Do Any Alternative Therapies for Asthma Have Proven Efficacy?
In a word: no. Well, at least not yet.
Despite this fact, many patients and parents are curious about alternative therapies for any chronic disease, and asthma is no exception. All physicians should be aware of the reality that it is quite possible that their patients are using one or more alternative therapies. This fact needs to be explored as part of comprehensive medical management and not just comprehensive asthma management.
According to the National Center for Complementary and Alternative Medicine (NCCAM), complementary and alternative medicine (CAM) is “a group of diverse medical and health care systems, practices, and products that are generally not considered part of conventional medicine.”1 As shown in Table 13-1, different types of CAM can be subdivided into several categories:
1) natural products, such as herbal supplements; 2) mind-body medicine; and 3) manipulative and body-based practices, such as yoga, acupuncture, massage therapy, osteopathic manipulative treatment (OMT), and chiropractic manipulation.1
One of the challenges confronting allopathic physicians is that patients may not report their use of CAM. In addition, there are limitations to the available questionnaire studies evaluating the usage of CAM, and these data need to be evaluated with care. Similarly, there is a general lack of high-quality medical evidence about the safety and efficacy of CAM, both due to an overall lack of clinical studies and the lack of governmental regulations that require study of some nonallopathic medical treatments. There are simply very few randomized, placebo-controlled studies evaluating CAM treatments, and furthermore, some forms of CAM are by their nature very difficult to study. With these caveats in mind, some of what is known about CAM is reviewed in the following paragraphs.
A recent Cochrane review article examined manual therapy in asthma.2 In this paper, 68 articles were evaluated through August 2004; however, only 3 randomized, controlled trials met criteria for review. Two of these studies were chiropractic, and one study looked at massage therapy. One of the chiropractic studies and the massage therapy study were pediatric studies. Both chiropractic studies included a sham procedure for the control group. With the 2 chiropractic studies, the authors concluded there was no evidence to support the use of spinal manipulation therapy in asthma. Efficacy was unclear in the massage therapy study, and final conclusions about these therapies are not able to be drawn until there is further information according to these Cochrane reviewers.2
In the same Cochrane review, no studies involving OMT were included. OMT also involves physical manipulation of the patient’s body in specific ways, and is designed to address somatic dysfunctions identified from an osteopathic structural examination. In August 2004, Guiney and colleagues published the results of a randomized, controlled trial involving OMT and pediatric patients.3 Peak expiratory flow rates were the main outcome measure, and the control group received a sham OMT procedure. While this study only looked at immediate effects following OMT (n = 90) versus sham (n = 50), a significant improvement in the peak expiratory flow rates in the OMT group was seen compared to the control group. The study authors discussed that a larger trial with longer follow-up, in addition to spirometry as part of the outcome measures, was needed to further address the efficacy of OMT in pediatric asthma.
Dietary supplements, herbal medicines, vitamins, and minerals are commonly used as CAM in both adults and children. Dietary supplements are not regulated by the Food and Drug Administration (FDA) to the same standards of stability, purity, and consistency as are allopathic medications. Simply put, there are different regulations for foods and drugs, and supplements are regulated as foods. Similarly, the FDA does not evaluate health claims made by supplement manufacturers as stringently as they do for allopathic medications. Finally, there is no requirement for the manufacturers of dietary supplements to report safety concerns regarding these products. This creates an additional element of risk when these products are used. While apparently rare, contamination of dietary supplements has been reported with resultant untoward effects in both adults and children. Physicians should be aware of these differences between supplements and medications and should counsel patients, particularly parents of children, accordingly (Table 13-2). When buying a supplement, it is often difficult, if not impossible, to know precisely what one is buying.
As with manual therapies, studies showing efficacy of dietary supplements, herbal medicine, vitamins, and minerals are lacking. Gardiner briefly reviewed a study looking at ginkgo biloba in asthma.4 However, this study is in Chinese, so the primary source was unable to be reviewed completely. An additional challenge to the relevance of this study is the fact that ginkgo leaf extract was used in addition to a methylprednisolone inhaler, which is not used in the United States. An additional Cochrane review analyzed fish oil in both adults and children with asthma.5 In this review of 9 randomized, controlled trials, there was no consistent effect on five different asthma outcomes.
Survey questionnaires are frequently used to determine what patients actually do, or take, for their chronic diseases, including asthma. Slader and colleagues reviewed 17 studies that investigated the use of CAM in asthma patients.6 In adults, acupuncture, aromatherapy, breathing techniques, herbal products, homeopathy, and yoga were most frequently used. In children, breathing techniques, diet therapy, herbal medicine, homeopathy, massage, positive therapy, physical therapy, prayer, relaxation techniques, vitamins, and minerals were used most commonly.6 The authors concluded that 20% to 30% of adults and 50% to 60% of children with asthma had used CAM. These results are higher when compared to an initial survey Chidekel and I conducted where 79 parents of 83 children with asthma responded to a questionnaire about OMT and other CAM therapies.7 Our results showed that only 4.8% of children had received CAM, which included Chinese herbal therapy, prayer, and yoga. However, 69.9% of the parents had received one or more types of CAM, with prayer, chiropractic, dietary supplements, and massage being the most common modalities. These differences highlight the difficulty in assessing and generalizing the results of questionnaire studies.
Clearly, it is best to ask patients directly about their interest in and usage of CAM. Frequently, parents or patients do not tell their physicians that they or their children are using CAM unless directly asked. The reasons for CAM nondisclosure are likely multifactorial, but most notably it is because the physician never asked. Other reasons for “CAM nondisclosure” have included the perception that the health care provider does not need to know and the fact that patients consider these products to be supplements and not medications per se. A final reason involves the fear of a negative or judgmental response from the physician.
A practical approach to the use of complementary and alternative medical therapies in clinical practice is to address it in a clear and non-judgmental fashion. Asking curiously whether a patient or parent has either tried CAM or if they have any questions about the potential utility of alternative therapies is often sufficient to start an open conversation. Discussing the limitations of the current research regarding CAM, the limited evidence of efficacy, and the (rare) potential for harm, particularly of drug interactions, is important. Obviously, it is critical that a patient not be taking something that is known to be harmful, shown to be contaminated due to a manufacturing problem, or, in the case of a dietary supplement, containing an ingredient to which they or their child may be allergic. It is also helpful to have the patient bring in the bottle or forward any online information about the relevant product in question. Ask for the patient or parent to be open so that they can be informed of any new information about efficacy, side effects, and interactions with prescribed allopathic medical therapies, and follow up with them at each visit. Finally, review any new safety or efficacy information about the allopathic medications that are being prescribed, and reinforce the rationale for the prescription and any plans for dosage adjustments.
While CAM therapies currently have not shown efficacy in asthma management, research is ongoing, and this could change in the near future. Research investigating manual therapies is particularly challenging, as even a sham procedure in control groups could have its own effects. However, multiple surveys document at least some level of CAM use in children with asthma. Knowing which CAM therapies, if any, your patients are using or are interested in using is pertinent information that may get missed unless patients and their families are directly asked.
1. National Center for Complementary and Alternative Medicine. What is CAM? National Center for Complementary and Alternative Medicine Web site. Retrieved from www.nccam.nih.gov. Accessed November 30, 2010.
2. Hondras MA, Linde K, Jones AP. Manual therapy for asthma. Cochrane Database of Syst Rev. 2005;2:CD001002.
3. Guiney PA, Chou R, Vianna A, Lovenheim J. Effects of osteopathic manipulative treatment on pediatric patients with asthma: a randomized controlled trial. J Am Osteopath Assoc. 2005;105:7-12.
4. Gardiner P, Wornham W. Recent review of complementary and alternative medicine used by adolescents. Curr Opin Pediatr. 2000;12:298-302.
5. Woods RK. Dietary marine fatty acids (fish oil) for asthma in adults and children. Cochrane Database of Syst Rev. 2002;3:CD001283.
6. Slader CA, Reddel HK, Jenkins CR, Armour CL, Bosnic-Anticevich SZ. Complementary and alternative medicine use in asthma: who is using what? Respirology. 2006;11:373-387.
7. Hayes N, Chidekel A. Comparison of knowledge and attitudes regarding osteopathic manipulative treatment and other forms of complementary and alternative medicine therapies among parents of children with cystic fibrosis and asthma. Pediatr Pulmonol Suppl. 2006;29:A549.