Dr. Phil Shares: Healthy Aging: A Functional Medicine Approach to Sarcopenia

By 2020, more than 20% of the US population will be 65 and over.1 Healthy aging is and will continue to be an important focus in many Functional Medicine offices.

Sarcopenia, the gradual loss of muscle mass that occurs in healthy adults as they age, begins after the age of 30 and accelerates after 60. The difference between the muscle mass of a 20-year-old vs. an 80-year-old is about 30%.2

Loss of muscle contributes to reduced mobility, increased hospitalizations (fragility and falls), prolonged recovery, and mortality.Factors that contribute to earlier onset and more rapid progression of sarcopenia include lack of physical activity, inflammatory conditions, blood sugar imbalances, history of smoking, hormone imbalances, and low vitamin D status.4 Addressing these risk factors is part of an individualized, preventative approach.

Therapeutic considerations that may slow this sarcopenic process down and improve overall quality of life (QOL) in an otherwise healthy, aging adult include:

Protein

Adequate, daily protein intake is essential for muscle health and possibly even more important in the aging population. Based on the evidence, the ideal protein intake for a healthy, older adult is 1.0-1.2g protein/kg body weight/day, while higher intake levels may be required in patients with acute or chronic disease.5

Achieving optimal protein intake may generally be more difficult for elderly patients at high risk for sarcopenia. Based on the results of a 2011 analysis of health and aging trends, nearly 1/2 of all US adults over age 65 have difficulty or receive help with daily activities.6 Protein powders with added BCAAs are a convenient way to support patients in meeting their protein requirements and obtain critical nutrients to help address sarcopenia.7-8

Adequate protein may also reduce risk of other age-associated events such as strokes9 and hip fractures.10 Furthermore, a practitioner does not have to wait until signs of sarcopenia are present before assessing protein requirements. In combination with physical activity, adequate protein throughout adult life may offer protection against early onset and progression of sarcopenia.11

Key clinical points:

  • Addressing increased dietary guidelines for protein intake is important for preventing loss of muscle mass in older adults7
  • Higher protein intake and lower fat mass might be positively associated with physical performance in elderly women12
  • Practitioners may help delay onset and progression of sarcopenia by assessing protein intake prior to presence of clinical signs and symptoms11

Marine omega-3 fats

The diverse, significant health benefits of omega-3 polyunsaturated fatty acids (PUFAs), namely, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), are well documented. Specific to the aging population, research points to benefits in cognitive health and cardiovascular markers, as well as physical function.13

Despite the evidence, dietary intake of omega-3 fatty acids is consistently insufficient in North America, with over 90% of the population consuming <500 mg/day of EPA and DHA.14 This is a far cry from the therapeutic intake (for muscle mass and function) suggested in clinical trials of 2g-4g/day.15 Nutritional guidance around omega-3 intake provides a therapeutic opportunity for clinicians to support their aging patients.

Key clinical points

  • Supplementation with fish oil helps address the EPA+DHA nutrient gap from one’s diet14 and may help slow the decline in muscle mass and function in older adults.16
  • Increased omega-3 intake stimulates muscle protein synthesis and may be useful in prevention and treatment of sarcopenia15
  • Improvement in grip strength and muscle tone are positive benefits that may be achieved with fish oil supplementation16

Vitamin D

Vitamin D deficiency is a common occurrence in the elderly population, and its relationship to bone health is well-established. Furthermore, normal vitamin D status has also been positively correlated with functional outcomes in the elderly.18 Optimizing vitamin D status may prove to be an essential component of a protocol addressing age-related frailty and sarcopenia, especially when combined with physical activity and a protein-rich diet.17

Key clinical points

  • Treating vitamin D insufficiency and deficiency may lead to improved muscle performance, reduced risk of falls, decreased bone loss, and reduced fracture incidence18
  • Meta-analysis data indicates that serum 25-hydroxyvitamin D levels are significantly and directly associated with the risk of frailty19

Exercise

Regular exercise is important in the prevention and treatment of sarcopenia. By positively influencing blood sugar levels and body composition, physical activity helps reduce many of the risk factors associated with early onset of sarcopenia. Exercise also directly supports healthy muscle mass and function.

Whether young or old, encouraging patients to live an active lifestyle is an important and healthy addition to a sarcopenia prevention and management plan. Therapeutic benefit is optimized when fitness programs include resistance and endurance exercises 3x/week.2

Key clinical points

  • Physical activity consistently mitigates frailty and improves sarcopenia and physical function in older adults20
  • Older patients who participate in resistance and endurance exercise programs may improve not only their function and independence but also their quality of life21

The implications of sarcopenia are potentially severe. Many complications may be reduced and QOL improved with a Functional nutrition approach.

References

  1. Ortman J et al. Population Estimates and Projections Current Population Reports. https://www.census.gov/library/publications/2014/demo/p25-1140.html. Accessed September 14, 2018.
  2. Frontera W et al. Aging of skeletal muscle: a 12-yr longitudinal study. J Appl Physiol. 2000;88(4):1321-1326.
  3. Prado CM et al. Implications of low muscle mass across the continuum of care: a narrative review. Ann Med. 2018:1-19.
  4. Szulc P et al. Hormonal and lifestyle determinants of appendicular skeletal muscle mass in men: the MINOS study. Am J Clin Nutr. 2004; 80(2):496-503.
  5. N. Deutz et al. Protein intake and exercise for optimal muscle function with aging: recommendations from the ESPEN Expert Group. Clin Nutr. 2014;33(6):929-936.
  6. Disability and Care Needs of Older Americans: An Analysis of the 2011 National Health and Aging Trends Study. https://aspe.hhs.gov/report/disability-and-care-needs-older-americans-analysis-2011-national-health-and-aging-trends-study
  7. Garilli B. https://www.metagenicsinstitute.com/articles/bcaa-leucine-supplementation-increases-muscle-protein-synthesis-healthy-women/. Accessed September 14, 2018.
  8. Devries MC et al. Leucine, not total protein, content of a supplement is primary determinant of muscle protein anabolic responses in healthy older women. J Nutr. 2018;148(7):1088–1095.
  9. Zhang Z et al. Quantitative analysis of dietary protein intake and stroke risk. Neurology. 2014;83(1):19-25.
  10. Kim BJ et al. The positive association of total protein intake with femoral neck strength (KHANES IV). Osteoporos Int. 2018;29(6):1397-1405.
  11. Paddon-Jones D et al. Protein and healthy aging. Am J Clin Nutr. 2015;101(6):1339S–1345S.
  12. Isanejad M et al. Dietary protein intake is associated with better physical function and muscle strength among elderly women. Br J Nutr. 2016;115(7):1281-1291.
  13. Casas-Agustench P et al. Lipids and physical function in older adults. Curr Opin Clin Nutr. 2017;20(1):16-25.
  14. Richter CK et al. Total long-chain n-3 fatty acid intake and food sources in the United States compared to recommended intakes: NHANES 2003-2008. Lipids. 2017;52(11):917-927.
  15. Smith GI et al. Fish oil–derived n−3 PUFA therapy increases muscle mass and function in healthy older adults. Am J Clin Nutr. 2015;102(1):115–122.
  16. Smith GI et al. Dietary omega-3 fatty acid supplementation increases the rate of muscle protein synthesis in older adults: a randomized controlled trial. Am J Clin Nutr. 2011;93(2):402-412.
  17. Bauer JM et al. Effects of a vitamin D and leucine-enriched whey protein nutritional supplement on measures of sarcopenia in older adults, the PROVIDE study: a randomized, double-blind, placebo-controlled trial. J Am Med Dir Assoc. 2015;16(9):740-747.
  18. Dawson-Hughes B. Serum 25-hydroxyvitamin D and functional outcomes in the elderly. Am J Clin Nutr. 2008;88(2): 537S–540S.
  19. Ju SY et al. Kim. Low 25-hydroxyvitamin D levels and the risk of frailty syndrome: a systematic review and dose-response meta-analysis. BMC Geriatr. 2018;18(1):206.
  20. Phu S et al. Exercise and sarcopenia. J Clin Densitom. 2015;18(4):488-492.
  21. Landi F et al. Exercise as a remedy for sarcopenia. Curr Opin Clin Nutr Metab Care. 2014;17(1):25-31.

By Melissa Blake, BSc, ND

Shared by Dr. Phil McAllister @ Forward Health Guelph

Dr. Laura: Why Estrogen Makes You Stressed

How estrogen impacts stress

High levels of estrogen might increase your levels of stress. It clogs up the detoxification pathways and leaves neurochemicals in the body for too long. A build up of neurochemicals can make a person angry, irritable, anxious or exhibit compulsive symptoms.

The detoxification processes affected by high levels of estrogen:

  1. Methylation
  2. Breakdown

Methylation

Methylation keeps cells from oxidizing, aging, or simply “going bad”. Too much or too little methylation is linked to multiple diseases and cancer. Methylation aids in DNA and RNA synthesis, cell differentiation, neurotransmitter synthesis and metabolism, detoxification, hormone clearance, energy production, nerve conduction and histamine clearance.

Methylation is provided by foods that offer sources of B6,B12, zinc and folate (lots of vegetables, fruits, seafood, red meat, nuts & seeds). The MTHFR (methyl folate reduction) gene’s activity is observed through genetic and organic acid tests. Homocysteine can also be a blood biomarker for how well the methylation cycle works.

Breakdown of neurotransmitters

COMT Catechol-O-Methyltransferase (COMT) is one of several enzymes that degrade the neurotransmitters dopamine, epinephrine, and norepinephrine. COMT is heavily influenced by levels of estrogen. When the estrogen is high, the COMT is slowed down.

MAO, or monoamine oxidase, is an enzyme that affects the neurotransmitters dopamine, norepinephrine, and serotonin.

When we think of estrogen, we often think of females with Premenstrual Syndrome (PMS) and peri-menopausal women. These are times when the estrogen surges and drops, inflicting mild to severe mood swings.

Estrogens are not only a female concern. There are increased levels of estrogens in males and females due to environmental factors.

Xenoestrogens are not natural forms of estrogen and the body has difficulty eliminating them. Xenoestrogens come in the form of birth control pills, flame retardants, BPA, pesticides, heavy metals, aluminum, lead, mercury, arsenic and cadmium.

Increased xenoestrogens puts an increased toll on our COMT and MAO. When the COMT and MAO are busy with excess estrogen and  xenoestrogens it makes it more difficult for them to do their everyday job of clearing catecholamines, or brain chemicals like dopamine and adrenaline. When dopamine and adrenaline hang out for too long, the body endures long standing experiences of stress. This is why estrogen detoxification and support of methylation, COMT and MAO activity in general can lead to less anxiety and aggravation.

How well does your methylation, COMT and MAO work?

Find out how your hormones influence your levels of stress through blood,  dried urine, and salivary tests available with Dr. Laura:

Dr. Laura M. Brown, ND works with her patients to help them understand their genetic tendencies and educates on how to prevent disease, reduce experiences of stress and live with energy.

Dr. Laura: Surprising Number of Conditions Linked to Celiac Disease

I just received this post… hot off the press from the World Congress of Gastroenterology. We learn about all the conditions that are linked to Celiac disease. This means if you have migraines or anxiety attacks, more people with Celiac have them than not. Or, if you have a specific type of rash called dermatitis herpatiformis, you are pretty well guaranteed to have celiac. Have a look at the chart below and see if you have any of the following conditions and then look at the odds ratio that you may have Celiac Disease.

Celiac disease is an autoimmune condition related to the ingestion of gluten, or wheat. Wheat has over 100 proteins in it and gluten and gliadin are just two of these proteins. Your body can launch an immune attack to any of these proteins, then these could cross react with tissues in your body including your brain, liver, pancreas, skin muscles, or as in Celiac, your small intestinal villi. If your villi are damaged, then you are not absorbing vitamins, minerals and nutrients. So this can additionally lead to things like B12 deficiency (depression, brain fog, neuropathy) iron deficiency (dizzy, weak, pale), or osteoporosis.

Conventional medical testing will look at 2 markers for these proteins immune reactions. Functional Medical tests that I run will cover 24 markers, including these 2 from conventional means. You have to pay for both tests out of pocket, so I figure you may as well run the more complete test to get the bigger picture of what’s going on in your body. The broader testing means we can catch wheat related diseases – non-celiac gluten related disorders like cerebellar ataxia (problems with balance and walking) or wheat addiction (it’s like opioid addiction!) or tell it if is reacting with you muscles (polymyalgia?) or skin.

Table 1. Prevalence of Diagnoses in People With and Without Celiac Disease (P < .0001 for All)

Diagnosis With Celiac Disease, % Without Celiac Disease, % Odds Ratio
Migraine 18.6 4.1 5.5
Anxiety disorder 25.9 8.7 4.0
Arthritis 28.9 8.4 4.9
Dermatitis herpetiformis 1.3 0.0 4563.5
Liver disease 23.2 4.2 7.1
Gastroesophageal reflux disease 36.8 13.0 4.5
Eosinophilic esophagitis 0.6 0.1 8.8
Atrophic gastritis 3.9 0.1 8.0
Glossitis 0.4 0.1 4.4
Pancreatitis 15.8 0.7 25.0
Disorder of the pancreas 17.2 1.1 19.0
Cerebellar ataxia 0.1 0.0 4.1
Autism 4.0 0.2 19.9
Colitis 25.9 4.2 8.4
Turner syndrome 0.1 0 17.8
Down syndrome 0.6 0.1 8.1
Common variable immunodeficiency 0.2 0.0 10.2

Best Waffles Ever

Kale and collard greens, teff and eggs pack a punch of nutrition to start your day.

With all the rainy weather this summer, there is an upside – lots of dark leafy greens. My son is doing his masters in agriculture at Guelph and his hobby garden in our back yard is my paradise.

Dino (laminate) kale, red kale and curly kale, swiss chard and beet greens deck my plate at least three times a day, in some way.

This morning I though maybe I’d steam some greens and have them with my eggs, but I also really feel like have a warm waffle with a little maple syrup. Ideas merged and here is the recipe. It actually tastes pretty good (!), even if the waffles do look green.

GREEN WAFFLES 

Vitamix or blender – blend the following on high for about 2 minutes:

1c almond milk

3 eggs

1 c avocado oil

2c kale/collards/beet greens

In a medium mixing bowl combine well the dry ingredients:

1 cup teff grain

1/2c arrowroot flour

1c quinoa flour

1 tsp xanthum gum

1tsp baking soda

Pour wet with dry and stir well. Heat up waffle grill and oil it up (I used olive oil).

Pour some batter on and bake until waffles are crispy and slight brown on the outside.

Eat right away with a little maple syrup, or some fresh berries.

Sometimes I will mix a cup of thawed frozen blueberries  with 1tbsp or two of chia seeds and a 1/2c hot water and stir. Let it sit for a few minutes to gel up and it makes a lovely sugar free topping.

Store extra waffles in glass container in fridge or freezer for easy toaster warm up on another morning.

Teff is high in iron and calcium, dark leafy greens have iron, calcium and a ton of phytonutrients, almond milk has added calcium, eggs have B12 and protein (as does the quinoa flour).

From the heart and kitchen of Dr. Laura M, Brown, ND.

 

Fatigued? Could your Iron be low?

Fatigued?

Low iron could be part of the root cause of your fatigue. It could be a matter of absorption, health of the red blood cell, or compounding factors like thyroid, poor sleep, and related heart issues. ™There is preliminary evidence that iron supplementation might improve unexplained fatigue in non-anemic women. Low iron is one of the top reasons for fatigue, but it is not the only reason. Dr. Laura M. Brown ND can help you dig into the root cause of your fatigue.

Get help now.

Who is at Risk?

  • menstruating women
  • vegan and vegetarians
  • high performance athletes
  • those with Celiac, gluten sensitivity, Crohn’s or colitis
  • long term use of proton pump inhibitors
  • H.Pylori infection
  • internal bleeding of any kind

Food Sources of Iron

™Food Sources: meats of all kinds, liver and organ meats (animal sources best absorbed), kelp, legumes, tofu, whole grains, molasses, nuts and seeds, wheat, millet, dark leafy greens, sardines, prune juice and oysters.

Iron Absorption

Iron absorption depends on proper stomach acid and the ability for the gastrointestinal (GI) tract to absorb. The body will only absorb what iron it needs, and pass the rest along in the stool. Animal based heme (iron) is best absorbed. Vegetable based iron sources are absorbed at a fraction of animal based sources. If there are stomach acid issues, like an H.Pylori infection or prolonged use of Proton Pump Inhibitors (PPI’s), or issues with the GI lining like in Celiac, Crohn’s or Colitis, then absorption of iron and other vital nutrients may be impaired.

Your iron could be low if you have these symptoms:

™Fatigue, weakness

™Dizziness, especially on rising quickly

™Shortness of breath on exertion, chest pain

™Headache

™Coldness in your hands and feet

™Pale skin, tongue, conjunctiva

™Brittle nails

™Swelling or sore tongue, cracks at side mouth

™Enlarged spleen, frequent infections

Why do I feel this way?

™Iron is also a cofactor in the synthesis of neurotransmitters such as dopamine, norepinephrine, and serotonin. This is why low iron has the potential to contribute to low mood.

Iron deficiency may affect selenium absorption, which could then affect thyroid hormone production. Low thyroid function can can contribute to a state of fatigue.

™Iron deficiency can also cause restless legs, contributing to poor sleep, which means less healing in sleep, more hormonal imbalance and compounded issues of fatigue.

If you don’t have enough hemoglobin-carrying red blood cells, your heart has to work harder to move oxygen-rich blood through your body. This can lead to arrhythmias, murmur, enlarged heart, or even heart failure.

Iron is used to make the hemoglobin complex on the red blood cells.

™If your red blood cells are breaking down or not enough are made, you will not have the ability to use the iron to make the hemoglobin.

™There are four “parking spots” for Oxygen and carbon dioxide on your red blood cells – this is the iron binding capacity or “TIBC” you see on your blood work.

™When the TIBC is high you iron might be low.

Sometimes serum iron is fine but the ferritin is high. The body squirrels away iron when there is an infection. This is because virus and bacteria use iron to help replicate. What a smart body we have!  Inflammatory factors of infection and low iron contributes to fatigue.

 

Diagnosing Low Iron

Clinical presentation (your signs and symptoms) are the first clue to low iron. A simple blood test including a CBC and Iron Panel will help dig into the root cause of your fatigue. Further exploration and tests may be required to diagnose other contributing factors of health as mentioned above. A naturopathic doctor is always on the look out for the true root cause of your health concerns.

™CBC – complete blood count

–Number, size of red blood cells (RBC) (iron def. anemia red blood cells are smaller than normal)

–Number, size of white blood cells

–Number of platelets

–Reticulocyte count – immature RBC – tells if bone marrow production rate of RBCs is normal

–Hemoglobin- iron rich protein on your red blood cells that carries oxygen to your tissues and carbon dioxide away

–Hematocrit – measures how much space your red blood cells take up in your blood

™Serum iron – amount of iron in your blood. Not always indicative of the total amount of iron in your body.

™Serum ferritin – think tin is something you store things in– this is your iron storage.

™Transferrin – trans for transfer – this protein carries iron in your blood

™TIBC – measures how much of the transferrin is around and not carrying any iron

Dr.  Laura M. Brown, ND 

7 Added Benefits For Adults In Guelph Who See A Chiropractor

Shared By kyphotic-spine-webDr. Phil McAllister, from Life Natural Health News

When most of us think about seeing our chiropractor, we think about getting help with back pain or some other kind of musculoskeletal problem. But did you know that chiropractic is also a great way to improve your general health and wellness?

The core concept of chiropractic is to restore the function of your nervous system so that it can do what’s it’s designed to do: keeping your body healthy and active. Chiropractic is truly about prevention. If you keep your nervous system working smoothly and without interference, many health issues become non-issues!

Don’t take our word for it, though. Over the last few years, there’s been a lot of scientific research that shows that chiropractic is good for much more than just aches and pains. Here’s a review of some of this literature.

1 – Boosts Immune Function

A 2010 study1 found that chiropractic adjustments actually boosted blood serum levels of some important natural antibodies in patients. The authors suggested that chiropractic adjustments might “prime” the immune system, making it easier to ward off infection and illness.

2 – Reduces Inflammation

Researchers in a 2011 study2 compared back pain patients to people with no pain and gave both groups chiropractic adjustments. The authors found that the back pain patients who received chiropractic care had dramatically lower levels of a key inflammatory cytokine, known as TNF-α. High levels of TNF-α have been linked to inflammatory diseases like rheumatoid arthritis, inflammatory bowel disease, and psoriasis.

3 – Chiropractic Reduces Blood Pressure

Hypertension is a huge public health issue in the US; it’s estimated that about 30% of adults suffer from this serious condition. A 2007 study3 in the Journal of Human Hypertension looked at a group of patients with high blood pressure. Half received received an adjustment of their atlas, and the other half received a sham adjustment.

The decrease in blood pressure was so dramatic in the patients who received real adjustments that the researchers wrote that it “is similar to that seen by giving two different anti-hypertensive agents simultaneously.” In fact, 85% of the study patients had improvement after just one adjustment!

4 – Reduces Stress

An interesting study by a team of Japanese researchers4 in 2011 gave chiropractic adjustments to 12 men and examined PET scan images and blood chemistry to examine the effect that chiropractic has on the autonomic nervous system.

After receiving a chiropractic neck adjustment, patients had altered brain activity in the parts of the brain responsible for pain processing and stress reactions. They also had significantly reduced cortisol levels, indicating decreased stress. Participants also reported lower pain scores and a better quality of life after treatment.

5 – Improves Balance

As we age, sometimes we start to lose some of our balance, strength, and flexibility that we had in our youth. Because of this, older folks are vulnerable to serious injuries from trips and falls. Chiropractic helps keep your body active by restoring the normal, healthy functioning of your spine. One of the important roles of your spine is balance, aided by nerves called proprioceptors. These propriocepters relay information to your brain on the position of your body.

A small study5 from 2009 found that people who received chiropractic adjustments had reduced dizziness and improved balance. A 2015 review of the literature6 suggests that chiropractic care might be an effective, natural way to help prevent falls in elderly patients.

6 – Relieves Colic in Babies

In 2012, researchers7 studied 104 infants who were suffering from colic. One-third of the infants were treated with chiropractic adjustments and the parents were aware of the treatment; one-third were treated and the parents were unaware of the treatment; and one-third were untreated but the parents were anaware.

The authors found that the parents reported a significant decrease in infant crying in the treated babies, compared to the infants who didn’t receive treatment. The knowledge of the parent had no effect on the improvement.

7 – Relieves Asthma Symptoms

A 2013 study8 reported that chiropractic adjustments were effective at increasing lung functioning, and some recent research9 shows that chiropractic care can help reduce the symptoms of asthma in some children.

 

To find a chiropractor in your community who can help you restore your health, use our handyChiropractor Search Directory.

Reference Studies

  1. Teodorczyk-Injeyan JA, McGregor M, Ruegg R, Injeyan HS. Interleukin 2-regulated in vitro antibody production following a single spinal manipulative treatment in normal subjects. Chiropractic & Osteopathy 2010;(18)26.
  2. Teodorczyk-Injeyan JA, Triano JJ, McGregor M, Woodhouse L, Injeyan HS. Elevated production of inflammatory mediators including nociceptive chemokines in patients with neck pain: a cross-sectional evaluation. Journal of Manipulative and Physiological Therapeutics 2011;34(8):498-505.
  3. Bakris G, Dickholtz M Sr, Meyer PM, Kravitz G, Avery E, Miller M, Brown J, Woodfield C, Bell B. Atlas vertebra realignment and achievement of arterial pressure goal in hypertensive patients: a pilot study. Journal of Human Hypertension 2007;21(5):347-52.
  4. Ogura, Takeshi and Manabu Tashiro, Mehedi,Shoichi Watanuki, Katsuhiko Shibuya, Keiichiro Yamaguchi, Masatoshi Itoh, Hiroshi Fukuda, Kazuhiko Yanai. Cerebral metabolic changes in men after chiropractic spinal manipulation for neck pain. Alternative Therapies. 2011;17(6):12-17.
  5. Strunk RG, Hawk C. Effects of chiropractic care on dizziness, neck pain, and balance: a single-group, pre-experimental, feasibility study. Journal of Chiropractic Medicine 2009;8(4):156–164.
  6. Kendall JC, Hartvigsen J, French SD, Azari MF. Is there a role for neck manipulation in elderly falls prevention? – An overview. Journal of the Canadian Chiropractic Association 2015;9(1):53-63.
  7. Miller JE, Newell D, Bolton JE. Efficacy of chiropractic manual therapy on infant colic: a pragmatic single-blind, randomized controlled trial. Journal of Manipulative and Physiological Therapeutics 2012;35(8):600-7.
  8. Engel RM, Vemulpad SR, Beath K. Short-term effects of a course of manual therapy and exercise in people with moderate chronic obstructive pulmonary disease: a preliminary clinical trial. Journal of Manipulative and Physiological Therapeutics 2013;36(8):490-6.
  9. Pepino VC, Ribeiro JD, Ribeiro MA, de Noronha M, Mezzacappa MA, Schivinski CI. Manual therapy for childhood respiratory disease: A systematic review. Journal of Manipulative and Physiological Therapeutics 2013;36(1):57-65.