specific techniques can be used include:

 Myofascial release: helps to release adhesions and reshape restricted fascia

surrounding muscle fibres.
 Deep muscle stripping (longitudinal) using knuckles or thumbs – help release muscle
tension (i.e. scalenes and deep cervical muscles)
 Trigger point therapy at relevant regions (i.e. upper trapezius, Levator scapulae,
rotator cuff, SCM)
 Hydrotherapy – use of heat to help relieve muscle spasms, relax muscle fibres or ice
to reduce inflammation. Alternate to create pump action for chronically contracted
muscles
 Massage of the lower rib cage: standing on the opposite side to the rib cage being
worked effleurage the intercostal between the ribs. Try to access the lateral sides as
far as you can. ‘Trace’ the rib cage in this way several times gradually increasing
finger pressure. Repeat on the other side.

3e. Massage tends to help relaxation, and as stress is a known and common trigger for
asthma, it is possible that the relaxation effects of massage could help with asthma
symptoms. It also could release all stiffed muscle that contracted during asthma attack. It
could help to ease the stress due to the asthma disease. That will bring my client to easier to
manage a better quality of life.

3f.Treatment can be started with 1 hour session/week for 10 treatments then can be
changed to 1 hour session/fortnightly as needed for next 2 months and then re-evaluated.

3g. Treatment will be evaluated every session according to feedback from client. Questions
will be given to client whether she feels better or need to focus the massage on some area.
If the response was positive, the session will keep continued as planned. If response was
negative the referral to other specialist/therapist will be given off.

4. TREATMENT PLAN

Back

Start in prone position. Use the increasing pressure with effleurage to warm entire back.

 Using deep effleurage , concentrate on stretching and warming up superficial muscle

of the low back, finish with gentle pushes on the ilium

 Using firm thumb pressure strokes, work one side of the spine down into the SI joints
and around the iliac crests, then the other.

 Follow by using the heel of your hand in the same area.

 Stand on left side of client. Using middle fingers, with one hand on top of the other
use transverse strokes to separate and stretch muscles between the lumber spine
and iliac crest. Repeat for 5 to 6 times.

 Warm up gluteals using gentle compressions, heels of hand and knuckles from iliac
crest and sacrum to greater trochanter.

 Apply deep strokes through the gluteal using middle fingers from the origins to
insertions.

 Change the side of table now. Standing on the same side as you have been working.
(client right side), use sustained pressure and work QL, up from ilac crest to 12th rib
using heels of palms and thumbs. Repeat 3-4x

 Repeat sequence to clients left side.

 Standing at the head of the table, apply slow, firm effleurage from shoulders to
sacrum 2-3x

 Knead upper trapezius, working across the table

 With one hand over the other, strip along rhomboids and levator scapula.

 Effleurage over latissimus dorsi, pulling from hip to shoulder using alternating hands.

 Wing scapula and work into upper trapezius, E.S, and apply gentle stretch on clents
exhale.
  Repeat sequence to other side.

 Finish the general effleurage followed by light strokes up towards head from hip.

Neck/Shoulder:

Start with general heart shaped effleurage to warm up pectoralis, upper trapezius and neck
while client in supine position for 3-4 repetitions.

 Stand to one side of client and effleurage from sternum to shoulder applying
increasingly firm pressure over pectoralis major. Point pressure can be applied to the
intercostal muscles.

 Repeat heart shaped effleurage and repeat above on the other side.

 Release scalene: in supine position, support head with one hand; rotate and laterally
flex head slightly, x-fibre at 1st and 2nd ribs and cervical attachments with fingers and
thumb at the other hand. Maintain this position and lightly stroke the scalanes using
the thumbs while gently increasing pressure with each repetition. Please remind do
not works too deeply as this could compress the carotid artery and jugular veins
witch lie beneath these muscles) include isometric contractions. And passive flexion
and lateralstrtches to both side of the neck.

 Release SCM. Supine position: x-fibre at attachments sites with head gently flexed
stretch and friction SCM between thumb and pointer finger working proximal to distal
gently raising muscle to prevent damage to underlying blood vessel.

 Release cervical attachments sites. Prone: x-fibre at occiput and mastoid process,
tranverse frictions at vertebral ligament attachment points, supine: stroking and
friction of posterior cervical muscle and upper trapezius using the weight of client’s
head, x-fibre or circular frictions at occiput, unilateral knuckle slides for 3-4x each

 Pressure points along temporalis, SCM and masseter muscles.

 Deep thumbs stroke down masseter asking client to drop jaw on your downward
stroke. Gentle circular friction intoTMJ while client gently opens and closes mouth.
Finish with general circular effleurage to cheeks, jaw and neck.

 End with a general heart shaped effleurage as before. Point pressure along bladder
meridian of scalp

 Finish with scalp massage and gentle ear traction.

5. COMMUNICATION

5a. Pre-treatment:
According to your symptoms and your assessment, I found that there are stiffness and in the
shoulder, neck and chest. Palpation also showing that chest area, shoulder, trapezius and
neck has some tightness, I assumed it happens after asthma attack.

In this session today, I would like to focus first on your neck and shoulder to release stiffness
and muscle tension. I hope you will give me feedback for this matter. I will start slowly and
lightly massage. Do you have any question? I am glad to answer it.

Post-treatment

My suggestion is we continue the session each week for an hour until 10 sessions. You may
choose the time and day that suits you. We will re-asses you in third session. If there is only
little improvement after few sessions to your condition we will see for other option including
referring you to GP or other specialist. Please ask me if there is any concern about this or
other question?

Question can be asked to me not only after or before session. I also give some self-massage
knowledge for my client in case she needs it after asthma attack. .

5b.

Strategy 1

03/10/2011 Healing Palm Massage

533-535 Elizabeth st

Surry Hills, NSW

To: Counselor Martha

Dear Martha,

I’m referring my client, Joann Bach under your supervising to check her asthma side effect
problem and get more details about it. Joann Bach has asthma for more than a year and it
reduces her confidence due to she has to use inhaler if the asthma attack while she was
working or out with friends. Although all of her friends and working mates know about her
condition, it doesn’t make her confidence enough.

In my supervise, I give her remedial massage for neck, shoulder and chest to ease her
breathing and her muscles during and after asthma attack. Please advise.

Regards,

Bella Wang
Strategy 2

03/10/2011 Healing Palm Massage

533-535 Elizabeth st

Surry Hills, NSW

To: Dr. Seaman

Joann Bach is my client who has asthma for more than a year. Her condition relatively stable
these days due to her inhaler medication. I give her massage in the neck, shoulder and
chest to release her muscles from tightness. As she is also under your medical care, I would
like to have more detail about her condition so I can give her more massage therapy needed
to help her ease her asthma. For now I give her 1 hour session/week for massage which can
be re-evaluate as needed.

I thank you for referring this client.

Best regards,

Bella Wang

Strategy 3

3//10/2011 Healing Palm Massage

533-535 Elizabeth st

Surry Hills, NSW

Pacific Health Insurance Company

To: Whom It May Concern,

Case Number: 078

Joann Bach has presented with asthma symptoms. I have asserted Joann Bach and gave
found that there is stiffness in trapezius, splenius, rhomboideus, pectoralis major. Her
problems occur when asthma attack come where she stressed her chest, shoulder and
neck.

Treatment plan for Joann Bach is as follow: 1hour session/week for 10 treatments. Re-
evaluation for treatment will be given after 3rd session based on feedback from Joann Bach.
Massage focus on releasing the stiffness of muscle to ease her during and after asthma
attack occurs.

If there any question or looking for more information, do not hesitate to contact me.

Best regards,

Bella Wang.
Strategy 4

3/11/2011 Healing Palm Massage

533-535 Elizabeth st

Surry Hills, NSW

To: Dr. Allan Harper (Chiropractor)

Dear Dr. Allan,

I am referring Joann Bach for deeper and detail assessment of her chest and back including
neck and shoulder. She has asthma for more than 1 year that has side effect to her muscles
and bones. She has no whatsoever other major problem in the pass except this asthma.

I thank you for your reviewing to this client.

Regards,

Bella Wang

6. Specialized Treatment

Children and adolescent

Every child, no matter the age, should be massaged at bedtime on a regular basis. Massage
is a wonderful stress-buster for children. Even young infants and children are prone to
stress. For example, a young child starting school who is unfamiliar with the area or children
in the class will experience stress. Family illness or financial problems, divorce and even
vacations can produce emotional strain. If stress hormones are chronically elevated, the
hormone cortisol will destroy the healthy immune cells that fight viruses and tumours and
keep the immune system healthy.

If it's the child's first massage, they may squirm a bit because they are not familiar with this
type of touch. Due to the discomfort and pain of medical procedures inflicted on them,
infants and especially premature babies may have developed a negative association with
touch. Given this new, positive experience they relax and their bodies quiet down.

With infants, a gentle gliding stroke is applied to the body, but as the child grows older, the
massage may become more sophisticated to include work on the feet, fingers and toes, and
use of more extensive types of strokes and techniques. Teens are a little different. With
young children we can train the mother or parent to do massage for a daily dose. Teens,
however, don't seem to like their parents giving them massage. They respond better to a
massage therapist.

Women

Many women know that massage therapy helps reduce pain and improve relaxation. But you
might not be aware that massage for women also provides relief for a multitude of specific
health concerns.
Massage therapy is has been shown to improve flexibility and range of motion, strengthen
the immune system and relieve headaches and migraines in women. Research found that
massage therapy decreased the occurrence of headaches, sleep disturbances and distress
symptoms while increasing serotonin levels in adults with migraine headaches.

For women who are pregnant, there are numerous benefits from prenatal massage therapy.
One study suggests that massage therapy during pregnancy may lower anxiety, decrease
back and leg pain, improve sleep quality, and decrease levels of the stress hormone
norepinephrine. In another study of pregnancy massage in depressed women, researchers
found that prenatal massage therapy increased levels of the feel-good hormones serotonin
and dopamine, decreased levels of cortisol (an indicator of stress) and resulted in an overall
improvement in mood.

Men

A man’s muscles take a beating, whether he works at a construction site, exercises hard or
simply is sore from yard work they all hurt. A tense upper body makes nearly every part of
daily life more difficult. Sometimes the only way to cure this problem is by giving him a deep
massage. A good massage can unlock tense muscles in the shoulder and back.

Massage is an important part of a man's physical health. Stress and daily wear and tear on a
man's body cause pressure points to build up in joints and around muscles. You should
massage a man's body on a weekly or twice-monthly basis in order to provide him with the
tension relief he needs to keep his body healthy.

80-minute hand-and-foot massage significantly lowered men's heart rates, cortisol levels and
insulin levels-all of which help lower stress. Not only can massage therapy for men help
alleviate stress and tension, but it's also has been shown to relieve neck and back pain,
reduce heart rate and high blood pressure and improve athletic performance in men.

Geriatric Care

This type of massage takes age-related health conditions into account. Health conditions
such as diabetes, dementia, Alzheimer and others need special attention. Healthy elderly
populations also have special considerations such as the thinning of the skin and increased
bruising to just name a few. To do this successfully requires theoretical knowledge and
technical skills that go beyond what is usually taught in massage schools.

Elderly clients also cannot usually lie flat on the massage table or turn over easily. Learning
to massage with these special needs is required. Geriatric clients also can be very healthy
and active adults who just want to use massage to keep them that way.

If clients have a specific health condition, they should receive permission from their
physician to proceed with massage. As with any population, there are certain conditions that
are not recommended for massage, hence the importance of communication with doctor.
Once they have obtained permission, be sure to specify their preference for geriatric
massage when scheduling appointment.

Mental health care

Massage therapy is becoming an increasingly popular method of treating depression and
other mental disorders, and one that has gotten a lot of attention over the last few years. And
while the option doesn’t get the publicity that psychotherapy and medicine tend to get, it is a
very real and very legitimate means of dealing with the condition and deserves recognition
as such.

In a massage, the body releases a number of mood- and health-enhancing chemicals that in
turn boost serotonin and dopamine in the body. At the same time, the body also reduces
stress hormones like adrenaline and cortisol while experiencing a massage. The relaxation
that sweeps the body serves to ease the mind of all concerns and worries, and thus, helps
battle against depression and other mental health problems.

Massage can reduce a stress hormone that can wreck havoc on one’s mental wellbeing. It
also stabilizes blood sugar levels, improves lung function and helps in the proper functioning
of the immune system. The therapeutic value of massages as it relates to decreasing stress
and anxiety, as well as aiding with good mental health is particularly high. As per the study,
massages helped people sleep better, function more productively throughout the day, and
exhibit healthy emotions when dealing with family, friends and co-workers.

While a massage every given week may not entirely cure someone of the mental disorder, it
will go a long way in aiding the process along, and it certainly can’t hurt.