J Manipulative Physiol Ther. 2013 (Jan); 36 (1): 57–65 ~ FULL TEXT
Vanessa Carina Pepino, José Dirceu Ribeiro, PhD,
Maria Angela Gonçalves de Oliveira Ribeiro, PhD, Marcos de Noronha, PhD,
Maria Aparecida Mezzacappa, PhD, Camila Isabel Santos Schivinski, PhD
State University of Campinas,
São Paulo, Brazil.
OBJECTIVE: This study reviewed the scientific evidence available on the effects of manipulative techniques on children with respiratory diseases.
METHOD: Three databases (SciELO, PEDro, and MEDLINE) were searched for clinical trials on the effects of manual therapy techniques on children and adolescents with respiratory diseases. The relevant studies were chosen by 2 independent researchers who assessed their abstracts and selected the studies that met the criteria for a complete and structured review.
RESULTS: Of the 1147 relevant titles, 103 titles were selected for abstract assessment, and of these, 24 were selected for a full-text review. After critical analysis, 8 studies were included in the review and 16 were excluded for the following reasons: 1 covered only conventional therapy, 7 were not about the studied theme, and 8 included adults. Of the 8 studies included in the present review, 5 consisted of asthmatic children and the others of children with the following conditions: cystic fibrosis, bronchiolitis, recurrent respiratory infections, among others. Only 2 studies did not identify positive results with the use of manual therapy. The other 6 studies found some benefit, specifically in spirometric parameters, immunologic tests, anxiety questionnaire, or level of salivary cortisol.
CONCLUSION: The use of manual techniques on children with respiratory diseases seems to be beneficial. Chiropractic, osteopathic medicine, and massage are the most common interventions. The lack of standardized procedures and limited variety of methods used evidenced the need for more studies on the subject.
From the Full-Text Article:
Manipulative therapy has been studied since the 19th century. Chiropractic and osteopathic medicine have been used as therapeutic approaches, alone or together with other techniques, for the treatment of different diseases. The benefits of manipulative therapy for the treatment of spinal conditions have been published and shown effective for managing some diseases. [1–3] In recent years, manipulative therapy has also been used as a complementary treatment to pharmacologic therapy to help in the management of respiratory diseases in adults and children. 
Considering that for most conditions, a treatment applied to an adult may be different when applied to a child, differences in treatment between children and adults are also expected when using manipulative therapy. Differences such as technique, frequency, and expected response should be considered when treating children with manipulative therapy. However, there are only a small number of studies in which the main objective was to investigate the effects of manipulative therapy in children, and among them, there is a small proportion that involves manipulative therapy and respiratory diseases.
Because conventional respiratory physiotherapy using manual techniques and other resources showed positive results in children with cystic fibrosis and asthma, [5, 6] other manipulative approaches also gained acceptance in the management of respiratory diseases. [7–9, 16, 17]
Hence, this type of therapy has been included in clinical practice and investigative methods that involve physiotherapy and respiratory diseases. [7–9] Various scientific articles have been published on the subject, some demonstrating the benefits of manual therapies on children with pulmonary diseases. [7–9] For example, a clinical trial done in 2001 found that the quality of life of children with asthma improved after 3 months of treatment with spinal chiropractic techniques.  Even the pulmonary function of healthy individuals have benefited from these techniques.  A study with asthmatic children found that their peak expiratory flow (PEF) improved after treatment with manipulative therapy, specifically osteopathic medicine techniques. 
Considering that there is evidence on the effects of manipulative therapy in children with respiratory disease, the objective of this review is to investigate systematically the scientific evidence of the effects of manipulative techniques on children with different respiratory diseases, list the techniques used, and disclose these results.
The 3 types of manipulative therapies studied (chiropractic, osteopathic, and massage) proved beneficial; 6 articles demonstrated positive results with these methods.
Chiropractic manipulation is a type of manual therapy developed at the end of the 19th century. Currently, doctors of chiropractic are the third largest group of health professionals in the United States, behind physicians and dentists. Therapeutic resources associated with the chiropractic care include spinal manipulation, rehabilitation, and counseling on life habits. One of the aims of this practice is to correct spinal misalignments or dysfunction to encourage the self-healing mechanisms of the body. 
A study that investigated the effects of chiropractic manipulation on the pulmonary function and quality of life of asthmatic children did not find significant differences between the treated and the control groups.  However, the children in the control group were given massage, which is another intervention method, so it is not possible to state that the results of this study refute manipulative therapy. Alcantara et al  stated that the intervention done in the placebo group by Balon et al can be mistaken for treatment and has affected the results. A similar critique was made by Brian  in 1999, who reported that the massage of the paraspinal muscle given to the control group can benefit children with asthma, as demonstrated by Field et al.  On the other hand, another study that used a questionnaire to assess the use of chiropractic on asthmatic children found that chiropractic improves quality of life and reduces asthma severity. 
Osteopathic manipulation was found to improve the PEF of asthmatic children significantly, from 7 to 9 L/min, measured before and after the intervention.  In this study, the author suggests that the compromised rib cage of these patients may have become more flexible after intervention with osteopathic techniques, improving their breathing. Osteopathic medicine aims to improve bodily functions including the use of manipulative techniques. Osteopathic medicine was developed by Andrew Taylor Still in 1874 (as cited by Ricard and Sallé ).
Another 2 studies investigated the effects of massage on asthmatic children. [16, 17] The techniques described in these articles as massage are characterized by direct touching of the patient by the hands of professional therapists or previously trained parents/caregivers. In these studies, the parents massaged their children every evening before bedtime, and this practice had a positive impact on the spirometric data of these children  and also reduced their anxiety.  Massage had a positive impact on children with cystic fibrosis, according to Hernandez-Reif et al, who found that massage done by parents benefited the children, reducing their anxiety and improving their mood and PEF, also reduced the parents' anxiety. The effects of massage were also analyzed in children with recurrent respiratory infections by measuring changes in their serum levels of complement and immunoglobulin, and the results showed improved immune function. Contrary to other studies, this study used acupuncture points to guide therapeutic manipulation. 
The diversity of manipulative therapies used in these studies is evident. They include chiropractic, [8, 9] osteopathy, [7, 18] and massage, [14–17] and each one of them presents its particularities, preventing comparative analyses of their effects on the studied illnesses.
Although these studies showed only benefits with the use of manipulative therapies in children with respiratory diseases, their questionable methodological quality renders the results equally questionable. Hence, these do not necessarily provide substantial evidence for indicating manipulative therapy for this group of patients. The quality of the studies was determined according to the criteria proposed in the PEDro database, which were established by a consensus of experts, not by empirical data. These criteria help to identify randomized, controlled studies with good internal validity and sufficient statistical information for the correct interpretation of the results. Given the low score obtained by most of the studies presently reviewed, general statements about the effects of these treatments in different clinical situations demand caution.
Another noteworthy point in this review is the prevalence of studies on asthma. Hondras et al  made a review about the effect of manual therapy on asthmatic patients and concluded that “the evidence is inadequate to confirm or refute possible benefits of manual therapy on patients with asthma.” Another recent review (2010) assessed the effectiveness of manual therapy on patients with different diseases, classified by the authors as either musculoskeletal or not musculoskeletal, and with respect to asthma, the authors consider that the studies using spinal manipulation as complementary treatment to conventional treatment did not obtain good results and the evidence from studies using massage was inconclusive. These observations are indirectly based on an adapted version of the classification system developed by the US Preventive Services Task Force, according to a scale recommended by Cochrane systematic reviews,  which, in turn, are based on the methods used in studies and their possible biases.
In this context, the asthma guidelines made by the US National Heart, Lung and Blood Institutes and by the British Thoracic Society, according to a review made by Bronfort et al,  stated that the amount of evidence available is not enough to recommend the use of chiropractic or manual techniques for treating asthma and reassert that the studies have a high risk of bias.
It is important to point out that there is an ongoing discussion about classifying asthma as exclusively musculoskeletal. In 1999, Brian  published a letter questioning the study of Balon et al,  because Balon did not consider the excessive use of accessory respiratory muscles and compromised posture secondary to asthma. For Brian,  one cannot ignore these musculoskeletal elements because they compromise the patient's quality of life and, therefore, proposed treatments be considered not only “curing asthma” but also the patient's global condition.
Only one pilot study on acute diseases such as bronchiolitis was found, but its PEDro score reflects its poor methodological quality. The work examines the effects of osteopathic techniques and postural drainage on breastfed infants using bronchodilators. The author did not observe significant results and attributed this to the small sample size. He went on to suggest that more studies should investigate the effects of this protocol,  but so far, this has not been done.
The amount of evidence on the efficiency of manipulative treatments on children with respiratory diseases is small and limited. The lack of good-quality studies also limits the possibility of running meta-analyses, which could help us to have a definitive conclusion.
For the current study, we used 3 databases that are the most known in health sciences (MEDLINE), the most known and used for physiotherapy intervention (PEDro), and the most used in Latin America (Scielo), hoping to cover all relevant articles published in the field. However, we cannot rule out the possibility of having missed articles because other important databases such as CINAHL and EMBASE were not used because of lack of access. Other limitations involve the decision on what to consider as manual therapy and the difficulty of performing double-blind studies in this area. 
The current review has identified the lack of good-quality randomized controlled trials investigating the effects of manual therapy in children with respiratory diseases. Future investigations should focus on following guidelines to guarantee the quality of the studies. Furthermore, the effects of all possible manual therapy interventions, regarding any common respiratory disease in children, have not been well investigated and needs further clarification. Hence, it is important to encourage clinical trials in this area and make sure that these trials control for biases and use appropriate research methods. This will allow indication of treatments associating manual therapy with conventional therapy to be based on concrete evidence and benefit pediatric patients with respiratory diseases.
The present study reviewed the scientific evidence on the benefits of manipulative techniques on children with respiratory diseases. The most common interventions use chiropractic, osteopathy, and massage. However, most studies used distinct administration methods and assessment parameters, and their statistically inconsistent results justify the absolute need of further research in this area.
There is some evidence, although from low-quality studies, suggesting that
manual therapy has some beneficial effect on children with respiratory disease.
Massage, osteopathy, and chiropractic are the most used therapeutic modalities.
Funding Sources and Potential Conflicts of Interest
No funding sources or conflicts of interest were reported for this study.