Osteopathic treatment following open-heart surgery.

INTRODUCTION

The aim of this report is to describe how osteopathic treatment following open-heart surgery has been applied to treat the chronic musculoskeletal dysfunctions related to it and document the outcomes of a long term management plan of a 24 year old female patient.

There is evidence showing the effects of open-heart surgery on the musculoskeletal system. Although the incidence of persistent pain after sternotomy has reduced compared to the past, the prevalence of postoperative pain after cardiac surgery should not be underestimated (Lahtinen at al. 2006). In fact it has been found to be experienced by 47% to 75% of patients (Chung & Lui, 2003), with the sternum being the most painful area and the thoracic spine the second most reported site of pain (Baumgarten at al. 2009). This case study documents the care and outcomes for a patient who presented for osteopathic care of musculoskeletal symptoms following transverse sternotomy one year before the first consultation with the osteopathic clinic.

HISTORY

Ms Q is an active 24 year old office worker, positive and proactive. She weighs 49 kg and is 1.55 cm tall. Although her desk bound job keeps her sitting at the laptop for eight hours a day, she enjoys light aerobic sessions at the gym on a regular basis. No family responsibilities, no dependents.

Ms Q presented to our clinic complaining of central mid/lower thoracic spine pain, between T7 and T12 segments, described as a constant ache/pulling sensation occasionally spreading up towards the base of the neck and down to her lower back, bilaterally, as a stiff feeling. No neurological symptoms were reported to the upper or lower extremities, although occasional tingling/numbness over the T7/T10 segments were present. Sub-acute onset one year ago after an open-heart surgery via transverse sternotomy, fluctuating since then with a worsening of the symptoms in the past two months. The symptoms that were aggravated by deep breathing, intake of large meals, lying on her back and sitting at desk for long time. Relieving factors are massage and heat. Symptoms worsen as the day progresses with visual analogue scale (VAS) rated 6/10 at the time of the first consultation. The patient was not taking painkillers as able to deal with the symptoms using heat packs and massage therapy. However, as work aggravated, the symptoms were severely affecting her daily activities, preventing her from having a full night sleep without discomfort.

No past history of same presentation of symptoms was reported, although she claimed to be prone to thoracic spine widespread stiffness since a fall down the stairs landing on her sacrum when she was a teenager.

The patient was born with atrial-septal defect, which was only recently diagnosed, 4 years ago, when she started suffering from shortness of breath (SOB) and general fatigue. She underwent an operation in March 2013 which required open-heart surgery as the defect was too severe to treat via percutaneous catheter surgery. The recovery from the intervention was successful and the patient is currently off medication. No further medical treatment was required and the heart function had fully restored according to her last medical check two months before the first consultation with the osteopathic clinic.

PHYSICAL EXAMINATION

The standing examination revealed an increased thoracic kyphosis, associated with posterior shift of the centre of gravity and increased lumbar and cervical lordosis. The scar seemed to have recovered well, although the patient reported the tendency to “round her shoulders and bend slightly forward” by means of an anterior pull sensation, described as particularly evident while standing and eating large meals. The active movements examination revealed a reduction of the range of motion of the thoracic spine in extension between the cervico-thoracic (CT) and thoraco-lumbar (TL) segment and the reinforcement of this direction of motion was reproducing the anterior pull. The thoracic erector spinae muscles and rhomboids appeared hypertonic and tender to palpate. The passive examination confirmed the restriction in extension of the CT and TL junctions and of the thoracic vertebrae, specifically between T8 and T10, with changes in texture and quality of the skin over these segments. The lower ribs appeared to be bilaterally restricted in lateral expansion during inhalation, determining a poor descent of the diaphragm while breathing and revealing a predominant upper breathing pattern. The accessory muscles of respiration, such as sternocleidomastoids and scalenes, appeared hypertonic and fatigued. The diaphragm was found restricted in its excursion and tender to palpate on its attachments on the costal margin. Furthermore deep inhalation triggered the pain to the thoracic spine. The passive assessment of the lumbar spine revealed an increased mobility in extension of L2-L3 segments, which represented a hinge point between the thoracic spine and the lower lumbars, restricted in range of motion too.

WORKING DIAGNOSIS

Considering the clinical findings at the time of the first consultation, the working diagnosis incriminated the presence of a chronic postural fatigue of the thoracic spine with segmental dysfunction of T7-T10 and of CT and TL junctional areas. This was associated with bilateral muscular hypertonicity of thoracic erector spinae and rhomboids, and leading to an altered diaphragmatic function linked to the reduced range of motion of the ribs.

Predisposing factors were found in the open-heart surgery procedure. This had led to musculoskeletal structural alterations, such as sternum and rib fractures, and secondary soft tissue scarring, which might have played a key role in determining the increased kyphosis. The patient’s tendency to hold the thoracic spine into flexion, might have further overloaded the posterior muscular chain and contributed to the diaphragmatic dysfunction. This suggested the presence of an altered respiratory mechanism held in inhalation with a poor diaphragmatic descent and an involvement of the breathing mechanic in the dysfunctional pattern. The picture was maintained by the consequently poor thoracic spine compliance and by a day to day prolonged seated position and computer work.

OSTEOPATHIC MANAGEMENT & OUTCOME MEASUREMENTS

A management plan comprising of short, medium and long term goals, was discussed and agreed with the patient.

Short term: Treatments of structural and functional osteopathy to improve the mobility of thoracic and lumbar spine and reduce the muscular hypertonicity of the surrounding muscles – soft tissue, high velocity thrust (HVT) if anterior thoracic compression was allowed, myofascial release and muscle energy techniques (MET).

Medium term: osteopathic structural treatment focussing on restoring the function of the junctional segments CT and TL. Visceral osteopathy to release the diaphragm and the thoraco-lumbar fascia to aim for an improvement of the breathing mechanics.

Long term: discussion of physical activity/training on the relevant muscular groups and guidance on self management skills.

The patient received her first treatment at the time of the initial consultation. The sessions initially took place once a week with a total of three treatments, then as she improved they were spaced at 2/3-week intervals. The outcome measurement was represented by the VAS, chosen as it was considered reliable and valid (Price et al, 1983; Bijur et al, 2001) and because it represented a constant instrument of measurement during daily practice at the clinic.

Within three weeks from the initial assessment it was possible to progress from the short term to the medium term management plan. During these three first consultations the VAS score diminished from 6/10 to 4/10 and functional osteopathic techniques were used to deal with the initial acute pain (Boyling & Jull, 2004), allowing treatment without triggering extra pain to the sensitive areas. The use of MET was chosen to work on the shortened muscle fibres and on the restricted joints (Fryer, 2010), improving the functionality of the muscles’ contraction along with their lengthening. The positive initial response of the tissues allowed the introduction of manipulative techniques during the second session, which demonstrated a satisfactory effect on the thoracic spine and subsequently on the junctional segments CT and TL, whose role has been shown to be of relevance for a correct thoracic spine function (Walser et al. 2009).

By the third session (3 weeks), visceral techniques of diaphragmatic release were introduced into the treatment plan, focussing on the lower rib attachments via myofascial release and following the phases of the breathing pattern. This helped in achieving a better descent of the diaphragm during inhalation, allowing the lower ribs to move better during this phase. Furthermore the work on the junctional segments CT and TL concurred to the improvement of the thoracic and lumbar spine function, enhancing the adaptability of the body and its coping strategies (Stone, 1999).

This intermediate phase lasted for about four more sessions, bringing the duration of the treatment to 10/11 weeks. By this time the patient reported a further reduction of VAS score down to 2/10 and it was possible to incorporate the long term goals into the treatment plan.

The long term management plan took into consideration the customisation of physical activity and a home exercise program was proposed. This was based on the alternation of breathing exercises to help in the diaphragmatic release and posterior chain stretching postures following the principle of the Mézières Method of postural re-education. These focussed on lengthening and softening the muscular chains, treating the osteo-muscular structures involved in the postural unbalance (Mézières, 1954).

The patient attended a total of ten sessions at the clinic, spread over 16 weeks. By the end of the intervention the VAS was rated 0/10, with occasional presentation of the thoracic spine symptoms if sitting at the desk for more than two days without exercising. This represented a satisfactory outcome and allowed the patient to be discharged as she was able to cope with the occasional symptoms with the home exercise program. Advice and educational guidance were also provided towards an improvement of the patient’s postural awareness and self-management skills.

DISCUSSION

This case emphasised the benefits of combining several different osteopathic approaches on a patient suffering from chronic post-operative pain after open-heart surgery. The incidence of post-sternotomy chronic pain ranges from 18% to 61% (Bruce et al, 2003; Taillefer et al, 2006), with some evidence showing that subjects with moderate to severe acute post-operative pain are more likely to develop a chronic pattern of pain after a year (Lahtinen et al, 2006).

Osteopathy appears to have made a significant difference in improving the patient’s quality of life, contributing to enhancing her body awareness and self-management skills. Furthermore, touch and body work helped in dealing with the patient’s psychological acceptance of the sternal scar, allowing Ms Q to come to terms with her body image (Shaw, 1998).

The treatment of the diaphragm and the work on the breathing pattern represented key elements for the achievement of the outcomes. It has been relevant noticing how the visceral and structural release of these structures positively impacted on the thoracic spine symptoms, also allowing a better mobility of the lower ribs and therefore improving the descent of the diaphragm itself during inhalation (McCool & Tzelepis, 2012).

This element also contributed to resolving the occurrence of symptoms after the intake of large meals, probably connected with a mechanical enlargement of the abdomen resulting in a greater pressure on the lower ribs, the diaphragm and the oesophageal sphincter.

The analysis of this case allowed the author to engage, via a clinical experience, with what is theoretically taught during a typical osteopathic training: the principle which highlights the importance of a dynamic balance between intrinsic and extrinsic forces, potentially leading, if altered, to a challenge of the inherent healing capacity of the body (Rogers et al, 2002). The main extrinsic force being represented by the surgical procedure.

LEARNING POINTS

• This case illustrates that osteopathy can play a role and have beneficial effects on patients after major surgical interventions such as open-heart surgery for the treatment of atrial-septal cardiac disease.

• The integration of different osteopathic approaches such as functional, structural and visceral osteopathy can provide benefits and increase the quality of the outcomes.

• A home exercise program consisting of breathing exercises and stretching postures following the principles of the Mézières Method of postural re-education, is useful when addressing the long term management plan of a patient suffering from chronic postural fatigue.

• The role of the osteopath, via touch and body work, can help in the management of the patient’s psychological status towards the self-acceptance of the body.

• Further research on large samples of population would be needed to determine whether osteopathy is helpful in the management of patients with post-operative musculoskeletal disorders due to sternotomy procedure.