USE OF OSTEOPATHIC MANIPULATE TREATMENT FOR THE MANAGEMENT OF PECTUS EXCAVATUM: A CASE STUDY
Zhao Xiang Lin, Anna Perez, Mikhail Volokitin MD, DO
BACKGROUND AND RATIONALE
Pectus excavatum (PE) is a congenital defect that presents with anterior depression of the chest wall which can impact the function of the heart and lungs. Currently, only surgical correction has been shown to significantly improve cardiopulmonary function at rest and during exercise. This study explores a different modality using osteopathic manipulative treatment (OMT) as a possible alternative to improve exercise intolerance and other associated symptoms in a 25-year-old male with PE.
KEYWORDS: Pectus excavatum; osteopathic manipulative treatment; dyspnea on exertion, chest wall compression
REFERENCES
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2. Creswick HA, Stacey MW, Kelly RE, et al. Family study of the inheritance of pectus excavatum. Journal of Pediatric Surgery. 2006;41(10):1699-1703. doi:10.1016/j.jpedsurg.2006.05.071
3. Biavati M, Kozlitina J, Alder AC, et al. Prevalence of pectus excavatum in an adult population-based cohort estimated from radiographic indices of chest wall shape. PLoS One. 2020;15(5):e0232575. doi:10.1371/journal.pone.0232575
4. Lesbo M, Tang M, Nielsen HH, et al. Compromised cardiac function in exercising teenagers with pectus excavatum. Interactive CardioVascular and Thoracic Surgery. 2011;13(4):377-380. doi:10.1510/icvts.2011.267054
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Figure 1. Patient Presentation of Pectus Excavatum
RESULTS
OSE at baseline showed decreased cervical lordosis, flattening of bilaterally inhaled hemidiaphragms, concavity of the sternum from rib 6 to the xiphoid process at midline with right side-bending restrictions, exhalation dysfunction of ribs 1-5 on the left and 12th ribs bilaterally. Structural dysfunctions were addressed through OMT and dysfunctions all improved by Treatment 14. The respiratory rate decreased by over 33% from 18 breaths per minute at Observation 1 to 12 breaths per minute at Treatment 14. The FEV1/FVC ratio has shown no significant changes throughout treatment. The chest wall maximal excursion increased by 4 cm to 5 cm for the diaphragm, and 5 cm to 6 cm for the xiphoid process from Observation 1 to Treatment 14. Notably, the sternal angle improved by 200%, increasing from 2cm to 6cm after complete treatment. The patient reported subjective improvement in dyspnea on exertion, chest wall pain, and cough, with durable improvement in chest wall pain and cough at 10 months after cessation of OMT.
DISCUSSION
Studies have shown that the limitation in physical exercise for PE patients likely stems from a cardiovascular performance issue due to the compression of the anterior chest wall inhibiting cardiac output rather than a decrease in lung capacity. This can be seen by the limited enhancement in pulmonary function testing of the patient during and after OMT, despite improvement of symptoms reported for dyspnea on exertion, chest wall pain, and cough. In contrast, looking at the three-fold increase in sternal angle and considering the anatomic relationship between the sternum and the heart, improvements in symptoms suggest that OMT can reduce anterior chest wall compression and musculoskeletal somatic dysfunction of the thoracic cage.
CONCLUSION
This case study highlights the use of OMT for symptomatic management of PE, like cough, dyspnea, and chest pain. The improvement in symptoms, physical exam findings, and OSE findings in this patient with PE underscores the potential utility of OMT as a potential adjunct therapy alongside surgical correction. Further studies should examine the use of OMT as an early intervention in adolescent patients whose sternums have not yet begun to fuse.
Observation 1
Chest wall pain
SOB on exertion
Cough
Treatment 7
Intermittent chest pain
SOB on exertion
Cough
Treatment 14
No longer present
No longer present
No longer present
10 Month Follow Up
No longer present
Slight SOB on exertion
Slight cough
Figure 2. Patient Reported Symptoms Before and After OMT
CASE DESCRIPTION
A 25-year-old male presents with a history of PE and chronic dyspnea on exertion, chronic cough and intermittent chest wall pain. He reports a history of “weak lungs” as a child, with presentation of PE diagnosed in early adolescence. Patient has never sought out physical therapy or surgery for his PE. In this study, we aim to examine the use of OMT to address somatic dysfunctions of the rib, thorax, and diaphragm to improve management and other PE associated symptoms on the patient.
MATERIALS AND METHODS
Osteopathic structural exam (OSE), volumetric measurements of the thoracic cavity, vitals, and pulmonary function tests with spirometry were evaluated at baseline and before and after OMT. The diameter and width of the chest were measured with a ruler and tape measure to determine the severity of PE. The sternum, rib angle, and degree of rib flare were also measured before and after the use of OMT. The patient was treated with weekly OMT for 14 weeks, including myofascial release, muscle energy, rib raising, and doming of the diaphragm in conjunction with instructed daily stretching and breathing exercises.
Figure 3. Recorded Maximal Excursions Before and After OMT
| Baseline | Treatment 7 | Treatment 14 |
Sternum | concavity of the sternum from rib 6 to the xiphoid process at midline with right side-bending restriction in the frontal plane and vertical axis rotation restricted to the left | concavity of the sternum from rib 6 to the xiphoid process at midline, frontal plane, side bending to the right in the upper half is restricted; vertical axis rotation is restricted on the right, cephalad/caudad motion symmetrical | concavity of the sternum from rib 6 to the xiphoid process at midline |
Ribs | left thoracic cage rotation, exhalation dysfunction of ribs 1-5 on the left and 12th ribs bilaterally | left thoracic cage rotation, low ribs laterally left restricted, inhalation restriction of ribs 2-4 on the left | limited motion of the first rib on the right, inhalation dysfunction of rib 3 on the left, exhalation dysfunction of rib 5 on the right |
Diaphragm | bilaterally inhaled hemidiaphragms | Limited exhalation on the left | None present |
OSTEOPATHIC STRUCTURAL EXAM
Table 1: Observed Osteopathic Structural Exam Before and After OMT