Complementary Therapies in Clinical Practice xxx (2014) 1e4

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Complementary Therapies in Clinical Practice

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Physiotherapy in asthma using the new Lotorp method

€ whagen a, *, Per Bergqvist b
O. Lo
a €teborg, Sweden
Department of Internal Medicine, Sahlgenska Academy, University of Go
b €ping, Sweden
Bergqvist Massage Clinic, Linko

a b s t r a c t
Keywords: Background: Physiotherapy in bronchial asthma has given various results.
Asthma Aim: To test a new method focusing on breathing exercise and massage of the thoracic muscles.
Dysfunctional breathing
Patients and methods: Twenty-eight adult patients with a physician-diagnosed asthma were studied
Lung function test
Asthma symptoms
during 6 weeks. All patients were prescribed asthma medication. The new method [active group, n ¼ 17)
Physiotherapy was compared with physical training (control group, n ¼ 12).
Results: PEF was significantly improved (p ¼ 0.001) in the active group, however, FEV1 showed no sig-
nificant change. The symptoms “tightness of the chest”, “difficult breathing in”, “air hunger”, and the
individually dominating symptom (p ¼ 0.001) were significantly reduced in the active group. Exercise-
induced breathing troubles and chest expansion were also significantly reduced.
Conclusion: Physiotherapy including breathing exercise and massage of the thoracic muscles (the Lotorp
method) in patients with physician-diagnosed asthma resulted in significantly reduced respiratory
symptoms during rest and exercise and increased chest expansion. The improvements may be due to an
increased mobility of the chest and diaphragm.
© 2014 Elsevier Ltd. All rights reserved.

1. Introduction mechanisms may be confused with or coexist with “classic” asthma

Asthma is a chronic airway disease with a prevalence of 7e10%
in the Western world, with the highest percentage among younger
people. Four cornerstones characterize the disease, airway
inflammation, hyperresponsiveness, reversible bronchial obstruc-
tion and symptoms [1e3]. The symptoms listed in international
guidelines are breathlessness, wheezing, cough, tightness of the
chest, and shortness of breath [3,4]. The disease occurs in various
forms, commonly called phenotypes or endotypes [5e9]. In most
cases, the prescribed asthma medication is efficient, however, in
some cases the usual medication has no or only a slight effect
despite the presence of symptoms [10e15]. Follow-up studies
have also shown that physician-diagnosed asthma cannot be veri-
fied in a large proportion of investigated patients [16e18]. As many
non-asthma patients still have symptoms there must exist other
operating mechanisms than bronchial obstruction. Thus, there is a
need for new theories to explain the high proportion of treatment
failure and miss-diagnosis. Other possible mechanisms may be
related to sensory mechanisms, small airways disease, abnormal
breathing pattern and decreased chest mobility [19]. These
* Corresponding author.
€whagen).
E-mail address: olle.lowhagen@gu.se (O. Lo
[7,11,18,20e22]. A way to test different mechanisms is to treat
asthmatic patients with physiotherapy. The value of physiotherapy
in the treatment of asthma has been debated and some promising
effects have been reported [2].
2. Aim
In the present study, a new physiotherapeutic method was
tested in adult physician-diagnosed asthma, the Lotorp method,
which focuses on daily breathing exercises in combination with
intermittent massage of thoracic muscles.
3. Patients and methods
The criteria for including patients in the 6-week controlled
study were physician-diagnosed asthma. Baseline data are given in
Table 1. Twenty-eight adult patients, ages 20e52, were recruited.
All had been prescribed bronchodilators, and all, except for two,
were also prescribed inhaled corticosteroids. Exclusion criteria
were respiratory infection and other disorders that could affect
heart and lung function. Current medication was not changed
during the study. The active group, (n ¼ 17, mean age 32, range
20e52) was given physiotherapy at two clinics. The control group,
(n ¼ 12, mean age 43, range 23e50) was treated in a third similar

http://dx.doi.org/10.1016/j.ctcp.2014.07.004
1744-3881/© 2014 Elsevier Ltd. All rights reserved.

€whagen O, Bergqvist P, Physiotherapy in asthma using the new Lotorp method, Complementary Therapies
Please cite this article in press as: Lo
in Clinical Practice (2014), http://dx.doi.org/10.1016/j.ctcp.2014.07.004
2 €whagen, P. Bergqvist / Complementary Therapies in Clinical Practice xxx (2014) 1e4
O. Lo

external intercostal muscles, Sternum (several muscles attach to

Table 1 the sternum, and a rubbing movement is used to stimulate these
Baseline values. Duration of asthma, prescribed medication, chest expansion, lung attachments), Subclavius, Serratus anterior (upper parts), Scalenes,
function, dominating trigger factors and symptoms.
Sternocleidomastoideus, Diaphragm (external front part), abdom-
Active group Control group inal muscles (tranversus abdominis, obliquus internus abdominis,
Number of patients (n) 17 12 obliquus externus abdominis and rectus abdominis). After this
Age, mean (range) 32 (20e52) 43 (23e50) exhalations are manually assisted during exhalation by pressing the
Female/male (n) 11/6 9/3 chest, slowly but powerfully. The hands are placed along the side of
Duration in years, mean (range) 15 (1e35) 18 (1e49)
the chest and deep exhalations are performed 10 times. Then the
Inhaled corticosteroids (n) 17/17 10/12
Inhaled bronchodilators (n) 17/17 12/12
hands are moved to the upper parts of the chest. A similar manual
Chest expansion, mean (cm) 5.6 6.7 pressure during exhalation is performed 5 times. After this the
FEV1 % predicted, mean (range) 84 (42e106) 104 (85e124) patient is instructed to breathe in and out so that the thorax is
PEF % predicted, mean (range) 107 (84e139) 121 (107e134) moving as much as possible. Deep breathing using both intercostal
Trigger factors
muscles and the diaphragm is emphasized. These breathing exer-
Exercise (n) 9/17 6/12
Allergens (n) 7/17 8/12 cises will also be the patient's daily homework.
Scents (perfume) (n) 10/17 7/12 The rigidity of the chest is measured by assessing the chest
Dominating symptom expansion at the level of xiphoideus. The expansion is expressed as
Tighteness of the chest (n) 6/17 4/12
the increase in the circumference from maximum expiration to
Heavy breathing (n) 8/17 3/12
Wheeze (n) 0/17 0/12
maximum inspiration. The normal expansion at this level is
Air hunger/difficult breath in (n) 3/17 5/12 5e8 cm, biggest in males (unpublished data). In patients with
breathing problems the expansion may be as little as 1e2 cm.
The treatment given in the control group included daily exer-
clinic. These patients were instructed to carry out a physical exer- cise, walking up stairs or equivalent exercise for at least 30 min. In
cise program recommended by the Swedish National Board of addition the patients had to perform cardiovascular training for
Health and Welfare [23]. 20e60 min 3e5 times per week (running, aerobics, ball sports or
Before the study period all patients had to fill in a questionnaire similar) [23]. An experienced physiotherapist supervised the
about medical history, current symptoms, and trigger factors, treatment. To minimize the risk of subjective influence, in both the
asthma medication, smoking habits, etcetera. After the last treat- active and control group, the treating therapist did not perform the
ment the patients reassessed their symptoms and trigger factors, subsequent measurements.
without seeing the pre-study assessments. The objective mea- This controlled study was preceded by a pilot study comprising
surements before and after the study period included lung function 14 adult patients (12 women and 2 men, mean age 57, range
tests (PEF, FEV1, FVC), peripheral oxygen saturation (pulse oxime- 43e66) with a physician-diagnosed adult asthma. All had been
ter), maximum expansion of the chest (at the level of xiphoideus), prescribed asthma medication. The differences in symptom, trigger
pulse, and blood pressure. Because the patients reported different factors, lung function, and chest expansion between the start and
dominating airway symptoms (tightness, heavy breathing, difficult the end of the trial were calculated. The patients were instructed to
breathing in, air hunger), the most dominant one was selected as a continue daily breathing exercises and were followed up 4e6
separate study variable (Table 1). months after the end of the trial.
The Lotorp method (website www.lotorpsmetoden.se) has not
previously been published in the school medical literature. Lotorp is 4. Ethic
a community in Sweden where the physiotherapist Jan Karlsson
found that a patient with back pain was “cured” of his asthma by €teborg approved the study (No.
The local ethics committee in Go
massaging the thoracic muscles with the aim of improving the 187-07). The patients were informed both orally and written. All
chest mobility to reduce the back pain. In this case, it was likely that patients signed consent forms.
the increased mobility of the chest was “the cure” for the respira-
tory problems. This was the starting point for the “the Lotorp 5. Statistics
method”, which nowadays consist of a combination of breathing
exercises and massage. The massage techniques used are based on Symptoms and trigger factors were assessed subjectively on a
classical Swedish massage. The breathing exercises are similar to visual scale, from 0 ¼ never to 10 ¼ daily problem for symptoms,
other methods, but massage specifically aimed at treating respira- and 0 ¼ no to 10 ¼ severe breathing problems for trigger factors.
tory muscles has not previously been reported. The clinical expe- PASW Statistics 18.0 was used for non-parametric tests of the dif-
rience is that hundreds of patients with asthma or asthma-like ferences between the two groups. First the difference before-after
symptoms have been improved by this method. study was calculated for each parameter and each group. After
To get permission to work with the method clinically a special that the differences between the groups (difference of difference)
license is required. It is a two-part therapy involving daily breathing was calculated. P < 0.05 was considered as statistically significant.
exercises and massage of thoracic muscles at the clinic every third The null hypothesis is that there is no difference between this new
week. The treatment at the clinic is performed for a time of about method and physical exercise.
60 min. It starts with massage based on classic Swedish massage,
combined with trigger point treatment if the therapist finds 6. Results
specially tense points in the muscles. On the larger muscles are
performed a little faster rubbing movement. The patient lies on his/ All patients except for two in the control group fulfilled the
her stomach when the back is treated. Back muscles and tendons study. The dropouts were caused by social reasons. No adverse
treated with deep massage are: Erector spinae (the sacro spinal events were reported. Baseline values are shown in Table 1. When
system), Romboideus major and minor, Quadratus lumborum, and changes in lung function values, before and after treatment, were
external intercostal muscles. Then, the patient lies on his/her back. compared there was a significant improvement in PEF in the active
Muscles and tendons treated are: Pectoralis major, Pectoralis minor, group (p < 0.005) but no significant improvement in FEV1 (p ¼ 0.45)

€whagen O, Bergqvist P, Physiotherapy in asthma using the new Lotorp method, Complementary Therapies
Please cite this article in press as: Lo
in Clinical Practice (2014), http://dx.doi.org/10.1016/j.ctcp.2014.07.004
 €whagen, P. Bergqvist / Complementary Therapies in Clinical Practice xxx (2014) 1e4
O. Lo
Table 2
Differences between active and control group after calculation
of differences between before and after in each group (differ-
ence of difference).
p-Value
PEF % predicted 0.007
FEV1 % predicted 0.448
Dominating symptoms 0.001
Tightness of the chest 0.012
Heavy breathing 0.068
Chest pressure/load 0.09
Difficult breathing in 0.015
Chest tenderness/pain 0.047
Difficult get air 0.008
Wheezing 0.077
Waking up at night 0.075
Perfume 0.363
Walk on flat ground 0.021
Up hill/stairs 0.002
Jogging/running 0.014
Chest expansion 0.018
P-values in bold indicate significant improvements in the active
group compared to the controls.
and FVC (p ¼ 0.59) (Table 2). When comparing symptoms in the
active and the control group, “tightness of the chest” (p ¼ 0.012),
“difficult breathing in” (p ¼ 0.015), and “difficult to get air/air
hunger” (p ¼ 0.008) were significantly more reduced in the active
group. The individually dominant symptom was highly significantly
reduced in the active group (p ¼ 0.001). For “heavy breathing”
(p ¼ 0.07) and “wheezing” (p ¼ 0.08) there were no significant
differences. For exercise-induced breathing troubles (stairs/hills,
p ¼ 0.002), jogging/running, (p ¼ 0.014), and chest expansion
(p ¼ 0.018) (Table 2) there were significant improvements in the
active group.
In the preceding pilot study, the predominant symptom
improved in 12/14 patients. Chest expansion was improved in 14/14
patients (mean increase 2.5 cm), and exercise (stairs/hills) in 9/14
patients. The mean changes in PEF and FEV1 were small and non-
significant. At the follow-up 4e6 months after the end of the
trial, the predominant symptom was still improved in 10/14 pa-
tients. The chest expansion was still improved in all patients.
7. Discussion
Using a new physiotherapeutic method, the Lotorp method,
respiratory symptoms during rest and exercise were significantly
improved in patients with physician-diagnosed asthma. There was
also a significant increase in chest expansion indicating an
increased mobility of the chest and diaphragm. The main clinical
criterion for asthma is reversible bronchial obstruction expressed
as an improvement in pulmonary function tests, usually FEV1, FVC
or PEF. In this study the mean PEF-values were significantly
improved in the active group. However, in the absence of
concomitant effect on mean FEV1 and FVC it is not possible to assess
the new method's effect on bronchial obstruction. Even in previous
studies, no significant changes in lung function have been reported
[24e27]. At this stage it is more likely that the clinical improvement
was due to an increased mobility of the chest and diaphragm,
expressed as increased chest expansion giving a greater power in
the forced expiration. This assumption is also supported by the
previous pilot study where increased chest mobility was observed
after up to 4e6 months. Symptoms, quality of life and psychological
factors have been improved in previous physiotherapeutic studies,
but in no study the responsible mechanism behind the improve-
ments have been identified [24e28]. It seems logical that muscles
that are treated by physiotherapy will be positively affected, in this
€whagen O, Bergqvist P, Physiotherapy in asthma using the new Lotorp method, Complementary Therapies
Please cite this article in press as: Lo
in Clinical Practice (2014), http://dx.doi.org/10.1016/j.ctcp.2014.07.004
3
case the whole chest. The importance of the chest mobility in
respiratory diseases may not have been recognised in earlier
studies. When using methods aiming to reduce hyperventilation
(e.g. the Buteyko and the Papworth method) there are, in fact, no
reports of the effect on hyperventilation. Instead the quality of life
or other subjective parameters are measured [24,25]. Acute hy-
perventilation is well documented, however, the occurrence of
chronic hyperventilation is much debated [24].
All patients reported a physician-diagnosed asthma. The medi-
cal records were not available but support for the diagnosis was the
fact that all patients were prescribed asthma medication. All pa-
tients, except two, were prescribed inhaled corticosteroids, which
are recommended in moderate to severe asthma [3,4,29,30]. On-
going treatment may explain non-improved FEV1 and FVC-values,
however, all patients still had symptoms. The question whether
physician-diagnosed is always correct requires further review. In
trials where the asthma diagnosis has been re-evaluated, re-
searchers have found that the asthma diagnosis in many cases
cannot be confirmed [16e19]. In agreement with this, several au-
thors have also observed a lack of efficacy of asthma medications
[10e12]. One explanation to unchanged FEV1 and FVC could be the
presence of non-obstructive disorders such as airway sensory hy-
perreactivity [31,32], hyperventilation [33] and dysfunctional
breathing [19,31,34e40] These non-obstructive disorders may be
confused with “classic” asthma [19,32]. Dysfunctional breathing,
for example, is found in 35% of women and 20% of men with
diagnosed asthma [36,37].
Doing controlled trials of physiotherapy is complicated because
strict double-blind studies are not possible to perform. This needs
repeated studies with as good control as possible. Although this is
the first comparative study of the new treatment method, we
believe that the results provide support for the importance of an
efficient mobility of the chest and diaphragm. This is also in
agreement with a study by Johansson et al., who found that the
chest mobility and breathing movements were impaired in patients
with airway sensory hyperreactivity [32] and that the chest
mobility was improved by a physical training programme for 12
weeks (Johansson E-L approved PhD thesis to be published).
In conclusion, a 6-week study on patients with adult physician-
diagnosed asthma showed that daily breathing exercises and
intermittent massage of the thoracic muscles resulted in signifi-
cantly improved respiratory complaints during both rest and
physical exercise. The findings indicate that the improvement is
due to an increased mobility of the chest and diaphragm.
Conflict of interest statement
No economic or scientific conflicts reported.
Funding
The Swedish Asthma and Allergy Association supported the
study financially.
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