Alternative Medicine

Osteopathic manipulative medicine pertains to a medical approach that focuses in providing total care to a patient (Kuchera 2005).  This constituent of osteopathic medicine emphasizes the philosophy of healing using body-based treatments.  One unique feature of this field of medicine is to achieve a condition that balances the use of the latest trends for medical intervention and patient-centered caring.  Two advantages are strongly associated with osteopathic manipulative medicine, namely the extended differential of etiologies that are usually considered treatable, and a personalized treatment of pain that makes use of osteopathic principles.  This two-pronged approach results in a treatment regimen that offers relatively low risks to the patient, that is consequently effective in the healing process of the patient.

Rationale and osteopathic relevance  
This study aims to conduct a comprehensive research on the evidence-based reports on the use of cranial osteopathic techniques in the treatment of patients suffering from chronic pain.  It should be understood that osteopathic medicine was earlier considered as a field of medicine that did not have a distinct feature in terms of use for patient care (Rogers 2005).  Osteopathic medicine arose through the establishment of theoretical principles yet the number of medical reports that fully support this kind of approach was then insufficient. 

A number of medical reports have been published in the last few decades describing the effectiveness and safety of osteopathic approaches, thus prompting its integration to general patient care.  According to Rogers (2005), osteopathic manipulative treatment is fueled by three basic tenets, namely the fundamentalist approach to patient care, the traditional concepts established in the 1920s and the progressive component that is mainly based on the current application of osteopathic treatments in healthcare.  It is therefore time to review the available literature on the use of osteopathic modalities in specific medical conditions in order to determine the actual efficacy and safety of this regimen in patient care.  This literature review will focus on the application of osteopathic medical treatment of cranial conditions, including that of pain and other disorders involving the central nervous system.

The application of cranial osteopathic treatments in patient care   
Osteopathic treatment modalities have been used in the field of medicine for the last 100 years.  This approach is mainly based on the dogma that healing is influenced by positive energies from the body, as well as the employment of medical techniques that are technically considered as allopathic medical approaches. 

This combination essentially results in a patient-centered approach to treatment.  Initial documentation of the positive results of osteopathic medical treatments were based on anecdotal reports issued by physicians and thus this created an illusion that this field needed a more extensive examination into its effectiveness and safety. 

Osteopathic medical approaches have been extensively used in pain management.  According to Kuchera (2005), this medical field operates through the achievement of unity with the human body through the acknowledgment of interrelationships between the body and the mind.  Unfortunately, osteopathic medical approaches have not been extensively used by majority of physicians and this may possibly be due to its underlying principles and tenets. One possible factor that influenced the low degree of application of this approach is perception of allopathic physicians of the field of osteopathic medicine.  In a research study conducted by Reeves  Burke (2009), the poor perceptions of allopathic physicians of the field of osteopathic medicine is largely due to its unavailability across the entire United States.  Using a 20-item questionnaire that employed the Likert scale in converting the responses of the study participants, the investigators showed that the concentration of osteopathic physicians in the northern states of the United States has resulted in the under- and misrepresentation of the field of osteopathic medicine.  Their report provides evidence that the study and application of cranial osteopathy needs to be revisited the field of osteopathic medicine.

An accumulation of medical reports has been seen in the last few decades, bringing about the need to revisit the osteopathic medical approach.  A number of reports are described in this literature review, including essential points that provide descriptions of the promising benefits of the use of cranial osteopathy.  According to Fryer, Morse  Johnson (2009), osteopathic physicians mainly employ osteopathic medical approaches for cranial and myofascial conditions.  Cranial osteopathy is an effective approach in the treatment of children with cerebral palsy (Duncan et al 2008).  This randomized clinical trial engaged approximately 55 children within the age range of 1.6 to 12 years to participate in cranial osteopathy, acupuncture or a control program to compare the resulting mobility after participating in the program.  The study showed that cranial osteopathy resulted in the significant improvement of the childrens motor functions, while acupuncture and the control setup did not generate any improvements. 

In a study conducted by Timoshkin  Sandhouse (2008), cranial strain problems commonly afflict the general population, thus increasing the importance of osteopathic medical approach.  Their report determined the baseline information on the patterns of cranial strain among the normal, healthy population was determined.  Using approximately 142 healthy study participants as the target population, the study showed that the most common cranial strain problems were comprised of torsion, as well as side bending rotation, making up approximately 72 of the cases.  In addition, specific directional features were observed in the study population, wherein right torsion issues were more prevalent than left torsion problems, while left side-bending problems were more common than right side-bending problems.  

Osteopathic physicians are also trained in using palpatory tests for the diagnosis of cranial dysfunctions (Halma et al 2008).  Approximately 48 subjects were examined in their study, of which each was grouped as asthma, headache or control.  The blinded osteopathic physicians were assessed in terms of their precision in diagnosing health problems.  The study showed that cranial strain problems were the most reliable diagnoses that were generated by the osteopathic physicians.  Another effective osteopathic approach is the muscle energy technique, which is has long been employed in treating dysfunctions of the central nervous system.  A study conducted by Burns  Wells (2006), focusing on the application of this technique on cervical problems in motion, showed a significant improvement in cervical movement of individuals who were subjected to the muscle energy technique.  The improvement of these patients was far better in outcome as compared to that of the control group. 

Osteopathic medical approaches have also been employed in end-of-life care of patients.  According to a study conducted by Mason et al (2008), majority (89) of the osteopathic physicians expressed that they are well prepared to provide care to terminally ill patients.  In addition, most (79) osteopathic physicians feel that osteopathic techniques can significantly augment the condition of these patients.  A report published by Pomykala et al (2008) described the results of an investigation on the perceptions of patients regarding osteopathic manipulative treatments during their stay in the hospital.  The study was conducted by providing questionnaires to study participants approximately 24 hours after osteopathic treatment.  Majority (94) of the patients indicated that there was a significant decrease in their pain after osteopathic treatment, while 98 of the respondents recognized osteopathic approaches as a key factor to their recovery.     

Summary and conclusions
Osteopathic treatment modalities pertain to a combinatorial form of healing that is influenced by positive energies from the body, as well as the employment of medical techniques.  This patient-centered approach to treatment is currently considered as a highly effective and safe medical approach that yet needs to be extensively recognized in the medical field.  Research reports have published positive results generated from the application of osteopathic approaches, especially in cases involving cranial dysfunctions, central nervous system disorders and end-of-life conditions.  The improvement of specific medical conditions thus prompts the need to further employ osteopathic approaches in patient care.

The study determines the effectiveness of spinal manipulation on asthma.  Spinal manipulation is seldom associated with adverse effects and can prove to be a cheaper alternative.  There are two schools of though regarding spinal manipulation in asthma, one is that the chiropractor is the primary healthcare provider and second he is responsible for the co-management along with others.  Spinal manipulation can improve the symptoms of asthma or can improve the spinal symptoms of asthma and in this way provide relief. In this study more than 78 studies were identified from 5 databases and 8 appropriate studies were included as part of the study.  Spinal manipulation may not be as effective in the treatment of asthma as compared to sham manipulation.  However, the severity of the disease, quality of life and the dose of medications can be reduced.  Chiropractic also needs to utilize more scientific basis to develop hypothesis.  Chiropractic can be used in the co-management of asthma along with other medical therapies.  Certain subjective and objective outcome measures need to be developed. 
 
Today, chiropractic is one of the most widely used forms of healthcare intervention and is gaining huge acceptance throughout the world for its effectiveness in treating neck pain and back pain.  Thousands and thousands of people from across the world have reported to gain benefits from chiropractic.  Chiropractic spinal manipulation was first introduced by Daniel D Palmer in 1895, where he had first cured a patient of deafness through spinal manipulation.  He initiated the Palmer Chiropractic School.  Later, a lawyer from Oklahoma had opened a competing chiropractic school, and developed another school of thought.  Willard Carver strongly believed that chiropractic needed to incorporate other modes of treatment such as nutrient therapy, herbal treatments, etc, which when combined with chiropractic would be more effective.  This is still a competing school of thought in chiropractic.  Most of the scientific branches of medicine work on the principle on scientific evidences.  However, chiropractic gained popularity even before scientific evidences were drawn out.  Many people started schools of chiropractic, but the practice of chiropractic did not be based on any kind of theory.  It was only in the 1970s that scientific research in the field of chiropractic began and slowly a proper program to train and develop chiropractic research was being developed.
   
Spinal manipulation is a treatment technique in which the spine and its interrelationship with the nervous system are seen as a mean of restoring health.  Chiropractic involves modifying subluxated vertebrae that have changed their position in the spine.  It is said that due to the subluxation, the nerve that are present near the spine are impeded and are responsible for various disease and pain syndromes.  Spinal manipulation is a technique in which these vertebrae are put back into position so that their function is restored.  There is no evidence to show that pain is relieved by altering the position of the spine, although there is evidence that spinal manipulation resulting in loosening and easing the vertebrae.  Another idea that has been proven by studies is that spinal manipulation results in better responses from the nerves, leading to a positive effect on the central nerves system, causing an improvement in pain relief. 
   
Spinal manipulation is used to treat several muscular skeletal disorders, nervous disorders and the effect of these disorders over general health.  Spinal manipulation is often used to treat neuro-musculoskeletal disorders that affect the arms, legs, neck, back and also headaches.  Spinal manipulation can be used to treat acute as well as chronic disorders, and can also be used during pregnancy to manage pain during breech positioning of the baby.  Besides, spinal manipulation can also be used to treat frequent common colds, infantile colic and respiratory disorders.  In children who frequently fall and injure themselves, pain in the back, neck and legs is common, and often spinal manipulation can be utilized to manage back and neck problems such as pain, stiffness, soreness, discomfort, etc. 

Chiropractic can be utilized both on an outpatient or an inpatient basis, and in certain instances, an inpatient can be advocated spinal manipulation as part of hisher rehabilitation.  The chiropractor would be using their hands to manipulate the joints, especially the spine so as to improve function, restore integrity of the spine and lower pain.  Patients during the process of spinal adjustments hear a popping sound that is heard due to release of gas bubbles from between the joints that may be present in the lubrication fluid of the joint.  The release of these gas bubbles does not cause pain in anyway.  A joint consists of the surface of the bone that fit into each other and is lined by a smooth cartilage that is enclosed in the joint capsule.  A fluid fills and lubricates the movements of the joint.  As gases are dissolved in this fluid, during the stretching of the joint capsule some amount of gases are released which helps to reduce the pressure within the joint.
   
The process of manipulation is considered to be safest and the most non-invasive of any that is available for the treatment of neuro-musculoskeletal disorders that are available, provided the same is performed by a qualified chiropractor.  However, no intervention is free from potential adverse effects.  Minor discomfort following chiropractic is common and occurs (but disappears) within 24 hours of treatment.  Some people may experience a temporary rise in the symptoms along with fatigue, discomfort, headache, radiating pain at the site of manipulation, etc.  Usually serious complications are rare and are associated with cervical spine manipulation.  It is common in people affected with stroke, serious pinching or trauma of the nerve, fracture of the vertebrae, tracheal damage, disc herniation, etc.  Often the vertebral artery at the base of the neck is damaged leading to stroke (NYU Longone MEdical Centre, 2010). 

Figure 1. Serious  Rare Complications of Spinal Manipulation
Studies performed to identify those at a high-risk for stroke during spinal manipulation have been inconclusive.  However, the rate of serious complications following spinal manipulation is very rare, and occurs at the rate of 1 in every million cases.  In patients receiving spinal manipulation for the neck, the rate of morbidity (complication) is about 1 in 100,000 and mortality of about 1 in 400,000.  On the other hand, non-invasive allopathic treatment such as NSAIDS Administration, etc, has a 10 times higher complication rate. 
   
For patients undergoing spinal manipulation, a proper history should be taken, with the mode of onset of the symptoms, aggravating and relieving factors, and any red flags (physical pathology in which spinal manipulation has been contraindicated such as severe trauma, thoracic pain, cancers, HIV, drug abuse, structural deformities, etc).  The practitioner should also note any important medical history, drugs or past history that would include any condition in which spinal manipulation should not be performed (The Pain Clinic, 2009).  These include-

Figure 2. Contraindications of Spinal Manipulation
It is also important to determine the yellow flags of the patient, which includes a mental assessment to identify the presence of anxiety, depression or any other mental disorder in which the patient would not cooperate towards the performance of the procedure.  If the patient would not cooperate for spinal manipulation, the success of the treatment is unlikely. 
   
Today more than 100 people around the world are affected with asthma.  Chiropractic is one of the three most popular complementary and alternative medicine therapies (CAM).  Since a long-time, chiropractors have been reporting successes at treating non-musculoskeletal disorders.  Today with a greater expansion in the interventions of chiropractic, it has expanded from merely therapeutic spinal manipulation to greater prescription of nutrients and administering exercises.  However, there are two schools of thought in the role of the chiropractors in managing asthma (Chiropractic care for patients with asthma A systematic review of the literature, 2010). 

Figure 3. Two Schools of Thought of Spinal Chiropractors   
This depends on the role chiropractic plays on asthma.  There may several mechanisms by which chiropractic works on asthma-

Figure 4. Mechanisms by which Chiropractic works in Asthma
In the past several studies have been conducted to determine the role of spinal manipulation treatment over several issues in asthma including-

Figure 5. Effectiveness of Chiropractic in Asthma
In Australia, there is a several fold increase in the number of patients seeking management of asthma from non-allopathic professionals.  More than 45  of the Australians seek alternative treatment of asthma, and most often it is the chiropractic that advice is sought from.  Most of the Australians are equally satisfied with the treatment provided by the alternative practitioner.  There has been a lot of controversy regarding the use of beta-agonists and corticosteroids in the treatment of asthma as more and more alternative techniques are showing better results.  However, in many instances, alternative therapies also fail, causing a deterioration in the lung function and as such a scientific background is required to develop guidelines for managing asthma using alternative techniques.   Australian chiropractors make assumptions regarding the use of spinal manipulation in the treatment of asthma ( A Comparison of Active and Simulated Chiropractic Manipulation as Adjunctive Treatment for Childhood Asthma, 1998). 

Figure 6. How Asthma Occurs
In this study, a literature review would be conducted of the various studies that used spinal manipulation in the treatment of asthma (either alone or in combination with other forms of treatment), to determine the effectiveness and safety of spinal manipulation for asthma. 

Description
The study was a literature review of spinal manipulation being used in the treatment of asthma (either alone or in combination with other forms of treatment), to determine the effectiveness and safety of spinal manipulation for asthma.  The various databases searched were Pubmed, Cochrane, BMJ, TRIPS Database, SUM Search,  Google Scholar.
   
A total of about 78 studies were identified from the 5 Internet databases, and from these, 8 of the most relevant studies were identified and included as a part of the review for this dissertation. 
   
Graham 2000 (Complementaryalternative medicine in the treatment of asthma, 2000) tried to provide allergists and immunologists with knowledge of complementary and alternative forms of medicine that could be used in treating their patients.  Such specialists could have an idea of what forms of alternative therapy are existing so that patients willing or demanding alternative therapy can effectively obtain the same.  It is also important to take into consideration the various cultural issues whilst using alternative or complementary therapy.  In this paper, the role of complementary and alternative therapy beyond chiropractic and spinal manipulation is taken into consideration, as chiropractors should also have an idea of the various other forms of therapy that can be applicable for treating conditions such as asthma.  Not only should the chiropractor have such knowledge, but also the physician, nurse and specialists.  Graham used Medline searches to obtain data on complementary and alternative forms of therapy on asthma and atopy.  Several articles were obtained and further filtered out.  The articles that were included were randomized and double-blind placebo-controlled studies. 
   
Bronfort (2001) (Chronic pediatric asthma and chiropractic spinal manipulation a prospective clinical, 2001) conducted a study to determine the ability of chiropractic spinal manipulation therapy in managing medically the children suffering from asthma and improve the important clinical outcomes.  The study also tried to determine if a comprehensive RCT could be conducted and determine the difference with a sham spinal manipulation procedure.  In the US, many parents feel it safe and effective to use the services of the chiropractors for managing asthma in their children.  This was a pilot study, with the possibility of using a prospective design in future.  The observers were blinded and the clinical trial was conducted in a randomized basis.  The follow-up period was about 1 year.  The study was basically conducted in primary care settings, outpatient department of a college and a childcare hospital.  The study included about 36 patients between the ages of 6 to 17 years.  The patients were recruited to the active spinal manipulation therapy group or the sham spinal manipulation therapy group, and had to undergo 20 appointments during a 3 month period.  The patient had to undergo chiropractic in addition to their regular medical treatment.  The outcomes were determine through pulmonary function tests, quality of life factors that could be determined by the patient or the parent, the peak expiratory flow rates and also studying the recorded symptoms of the day and night of the patient recorded in a diary.  
   
Nielsen (2010) (Chronic asthma and chiropractic spinal manipulation a randomized clinical trial, 2010) conducted a study to determine the effectiveness of chiropractic in treating chronic asthma along with other drugs used for maintenance therapy.  The patients that were used in the trial were outpatients belonging to the national university Hospital of Copenhagen Denmark.  About 31 patients between the ages of 18 to 44 years were included in the study and the patients who were using bronchodilators and corticosteroid inhalers were included in the study.  The study excluded those patients who had received oral corticosteroids, immunotherapy or spinal manipulation during the last five years.  The patients were put into either group active manipulation therapy or sham manipulation therapy for 1 month, twice weekly, and were then moved into the opposing group to receive the treatment for another 1 month.  The phase between treatments was given a 2 week break.  The outcome measures that were determined included-

Figure 7. Outcome Measures
Hondras, MA (2009) was a study that tried to determine the evidence available of the effect of manual therapies for patients affected with bronchial asthma.  The author has felt that though medicines are effective in the treatment of asthma, having a non-medicine treatment would be a huge advancement in asthma management.  Hondras felt that spinal manipulation is aimed at increasing the motion of the rib cage, improving the quality of life by improved lung function, increasing the oxygen content in arterial blood and improving the lymphatic return of the blood.  Through chest percussion, vibration and mobilization of the patient, the bronchial secretions can be moved to the central airways thus helping the patient in expectoration and cough.  Manual therapy was compared with other forms of treatment to determine the morbidity, mortality, physiological outcomes and side-effects in asthmatic patients.  This review included only randomized and quasi-randomized studies where the patients were observed for at least 2 weeks.  Child and adults patients suffering from asthma were included in the studies and patients affected with COPD were excluded. 

Manual therapy such as manipulation, mobilization, massaging, physiotherapy, vibration and shaking were included and postural drainage alone was excluded from the study.  The outcomes that were included in this study were pulmonary function, vital capacity, FEV1, FEV1FVC ratio, use of drugs, quality of life, subjective symptoms of asthma, hospitalization and length of stay, emergency visits, etc.  A number of databases were searched for data including Cochrane, Chiropractic Research Archives Collection (CRAC), etc, from 2001 onwards.  There were three reviewers for this study, who individually examined and extracted the data in the standardized template. 
   
Kaminskyj 2010 conducted a systematic review of the literature to determine the rate of publishing and the quality of publishing studies on chiropractic especially spinal manipulation in patients suffering from bronchial asthma.  The authors feel that chiropractic is one of the most often used form of CAM therapy and asthma is becoming a serious public hazard across the world.  More and more chiropractors are using chiropractic for managing non-musculoskeletal conditions and are extending their treatment away from the traditional spinal manipulation therapy.  The question being asked in this study was whether chiropractic is beneficial in the case of asthma and whether chiropractors have a role in the co-management or serve as primary healthcare providers for asthma.  The outcome measures considered in this study was FEV, asthma severity self-reported, dependency on drugs, quality of life, etc. 

A number of databases were searched including Cochrane, MEDLINE, CINAHL, AMED, Alt Healthwatch, Chiropractic Index, Mantis, etc, for literature between January 1980 and March 2009.   Several searches were found and the searches had to be further refined.  Down and Black developed a checklist that had 27 items for assessing the findings of the randomized and non-randomized studies.  What was used in this study was a modified Down  Black questionnaire, so that the maximum score obtained was 27.  The quality scores that were included were 20 good, 11-20 moderate and 11 poor.  Each author individually studied each of the searches and rated the articles. 
   
Lowry 1995, reports that since 1995, chiropractors associations have been trying to use spinal manipulation for treating other disorders, other than back problems including asthma and enuresis.  Many chiropractors in Canada had a conservative view of Chiropractic and held that disorders other than back conditions should not be attempted with chiropractic.  In Canada the pediatrician community is against the idea of having chiropractors treating other disorders in infant and children.  Parents also need to be cautious in using the services of the chiropractors in such instances.  However, critics also say that evidences for the effectiveness and safety of chiropractic on asthma, bedwetting, ear infections and infantile colic should be researched rather than merely discarding the idea of using chiropractic.  Other critics feel that implementing chiropractic and delaying for the use of other medical treatments may be serious.

Chiropractors can play a vital role in the development of the infant and the child, and various infants are at the risk of facing developmental problems associated with the spine and the backbone.  Some experts in chiropractic feel that using the benefits of chiropractic for infantile colic and middle ear infections can in fact be effective and hence offer cheaper solutions to the healthcare system.  Many experts feel that the spine of children are young and hence are more effective to manipulation.  A simple point mentioned in the study regarding the effectiveness of chiropractic in asthma is that chiropractic spinal manipulation can help loosen the muscles in the back and in this way relieve asthma.  However, as asthma is an inflammatory disease, spinal adjustments cannot help overcome inflammation.         
   
Jamison, 1992 (Chiropractic adjustment in the management of visceral conditions a critical appraisal, 1992) tried to determine if Australian chiropractors consider spinal manipulation as an effective and safe option in treating patients affected with visceral disorders such as asthma, hypertension and dysmenorrhea.  This was a survey study that was distributed to several chiropractors in Australia.  The outcome measures were that the practitioner had to find certain usefulness of chiropractic in managing a visceral disorder.  The chiropractor had to comment on the personal experience for treating the visceral disorder and the manner in which adjustment had to be done to treat the visceral disorder. 
   
A systematic review was conducted by Ernst, E, to determine if spinal manipulation was effective in the treatment of asthma.  Most of the internet searches drawn from websites of famous American, Canadian and British Chiropractor associations stress upon that spinal manipulation are effective in the treatment of bronchial asthma.  DD Palmer the founder of chiropractic in fact said that most diseases including asthma was caused out of subluxation of the spine and adjustments were required to correct these disturbances.  However, till today, not much systematic reviews have been conducted to assert this fact.  This study by Ernst tries to review the various RCTs conducted on spinal manipulation for the treatment of asthma.  Ernst searches various internet databases in September 2008 including Medline, Ovid, CINAHL, AMED, EMBASE, etc, marrying the concepts of asthma and spinal manipulation.  No limits as such were used.  The criteria for selection were that the study had to determine the effectiveness of spinal manipulation in the treatment of asthma.  Any study that did not include spinal manipulation was excluded.  The studies had to present some sort of a measureable endpoint.  The Jadad Score was utilized to review the data. 

Figrue 8. Jadad Rating Scale
Results
Graham 2000 found that huge number of patients in the US considered complementary and alternative treatments for asthma (33 of the population).  However, literature of such treatment and their effectiveness, role and safety in treating asthma or atopy is not known, due to a lack of scientific basis for these systems to use evidence based criteria.  Alternative and complementary therapies have a huge role to offer in the treatment of asthma as the same is an allergic disorder.  Very few studies have been conducted to determine the role of complementary and alternative therapy in treating asthma.  The current level of evidence regarding CAM to treat asthma and other allergic disorders is rather insufficient to create clear practice guidelines.  Some of the flaws noted with CAM techniques include-

Figure 9. Flaws Noted with Studies conducted in CAM
Some of the physicians are lacking knowledge of which alternative therapy is available and the same if advisable can be used.  Hence, there needs to be certain amount of awareness amongst the professionals of which other forms of treatment could be used (Graham 2000).
   
Bronfort (2001) found that it was capable to blind the patients to either group. After the intervention was performed for 3 months, there was no improvement in the lung function test results, recorded symptoms.  The patient said that they composed 20 less of the bronchodilator and the quality of life improved by 10-28.  The severity of asthma reduced by about 39.  The parents and the guardians reported smaller improvements compared to the patient.  The child patients felt that the improvement in quality of life and reduction in the severity of asthma remained unchanged over the next one year.  Neither lung function nor hyper responsive improved.  The effects of improvement in the patient-related quality of life and the reduction of the severity of asthma is not likely to be due spinal manipulation therapy itself, but also related to other aspects of the medical management of the patient.  However, further studies are needed to determine the effect of spinal manipulation therapy on asthma. 
   
In Nielsen 2010, cross over analysis was used to determine the effectiveness of treatment of the active Spinal manipulation with that of sham spinal manipulation.  There were no important differences between the primary and secondary outcomes between both the forms of manipulation.  There were no changes with the lung function test outcomes, but the patient reported lesser severity of asthma by about 34 and the bronchial hyper reactivity improved by 36.  However, the study did not prove that spinal manipulation was better than sham manipulation to manage adults with asthma for four-week duration. 
   
In Hondras 2009, more than 473 articles were considered, but 68 were reviewed and included in the study that fulfilled the criteria of inclusion.  However, at the end, on three RCTs were considered in the study, which organized a total of 156 patients.  These three studies included Balon 1998, Field 1998 and Nielsen 1995.  The first two determined manual therapy in asthmatic children, whereas the later studied manual therapy in adults.  None of the trials found an appreciable difference between manual therapy and sham maneuvers based on the outcome measures.  There was a difference between massage therapy and relaxation therapy with respect to lung function outcomes, but the same could not be considered as the reporting characteristics of the trial was not proper.  However, in the end, there was inconclusive data regarding the effectiveness of spinal manipulation in the treatment of asthma.  Some of the measures that were present were not clinically important. 
   
In Kaminskyj 2010, more than 150 articles were initially obtained from the various databases. Finally 13 articles were finalized, out of which 8 articles were included which were 1 case study, 1 survey, 2 RCTs, 1 randomized patientobserver blinded cross-over trial, 1 self-reported questionnaire and 1 single blind cross study. The quality scores of the various studies ranged from 5 to 22 out of a maximum of 27, which were good to low as per the Down  Black criteria.  The main aim of chiropractic in asthma was to help increase the lung space, mobilize the ribs, improve the blood and lymphatic supply to the lungs, and improve the nerve supply, so that the symptoms of asthma could be improved.  According to this study, chiropractic did not only include spinal manipulation but also breathing exercises and soft tissue therapy.  Most the data obtained were from trials that lacked good quality and hence although the effect of chiropractic care on asthma had found to be useful, the results were questionable.  Hence, their therapeutic benefit could not be determined.  The effectiveness of chiropractic care on asthma is said to be multi-factorial depending on several objective and subjective outcome measures. 

Figure 10. Subjective  Objective Outcome Measures  
The articles lacked detail of the position of the manipulation and the type of therapy used.  Hence, the procedure could not be used on other patients and hence the studies could not be utilized to develop guidelines.  Besides, in some of the studies the children had received some drugs before the chiropractic treatment and hence, this could have altered the results of the chiropractic therapy.  In some children who were co-managed with chiropractic, there were beneficial effects to a very mild extent.  Most of the benefits that were noted were subjective in nature and very little objective benefits.  Chiropractors use various outcome measures which need to be further standardized.  There needs to be certain guidelines on the effective use of spinal manipulation in the treatment of asthma and further to utilize the same in the beneficial treatment of the patient.
   
Lowry 1995 find that Canadian Chiropractic students are often told to treat asthmatics back rather than the entire condition which is inflammatory in nature.  This should be irrespective of the fact that chiropractic would cure asthma by itself, but at least offer some relief to the symptoms.  In many other conditions such as bedwetting and middle ear infections, chiropractic may not offer a cure, but can be used to help lower the symptoms.  X-rays in chiropractic are only needed in case of back problems and not to treat non-musculoskeletal disorders.   
   
In Jamison 1992, about 22 of the 1300 odd chiropractors actually provided a response to the survey tool.  More than 50 of the practitioners held that spinal manipulation had a useful role in the treatment of visceral disorders such as asthma, dysmenorrhea and hypertension.  The extent to which it could be effective varied from one condition to another and often on the level to which adjustment could be done.  In the 1990s, there was very little public funding for chiropractic to be used in visceral disorders.  However, more detailed studies are required to determine the role of chiropractic in several visceral disorders especially asthma. 
   
Ernst E (2009) obtained 35 articles that fulfilled the selection criteria.  From this, 8 were duplicates, 4 were excluded as the data was not original, 14 were again excluded as the data was not randomized and finally 6 were excluded as there was no spinal manipulation involved.  This left the researchers with just 3 RCTs.  The data that is currently available suggests that spinal manipulation is not effective in the treatment of asthma and there was no significant difference compared to sham manipulation. 

The previous studies that were conducted in fact were false positive results.  The three studies that were finally included were Neilsen (1995), Balon (1998) and Bronfort (2001).  Usually in real practice, the need to use spinal manipulation is not always made on the basis of effectiveness, but also on the basis of safety and cost-effectiveness.  Rare complications to spinal manipulation do occur, and mild side-effects are more common.  The authors also feel that as the RCTs available to them currently are rather insufficient, the data available is not conclusive enough to make a decision whether spinal manipulation is effective for the treatment of asthma.  Several studies were excluded by Ernst 2009, basically for the reason of not meeting with the scientific protocol but demonstrating a positive outcome.  The authors also found that many journals that published data on complementary and alternative techniques in fact did not follow the scientific protocol nor did publish any kind of negative result.  Overall greater amount of data was required to demonstrate that spinal manipulation was effective in the treatment of asthma, but the current data demonstrated that spinal manipulation was in fact not effective in the treatment of asthma. 

Conclusion  Recommendations   
From the eight studies that form a part of the literature review, it is important to determine what action points need to form a part of guidelines for implementation into chiropractic.  To ensure that any kind of alternative therapy warrants some amount of success, chiropractors, physicians, nurses and specialists should have an idea of various forms of complementary and alternative treatment and should be able to apply the same to the patient to provide herhim with the most holistic form of treatment.  This is not only applicable in the case of asthma, but in any disorder in order to manage the patient as a whole.  Large number of patients may consider using CAM, and it is important that the branches of CAM have a scientific basis rather than a mere magical or unscientific background.
   
Some of the studies found that there was no improvement in the lung function test results, but there was a slight improvement in the quality of life, lesser use of bronchodilators or inhalers, and reduced severity of asthma as defined by the patient.  The parents and guardians noted much lesser improvements in quality of life and severity of asthma compared to the child patient.  However, it is not clear whether spinal manipulation has a direct improvement on the quality of life and reduced severity of asthma.  The mechanism of the same needs to be more closely understood, and at the same time clear criteria needs to be defined to enable understanding how asthmatics are benefited.
   
Although spinal manipulation may have some benefits at improving the quality of life, improving the lung function parameters, reducing the severity of asthma, lowering the consumption of medications, etc, it has been found that these criteria are similar to sham manipulation compared with spinal manipulation in asthmatics, raising a huge concern of the scientific basis of spinal manipulation.  This was observed on a short duration of 4-weeks of therapy.
   
Spinal manipulation is aimed at increasing the motion of the rib cage, improving the quality of life by improved lung function, increasing the oxygen content in arterial blood and improving the lymphatic return of the blood.  Through chest percussion, vibration and mobilization of the patient, the bronchial secretions can be moved to the central airways thus helping the patient in expectoration and cough.  In asthmatics, manual therapy in general may not seem to be superior to sham maneuvers and hence, spinal manipulation may be of no use.  However, closer research needs to be performed to understand the exact mechanism by which spinal manipulation works. 
   
With time, more and more chiropractors are using spinal manipulation for non-musculoskeletal disorders and are using a greater number of treatments along with traditional massage sessions (such as nutritional therapy, exercises, etc).  Chiropractors in asthma aim to increase the lung space, mobilize the ribs, improve the blood and lymphatic supply to the lungs, and improve the nerve supply, so that the symptoms of asthma could be improved. 
   
The use of chiropractic for disorders other than back and neck disorders needs to be made based on evidences and scientific data and not act as an unjustified limit to practice.  Chiropractic not only offers benefits but is also a cheaper and safer option if applied appropriately.  Common sense suggests that chiropractic helps to loosen the muscles of the back and in this way help the lungs to function better.  Even if the effect is similar to sham manipulation, chiropractic can be used as it is proven to have certain benefits rather than damage to the patient.  However, it also needs to be taken into consideration that asthma is an inflammatory disorder and hence spinal manipulation cannot reduce inflammation.  Chiropractic can be used in the co-management with asthma with other forms of medical treatment.
   
In general, chiropractors are of the opinion that spinal manipulation is effective for visceral disorders including asthma, through their experience of the use of the same.  Such opinions can further be developed to create guidelines so that the effectiveness of such therapy can be reaped into successes.  
   
Data that is currently available on spinal manipulation for asthma is not sufficient to create useful professional guidelines that can be followed.  The studies need to follow a scientific basis of blinding, removing all biases, and ensuring that certain inclusion and exclusion criteria are followed.  The studies should be long-term and should have a sufficient study size and good design.  

Eastern and Western medicine differ not only in practice, but in philosophy.  In the East medicine is an extension of the cultures philosophy.  Westerners, on the other hand, pride themselves on keeping philosophy andor religion separate from science and medicine.  In the process it is starting to seem as if we have separated man from medicine.  It is a separation that we can no longer afford.

Man and Medicine
Imagine yourself in the doctors office complaining of chronic headaches.  After a brief examination, the doctor stares at you quizzically, then asks Have you been obeying the Lord and resisting all forms of evil  Im sorry you ask, bewildered at the question.  The doctor smiles knowingly, then elaborates Surely you realize that Proverbs 35-8 says that fearing the Lord brings health to your body and nourishment to your bones.  Needless to say, such behavior would probably lead you to believe that your doctor was the one in need of some serious treatment.  And youd probably be right.  Doctors in the West simply dont say those kinds of things.  Thats because in the West we believe in the separation of church and science.  It may not be explicitly inscribed in the hypocratic oath, but then it doesnt have to be it goes without saying.  In the West science is kept separate from religion.  And philosophy.  Ones personal belief system with regards to the ordering of the universe, and who or whats behind it, is his own business.  Its personal, a matter of ones own faith, and not relevant to the discussion of science and medicine.
   
Thats how it is in the West.  Western medicine is about procedure and protocol.  Doctors prescribe specific medicines for specific conditions.  The safety and efficacy of those medicines have been subject to laboratory testing and clinical trials.  The results are published in medical journals.  They have passed inspection they have been approved and certified by the appropriate regulatory agencies.  Only after this rigorous process are drugs, treatments, and procedures approved for use.  There is nothing in this process pertaining to belief, philosophy, the universe, or really, even man himself.  Its strictly about observable, quantifiable, identifiable scientific results proven repeatedly under laboratory conditions. 
   
Not so in the East.  In the East science is driven by philosophy.  Elements of Eastern medicine such as balance, Yin and Yang, and chi, derive their importance from Eastern religious and philosophical systems.  Taoism, which dates back to the third century B.C., centers around the idea of the Tao (the Eastern equivelant of God).  The tao is the way the universe functions, the path taken by natural events.  It is     characterized by spontaneous creativity and by regular alterationsthat proceed     without effort.  Effortless action may be illustrated by the conduct of water, which     unresistingly accepts the lowest level and yet wears away the hardest substance. 

Acceptance is modeled after Taoist philosophy, whereby the free flow of chi throughout the body promotes good health.  The chi, in turn, depends upon a balance of the two opposing energies of yin and yang.  The meridians are the main channels of flow.  When energy is impededidleness may result.  Piercing the channelsis believed to correct the imbalances.
   
Eastern versus Western Medicine
Key DifferenceAwareness and use of bio-energy or Qi (chi, prana, life force) in the East, unawareness of it in the West. From this flow all the remaining differences definitions of health, illness, and symptoms, the model of medicine, methods of diagnosis, role of physician and patient and the patients psyche, prevention and responsibility for health, strengths and limitations. Eastern MedicineWestern MedicineKey Beliefs Qi is life. Qi is heart of medicine. Life and Medicine are one. Humans can control nature. Foreign invader causes illness. Control of symptoms  cure of disease. Health A state of well being in which the body is vital, balanced  adaptive to its environment. Absence of disease, pain, defect, or symptoms of illness (no theory of health). Illness, Sickness, Disease Disharmonyimbalance and loss of adaptability (a defect of functionenergy).
Any deviation of the body from its normal or healthy state (1st dictionary definition). A defect of tissue or structure.

A destructive process with a specific cause and characteristic symptoms, a particular disorder(2nd dictionary definition). Symptoms Manifestation of the bodys attempt to heal itself, therefore, messages, signals of unattended, underlying issues or signs that something needs balancing. Manifestation of the disease, therefore, they are disagreeable phenomena to be eliminated or suppressed. Patterns Of Symptoms Symptoms are considered only in terms of their pattern. Not addressed. Causes Of Illness Any actionforce which interferes with the balance and movement of bio-energy ones constitution, psyche, lifestyle, trauma, environmental stress (nature or human). A foreign invader, an extraneous force or pathogen distinct entities with unique causes originating outside the body for every clinical disorder. Multiple Causes Illness is the end result of multiple insults to the body (Pizzorno, p. 24). Singular causes for each disorderor disease.

Progression Of Illness Four stages of illness from 1) energy imbalances causing 2) functional changes that can initiate 3) a progression of chronic illness preceding 4) pathological changes in tissue. A progression of a particular disease is noted, but only disorders of form and structure (morphology) are recognized, not progression of functionality into structure. Personal Responsibility Key energetic changes are functions of ones psyche and lifestyle so preventing serious illness is primarily self care. Patients stories are mistrusted and personal conditions considered irrelevant. Prevention The major thrust of medicine, so Chinese doctors were only paid if people stayed well. Not the primary concern, actively discouraged by original insurance plans. Model Of Medicine Man as ecosystem, a garden harmony.

Man as machine conflict. The Physician As gardener, assistant to cultivate life, to help patient getstay well. As mechanic to fix what is broken. Diagnosis Understanding Illness Perceiving the relationships between all the patients signs and symptoms. Uncovering a disease entity separate from the patients being.Treatment Preventing illness by balancing disharmonious energy and counseling lifestyle management. Curing named disease and suppressing symptoms through drugs or surgery. Science Of observation and experimentation, the original science, of anciently understood Einsteinian physics and quantum field mechanics where EMC2. Of reduction and induction, analytic and controlled science, of a mechanical Newtonian physics, long ago proved wrong at the cosmic  sub-molecular levels. Measure For Diagnosis Human senses pulse, tongue, eyes, coloring. Laboratory equipment.

Bio-Energy Must be balanced (rhythmically), free-flowingcirculating, and continually replenishedof sufficient quantity. Not considered.Mind-Body Mind and body are one, inextricably interconnected. All medicine is psychosomatics. Mind and body are separate and not necessarily connected. Iatrogenic Illness (physician caused) Virtually non-existent.4th leading cause of death, harms millions. Key Limitation Dependent on harmony with nature, it was not developed to deal with the worst of Western life overwhelming and unprecedented environmental pollution, iatrogenic (physician-caused) illness, and consequences of the Western philosophy of individualism and the controlling and defeating nature. Unaware of energy-based physiology (Qi), it therefore cannot detect, classify, measure or alter its effects in its beginning stages of illness. From this flaw stem not only the remaining differences listed above, but the worst consequences of western medicineregularly and inevitably, it harms people. Key Strengths Prevention, handling functionalchronic illness and self-care Because it recognizes the key role of lifestyle and the psyche in energetic changes that can progress toward illness.Handling structural defects trauma and life-threatening illnesses

What is massage therapy
Massage therapy has grown to become a multi-billion dollar industry. According to the data compiled by the American Massage Therapy Association (2009), the industry generates sales ranging from six to eleven billion dollars every year. Sales should remain stable or even increase in the next years due to demand.
   
Massage therapy is a profession. The American Massage Therapy Association (AMTA) emerged to represent its 57,000 members in promoting massage therapy as a profession as well as to provide standards of practice. Entering the profession involves education, training, and hurdling of the licensure exam. Most of the states also regulate massage therapy by requiring certification prior to establishing practice in these states. (American Massage Therapy Association, 2010)
   
Massage therapy as a professional practice involves the use of touch to exert pressure on soft-tissue muscles of the targeted part of the body (Bureau of Labor Statistics, 2009). Knowledge of pressure points and skills in applying pressure are core competencies in massage therapy. There are a number of reasons for exerting pressure on soft-muscle tissues, which include
treatment of ailments        
alleviate pain
decompress worn-out muscles
ease stress
rehabilitate injuries from sports
keep general health (Bureau of Labor Statistics, 2009).
                
Massage therapy treats and relaxes the body. A massage therapist keeps and enhances health and wellbeing by applying manual pressure to human tissue in the appropriate manner to achieve a particular health benefit (Braun  Simonson, 2008).
In massage therapy, various forms of massage called modalities involve different techniques to achieve particular outcomes. There are around 80 modalities targeting a range of therapeutic and relaxation purposes (Bureau of Labor Statistics, 2009). These can fall under eight modality groupings, which are
Swedish
deep tissue
neuromuscular
energy
orientaleastern
structuralPostural
movement
special populations (Braun  Simonson, 2008).

One of the modalities is neuromuscular, which involve the integration of muscle and nerve functioning to achieve a reflex response (Braun  Simonson, 2008). Targeting the nervous system is the key to a number of muscle reflex reactions by controlling muscle functions. Applying pressure on nerves creates a response in the muscles. Neuromuscular modality is the focus of the succeeding discussions of massage therapy.
How does the nervous system work

The nervous system controls the functions of the human body (Jakab, 2006). The nervous system functions gives directions to the different organs of the body such pump more blood to the heart when the body is doing physical exercise or command movement. 
 
The nervous system commands the body through its two components. One component is the central nervous system comprised of the brain and the spinal column. The brain and spinal column are billions of nerve cells connected by dendrites and axons to create nerve fibers (Jakab, 2006). The interconnected nerve fibers serve as the communication network for different cells (Mailanoff, 2005). The other component is the peripheral nervous system. This is comprised of nerve fibers that extend to the different parts of the body reaching the fingers and toes (Jakab, 2006). The peripheral nervous system receives sensory transmissions and sends these to the central nervous system (Mailanoff, 2005).

The nerve fibers receive the sensory stimuli of exerted pressure on cells and transmit this to the brain for processing. The brain in turn sends out a command or response. The entire process can happen within a millisecond and continuously occur in a cycle.
               
Figure 1 The Nervous System
What is nervous system depression  
Nervous system depression refers to the state when the functioning of the nervous system slows down (Slonim  Allbee, 2010). The nervous system acts as a central command center by receiving and processing sensory stimuli as well as transmitting directions or instructions to different organs or parts of the body (Mailanoff, 2005). Depression of the nervous system means slower receipt, processing and transmission.
   
A more specific name for this condition is central nervous system depression because the slowdown occurs in the central nervous system by affecting brain functions (Al-Zubaidy  Mohammad, 2005 Karatas, 2009).

The division of the brain as an organ is into the left and right hemispheres. The left hemisphere takes control of the right side of the body while the right hemisphere controls the bodys left side. To achieve unison between the left and right parts of the body, communication between the two hemispheres happen via the bundle of nerve tissues called corpus callosum. (Jakab, 2006) Depression of the central nervous system means that there is a slowdown or delay in the communication between the two hemispheres. This translates into lack of coordination in movement.

The brain also has parts that facilitate bodily functions. One is the motor cortex, which is present in the frontal lobe. This part is responsible for planning and executing motor commands. The succession of movements intended to achieve a result is work of the motor cortex. (Mailanoff, 2005) In central nervous system depression, the series of movements could be slow, completed in a different sequence, or uncompleted.
The other parts are the basal ganglia and the thalamus connected through a circuit of nerve fibers. These are responsible for cognition and motor control. Cognition refers to awareness and perception together with learning and rational thought. This is important in making-sense of stimuli. Motor control is the exercise of directive power towards different organs and parts of the body to maintain anatomical processes and bodily movement. (Mailanoff, 2005) Having central nervous system depression relative to this part of the brain means distorted perception, impaired thinking, and non-responsive reflexes.
   
Nervous system depression is due to ingestion of certain drugs, exposure to certain compounds and chemicals, or intake of narcotic and alcoholic substances (Al-Zubaidy  Mohammad, 2005 Karatas, 2009).  It is an artificial or induced state, which is different from the natural and normal depression that occurs in the nervous system to support biological processes such as rest or sleep.
The medications that cause nervous system depression have this as a direct effect. Sedatives such as sleeping pills and pain relievers, medicines that prevent or treat convulsions, and anesthetics cause nervous system depression (Drug Enforcement Administration, 2010). While the proper dosage and intake of these medicines alleviate certain ailments, the excessive intake or prolonged use can cause artificial and serious nervous system depression.

Compounds and chemicals that cause nervous system depression are household products or industrial ingredients. The Department of Energy (2010) identified acetone, chloroform, methanol, and methyl alcohol as chemicals or components of products that cause central nervous system depression. There are also other chemicals and compounds with similar effect such as methylene chloride found in cologne, shampoo and paint, linalool found in soaps and detergent, ethanol found in hairsprays and detergents, and benzaldehyde found in deodorant and perfume (McBride, 2009). Exposure to these chemicals and compounds occur on a daily basis. Over exposure to these products can cause serious nervous system depression.  

Alcoholic beverages are also products with depressant effects. Ethyl alcohol is a component of alcoholic drinks and excessive doses absorbed by the body can have toxic effects on the brain (Foley  Nelson, 2010). Abuse of alcohol as well as long-term intake can depress the nervous system.

What are the signssymptoms of nervous system depression  
Nervous system disorder can be mild, moderate to severe depending on the cause, particularly the extent of intake of drugs or narcotics or exposure to chemicals and compounds. Medicines, chemicals and compounds, and alcohol and illicit drugs comprise stimulus to cells that nerves communicate to the brain (Al-Zubaidy  Mohammad, 2005 Karatas, 2009). The signs and symptoms of nervous system depression comprise the reaction of the brain to the stimulus based on the message communicated by the cells.
   
The mild signs of nervous system depression are dizziness or drowsiness, headache and giddiness (Wall, 2006 Slonim  Allbee, 2010). These signs can occur immediately as the intake or exposure reaches a level that affects the central nervous system.
 In the case of medicines, the effect can emerge in a few hours coinciding with the absorption rate and the period it takes to affect the brain, especially when the immediate dosage or intake is high. The effect can also emerge in a few days or weeks with continued intake, especially of medicines easily absorbed and retained by the body. (Drug Enforcement Administration, 2010) When the absorption level becomes too high, this affects the brain.  
   
With regard to chemicals and compounds, the mild signs of nervous system disorder can also show immediately or after a certain period. Chemicals in household products can cause immediate effects when exposure is in a closed space. The components of pesticides contaminating food can lead to the signs when the intake or exposure reaches a certain level. Direct exposure and exposure at high levels cause the signs to shown immediately or in a shorter period. (McBride, 2009)
   
Relative to alcohol and illegal drugs as a cause, the symptoms depend on the level of intake. In alcohol, the intoxication level is at .08 percent in most states (PADUI Association, 2010). At the level of alcohol intoxication, the mild signs of nervous system depression such as drowsiness and headaches show. The body directly absorbs alcohol and it takes time for the body to flush out alcohol. As such, alcohol intoxication affects the ability to drive or to do other things. With drugs, the signs show depending on the form of intake. When injected the symptoms of nervous system depression show immediately, while in ingestion, the symptoms occur after digestion and absorption into the blood stream (PADUI Association, 2010).
   
The moderate symptoms of nervous system depression are confusion, loss of coordination, stupor, muscle weakness, and respiratory depression (Wall, 2006 Slonim  Allbee, 2010). These comprise more severe signs that require immediate treatment to prevent escalation.
   
Some medicines such as metoclopramide, a drug used to treat gastroparesis and migraines, can cause drowsiness, muscle weakness, and poor response to distress (Al-Zubaidy  Mohammad, 2005). This means that intake of a certain dose of this medicine can cause the user to feel sleepy, experience a slowdown in reflex response and movement. Being in this state can cause further problems in certain situations such as when driving or doing work that demands physical strength or focus. Other medicines can cause varying symptoms of nervous system disorder.
   
Chemicals and compounds such as imidacloprid, a component of pesticides can cause stupor or a trance state and respiratory depression or shallow breathing (Karatas, 2009).   When in this state, the individual will be unable to think clearly or move well. The individual would likely be immobilized and find it hard to breath. Most of the time, intervention becomes necessary to alleviate the condition of the individual. While individuals can recover from nervous system depression, there is need for intervention to hasten the flushing of substances ingested, oxidize the blood, or counteract the effects.
   
In alcohol and illicit drug use, the individual can exhibit disorientation or pass out (PADUI Association, 2010).
   
The severe symptoms of nervous system disorder are convulsions or seizures, coma, and respiratory failure (Wall, 2006 Karatas, 2009 Slonim  Allbee, 2010).  The condition of patients may deteriorate from moderate to serious symptoms. The dosage or level of exposure may also be so high to cause the severe symptoms immediately. Lack of intervention could lead to death.
   
A high level of dosage of certain medicines and illicit drugs can cause convulsions, respiratory failure, and coma (Drug Enforcement Administration, 2010). Without immediate intervention, the symptoms can occur in minutes before causing death.
   
Ingestion of chemicals such as pesticides or cleaning agents usually leads to respiratory failure and then death without proper and immediate intervention (McBride, 2009).
   
In alcohol, the lethal level is set at around .4 percent, which is five times the alcohol intoxication level (PADUI Association, 2010). High alcohol levels in the blood can cause respiratory failure.
What are medical and alternative treatments to nervous system depression

 The treatment of nervous system depression depends on the symptoms. There is no single treatment and the employment of intervention to the condition occurs as these emerge. Often, treatment is a combination of interventions to address different symptoms.  The treatment of the symptoms is diverse. There are medical and alternative treatments for the mild, moderate and severe symptoms.
   
The medical treatment for mild symptoms of nervous system depression is to stabilize breathing and flush out the toxic substance. In the case of symptoms caused by drugs (medicine and illicit drugs), the administration of oxygen to ease breathing is an initial treatment. Placing the patient in a recovery position can alleviate breathing. (Slonim  Allbee, 2010) In mild cases, individuals can flush out drugs in the normal process of discharging urine and stool. There are also drugs that induce vomiting to clear the stomach of the drugs ingested. In the case of chemical exposure, the medical treatment is also oxygen administration andor gastric clearing. (Bateman, 1999) There are also drugs administered intravenously to counteract the effect of chemicals ingested (Karatas, 2009).
   
The medical treatment for moderate symptoms of nervous system disorder targets oxygenation, keeping the individual conscious, countering effects, and flushing out toxic substances. It may become necessary to resuscitate the individual, clear air passages, and administer oxygen. (Slonim  Allbee, 2010) In the case of skin poisoning of chemical substances, decontamination applies by cleaning the area of exposure with water or a counteracting agent. If ingested, induced gastric clearing andor intravenous administration of counteracting agents may be necessary. (Bateman, 1999) The treatment may be more intense and longer for moderate symptoms.   
   
The medical treatment for severe symptoms of nervous system depression is more drastic. Intravenous administration takes longer for conscious patients and those in a coma (Karatas, 2009). Oxygenation can also be part of the treatment for the duration of the stay at the health care center or hospital. Respiratory ventilation may also become necessary for patients suffering from respiratory failure. Tracheal intubation can also become necessary. (Bateman, 1999 Slonim  Allbee, 2010)
   
Alternative treatments are herbal medicine, acupuncture, and massage. Herbal medicines are forms of traditional medicine prominent in Chinese medicine and ayurveda healing in India (National Institutes of Health, 2007a). Certain plants with emetic effects, such as the epicacuanha plant from which epicac syrup is extracted, is used to treat drug overdose and poisoning by inducing vomiting (Bateman, 1999). The use of the syrup found use by some practitioners in mainstream medicine. Other herbal medicines with properties for curing certain types of poison and conditions exist.
   
Acupuncture is an ancient Chinese healing technique that involves the insertion of thin needles into the body to stimulate certain points in the human anatomy (National Institutes of Health, 2007b). Known effects are improved circulation and relief from pain. Although research is ongoing over how acupuncture affects the body, particularly the brain, a common idea is the stimulation of specific acupuncture points can stimulate chemical reactions to achieve certain outcomes at the cellular level (National Institutes of Health, 2007b) such as improve respiration, ease pain, or detoxify the body. Acupuncture can address symptoms of nervous system depression, particularly respiration depression, conditions treatable by improving circulation, and detoxification of substances in the body.
   
Massage is an alternative treatment that involves the use of touch to exert pressure on certain parts of the body to stimulate a response (Braun  Simonson, 2008). Massage therapy operates on a similar principle as acupuncture. The exertion of force on pressure points can cause reactions. The neuromuscular modality targets improved circulation to ensure sufficient oxygen supply to the brain, better communication and transmission between cells, and muscle relaxation or stimulation to improve motor skills and movement. Lymphatic detoxification massage can also ease the functioning of the waste disposal processes of the body to eliminate toxins such as drugs and poisons. (Braun  Simonson, 2008)

How can massage therapy treat nervous system depression   
Massage therapy comprise a complementary and alternative medicine (National Institutes of Health, 2007a). Massage therapy comprise a treatment on its own as well as a complementary intervention to medical treatment for cases of nervous system disorder.
   
The alleviation of the mild symptom of drowsiness or dizziness likely caused by circulation or respiration problems can be through the deep tissue, neuromuscular, and circulatory modalities that improve blood flow to oxygenize the brain and alleviate dizziness. The craniosacral massage, as a deep tissue modality, involves the manipulation of the cerebrospinal fluid flow to increase blood flow in the spinal column and brain. Neuromuscular therapy improves the integrative functioning of the muscles and nerves to ease brain functioning. Lymphatic massage under the circulatory modality also improves blood circulation. Neuromuscular therapy can ease headaches as well as giddiness by stimulating chemical reactions and relaxing the muscles. (Braun  Simonson, 2008)  
   
Massage therapy can also treat the moderate symptoms of nervous system depression. Confusion, loss of coordination and stupor likely co-occur with respiratory depression or the restricted supply of oxygen in the central nervous system that slows down its functioning. Craniosacral therapy, neuromuscular techniques, and lymphatic massage can improve blood flow to provide the brain more oxygen to improve its functioning. The impact of massage therapy can be immediate, especially in improving blood circulation. Loss of coordination and muscle weakness can be resolved through neuromuscular therapy and energy modality techniques. Neuromuscular therapy stimulates or relaxes the muscles and energy modality techniques target the manipulation or recharging of the Qi energy to ease tension and help the body commence the healing process.  Lymphatic massage can help detoxify the body to remove the substances impeding the functioning of the nervous system. (Braun  Simonson, 2008)
   
Massage therapy serves as a complementary treatment to the severe symptoms of nervous system disorder. Seizure, coma and respiratory failure require medical treatment (Karatas, 2009).
   
Massage therapy can serve as alternative treatment to most of the mild and severe symptoms of nervous system depression with similar rates of effectiveness given that a trained and licensed massage therapist is providing treatment. In cases of severe symptoms, massage therapy can complement medical treatment by multiplying the impact such as on blood flow and muscle stimulation or contributing to the effectiveness of the medical treatment.

How is massage therapy as a treatment for nervous system disorder
Massage therapy for nervous system disorder can be similarly effective relative to medical treatments to comprise an alternative treatment for the mild and moderate symptoms of nervous system disorder.
Massage therapy is non-invasive. It does not involve the use of products or devices by relying on the skill of the therapist in identifying the problem areas and employing the appropriate techniques to address these areas. This works for people uncomfortable with invasive medical techniques.
Massage therapy can apply to different people. Men and women can use massage therapy as a treatment for nervous system disorder. Children, adults, and those in the older age groups can also use massage therapy for the mild and moderate symptoms of nervous system disorder. Massage therapy customizes techniques according to the condition of the client as well as other individual conditions such as old age or disability.
Massage therapy is both accessible and affordable. There are thousands of trained and licensed therapists all over the country. Most massage therapists operate as an individual practice, which could cut the cost.

Dont ask dont tell is the nickname given to military defense policy banning gays and lesbians from serving openly in the military. The policy introduced in 1993 by president bill Clinton,  has a two sided argument, the first is dont ask means that high ranking military officials cannot initiate investigation into a persons sexual orientation unless faced with incriminating and substantial  evidence. On the other hand dont tell means that closeted gays can serve in the military for as long as they do not disclose their true sexual orientation or carry on a gay sexual relationship while serving. It is imperative the issue to be discussed openly as it affects one of the most sensitive security organ of the nation which is the military and ignoring it will disastrous to both the military and the nation.
                                             
Problem Background  
The dont ask dont tell military policy was introduced as a compromise, to give the gay people a chance to serve in the military while at the same time protecting the integrity of the profession.  Previously, sexual orientation in the military was governed by President Reagans policy, which declared explicitly that homosexuals could not serve in the military, and further that people engaged or found to be in homosexual relationships would immediately be dismissed from the military, (Scott and Stanley 1994, 147).  Reagans policy became the official ban on homosexuals in the military. President Bill Clinton held his presidential campaigns on the grounds that he would introduce policies that would allow people of all sexual orientation to serve in the military. The National Defense Research Institute was therefore commissioned by the president to find a way of introducing policies that could allow people to serve despite their sexual orientation. The research institute concluded that such policies would have to be introduced with special strategies and care in order to maintain the integrity of the military profession. After much deliberations and discussions, the president introduced the directive 1304.26, the dont ask, dont tell policy (Scott and Stanley 1994, p.152).
                                         
The Matter of Gays in the Military 
Over time the military and defense department has often worked hard to dispute the public opinion that the profession encourages homosexuality. Serving personnel have been dismissed abruptly and without their benefits for engaging in or suspicion of engaging in homosexual acts. Although the military sees these dismissals as necessary, less and less people are joining the military. After the introduction of the policy more than 14,000 military personnel have been dismissed on grounds of their sexual orientations. Gay rights movements however place the numbers at a much higher figure of 36,000. (Rimmerman, 1996, p.113). After the September 11 bombings it was found that the American military was suffering a period of low recruitment and high misconduct dismissals. The military is slowly weakening, and one of the reasons cited for this was the introduction of the dont ask dont tell military directive.
  
Gay rights activists have stated time and time again that each American citizen has a right to choose their profession irrespective of hisher sexual orientation. The activist have often viewed this policy as an infringement on the rights of homosexuals and a form of discrimination by the highest and most powerful offices in the United States. Stewart (2001, 195) In addition, the activists have pointed out that cases of gay bashing in the military have been on the high since the introduction of the ban. The gay rights movement has in fact shown that cases of assault, discrimination and abuse based on sexual orientation have been increasing since the introduction of the policy.
                                                   
Historical Solutions   
Though the American people and the government take a lot of pride in the democratic policies and protection of the rights of people, the military is one area where compromise has failed. There have been no steps by either the government or the military itself o protect the rights of gays wishing to serve in the military. The right of each American to choose the profession they wish and pursue it has not been applied previously. President Reagan declared homosexuality illegal in the military. The total ban on homosexuals led to the dismissal of more than 30,000 officers from the army and other military affiliates. The policy allowed military officials to dismiss people on the suspicion that they were homosexuals. This led to the wrongful dismissal of many military officers, (Stewart 2001, 196)
   
The only step taken by the government to provide a solution to the problem was the introduction of the Dont Ask, Dont tell policy. The policy at least allowed homosexuals to serve in the military though not openly. Gay rights movements have often petitioned courts suing the government, the military and its personnel for dismissing individuals on the basis of their sexual orientation. Although most of their cases have failed miserably, the publicity given to them has made the issue much more recognized by the public.
                                                              
Proposed Solution 
The solution to the problems caused by the dont ask, dont tell policy lies in the amendment of the entire Military act. The amendments must be considered as a whole to include the homosexuality itself, homosexual relationships and the homosexual acts. Each of these parts must be addressed in detail. The sexuality of an individual should continue to remain a matter of personal choice that does not reflect on the choice of career whatsoever.

The public and government needs to be made aware that the important qualifications for military recruitment lie not in the sexual orientation of a person but more on the strength, endurance and most importantly the desire of an individual to serve their country. No person should be denied the chance to serve their country because of their sexual orientation. Each American citizen has a right to serve in the military if they so wish and if they qualify to do so, (Scott and Stanley 1994, 159).
  
The proposed military readiness act (2010) is a step in the right direction. The act introduced and supported by president Obama protects the rights of homosexuals to serve openly in the government. The act also stops the use of federal funds to expel homosexuals from the military. It declares discrimination of any kind within the ranks of military illegal, and protects the right of each person to choose their sexual orientation without retribution.
                                                                
Opposition
The opponent of the policy review of homosexuality say that there are very urgent problems and matters to be  addressed  and  considered such as the health care dilemma, and the economic crisis that have almost paralyzed  the nation or taking the nation to the brink of collapse. As such many people consider the issue of homosexuality to be a small and insignificant matter that may warrant some attention in the future but not today and its all upon individual choices. Conservatives groups in fact questions the aspect of upholding morality and the ability of Gay military members to effectively discharge their duties in that status.   In addition there are those who feel that there are some other factors that need attention in the military such as equipping training camps, recruitment channels and the compensation of injured military officers. Americans seem to consider this as more pressing issues in the military as opposed to the sexual orientation of officers who are injured and killed protecting their country.
                                           
Alternative Solutions
Whereas providing a general act governing military conduct is an excellent solution, adopting and altering small portions of the act maybe easier. Homosexuals can be given the right to serve in the military under certain conditions which will be governed by the amendments. Discrimination on the grounds of sexual orientation should warrant severe punishment for the perpetrators.  Finally, the high ranking officials should be given the mandate to consider each case individually and find better solutions to them. Since the officers have much more contact with the supposed homosexuals they are at a much better position to judge them and their conduct. The question to be considered should not be the sexual orientation but the conduct of military personnel, (Stewart 2001, 194).
                                               
Rebuttal on the Opposition  
Although there are other urgent issues to be considered people need to understand that the military is the backbone of the American defense and protection of the American people and should always be perfect. Discrimination of homosexual individuals has often had negative effects on the morale of military personnel. The performance of military departments depends highly on the morale of the officers. Without morale, less and less people are willing to apply for recruitment and those already in the military are unwilling to serve whole heartedly.

In addition dismissal of military personnel has often put the military in the public negatively. Such dismissals are often considered discriminatory garnering the military bad publicity not only in the country but also the entire international community. Recruits are often discouraged by negative publicity, and the public becomes hostile to the people given the mandate to protect them.
                           
Reasons for Changing the Dont Ask Dont Tell Policy
Consequences Rimmerman (1996, 122), the Clinton policy has come under fire recently for its effect on new recruits. Fewer and fewer people are applying for recruitment and one of the reasons sighted is the stand of the military on homosexuality.

Secondly the military has dismissed many qualified personnel on the grounds of their sexual orientation. Many of these officers have skills that cannot be easily replaced. Much more money is being spent on training new personnel while there are some qualified personnel who are dismissed on flimsy grounds. The dismissals have also left holes in the military defense systems which are becoming harder and harder to fill, often leaving the military vulnerable to external attacks, (Scott and Stanley 1994, 184) More than 200milliom dollars have been spent on recruiting and training new personnel to replace those who have been dismissed. In addition, much more money has been spent implementing the policy. Officers who have contested their dismissal have required the military and government to spend even more on defending themselves and settling the cases. Personnel have been recruited to look into the homosexuality cases and implement the required steps. All these spending as many see it could have been directed to other much more worthy causes in the military such as compensation, and purchase of equipment (Rimmerman 1996, 118).

Category reasons The military is among the biggest employers in America in addition to being the biggest budget allocation. The matters that concern the military often draw a lot of attention because they reflect on the countrys defense system and protection of its citizens. With the recent attacks of terrorism on American soil, military personnel are becoming more and more important to the welfare of the country. The defense mechanism is relying much more on the military than there before.

The American government cannot afford to dismiss more personnel, when there are those dying in wars and the recruits are being fewer and fewer. If the rate of dismissal continues, the American defense system will become a laughing stock in the international arena. The attacks on United States and its citizens will increase and some areas will be left unprotected for lack of personnel, (Rush 2003, 56).

Resemblance The right to declare once sexual orientation in the military has often been compared and contrasted to the right of gay marriages. The issue has long been debated in public forums. Many people often feel that whatever policies apply to non homosexuals should also apply to the homosexuals. Each person has a right to love whomsoever they choose and to let the public know of this whether they acknowledge it or not.

Rush (2003, 58)Requiring that homosexual military personnel be quiet about their sexual orientation is similar to denying them the right to be themselves and to define themselves as they wish. The act is also considered to be discriminatory in nature because it poses different standards for military personnel based on sexual orientation. Whereas the straight military personnel are allowed to conduct themselves as they wish with whomsoever they love, the homosexual personnel are required to either conduct their relationships in secret or deny their sexual orientation altogether if they wish to serve.
     
Although the dont ask, dont tell policy did grant some reprieve for military homosexuals, it is not enough. There is need for the rights of homosexuals with regard to publicly declaring their sexual orientation and choosing careers to be taken seriously. American citizens have the right to serve their country if they wish despite their sexual orientation. The military will continue to remain a respectable profession despite the sexual orientation of its members. The judgment lies not on the nature of sexuality of the members but on the skill and performance level of the department as a whole. Those who choose the military as a profession are dedicated and brave American citizens who require our respect despite their sexual orientation.

For the past week I tried to perform three of the nine techniques and these are the following first is the technique used on the respiratory system second is the technique used on the urinary system third and final is the technique used for psychosomatic ailments.
   
For the respiratory system, my subject was my cousin who has experienced asthma attacks since childhood.  For me, the experience did a lot in my understanding about the application of reflexology on ailments, although I cannot say that the ailment totally diminished, especially since we did the technique only thrice for three days.  However, the subject has expressed his perception that the technique has partially relieved him, causing relief in his breathing, allowing his lungs to draw more oxygen after the second performance.
   
For the urinary system, my subject was my grandmother, who has had difficulty in extracting waste products for about a decade or so.  The experience was quite painful for the subject, and I had a hard time trying to perform the technique in a quick and painless manner.  However, the second time we did was less painful, and it helped her in extracting the wastes more painlessly and successfully.  The experience helped me a lot in becoming more precise while performing the technique.  There were some sections in the feet that became painful during the performance.  It was a bit distressing to see the subject in pain.     
   
For the psychosomatic ailments, my subject was my friend, who has experienced being depressed for many months.  We did the technique thrice for three days, and every time we completed the performance, my friend says that she can breathe more effectively and that she was more relaxed, especially after the third performance.  However, the first time we did it was not really that successful, since my friend told me that she discovered no effect and no difference before and after the performance, and that how she felt after the performance was the same as how she felt before itthere was still the presence of stress and depression.  The relief came after the third performance though, and I was happy to give her some help.