Case of the Week 7-9-12: Aggravated Rib with RA

The Case of the Week is a former patient previously treated for TMD, and returned with an acute onset of severe rib pain.

Subjective: Pt is a 29 yo female who reports on, she was doing a lot of heavy lifting and carrying boxes and items up and down stairs. The next day, she reported having severe left scapular area pain. She reports it started at 4-5/10 but progressively worsened to 10/10 with accompanying “migraine” HA, pain into the left jaw, and vomiting.  The following day she reported having pain radiating into her L hand. Sx currently rated 8-9/10 upon eval, very sharp as if being stabbed with a knife. Sx worse with deep breathing, lying on her back, and rising from supine to sitting positioning.  Sx better with ice, heat, pain medication, and muscle relaxers. PMH/PSH is significant for osteopenia, raynauds, and RA, crohn's disease,

Objective: fair sitting posture, minimal forward head, very cautious and reluctant to move, tenderness upon palpation around left mid ribs, sternal breathing

ROM
Cervical
flexion DP Mod - Pulling pain at L lower scapula
extension DN Mod
SB Left DP Min Right DN Min
Rot Left DP Mod Right FN

Thoracic
Rotation Left DP Sev Right DN Sev

Shoulder
Flexion Left FN Right FN
Abduction Left FN Right FN
Int Rot Left FN Right FN
Ext Rot Left FN Right FN 

Myofascia: Sev restrictions in left upper cervical/suboccipitals, paraspinals, levator scapula, upper trap, thoracic paraspinals, mid rib bony contours, left > right thoracic paraspinals

Palpation for position: posteriorly rotated left rib 6-7, tenderness to springing P/A


Assessment: Signs and Sx consistent with thoracic/rib dysfunction with cervical dysfunction and cervicogenic HA


Treatment: The first 4 days of Tx were consecutive days, important in acute presentations.


Day 1: light P/A mobs to thoracic spine, light STM to cervical and thoracic paraspinals. Instructed on open book thoracic rotation in sidelying to tolerance. Pt reports 6-7/10 from 10/10 upon leaving. Reviewed cervical retraction and repeated scapula setting to relax upper trap/levator scapula from previous HEP.


Day 2: Sx rated 8/10. Cervical pain and HA abolished, mainly c/o severe left rib pain and pain with breathing. Continued light STM to cervical and thoracic paraspinals, added left upper trap and bony contours of involved left ribs. Light P/A springing was performed to the left ribs. The patient noticed 50% reduction in pain with thoracic rotation but not breathing. Reviewed previous HEP.


Day 3: Sx rated 8/10 in left rib, sharp with breathing. Trunk rotation Left DP, severe Right, DN, mod. Spent 20 minutes on diaphragmatic breathing, which reduced patient's complaints and increased left rotation to mod loss only, still DP. Rib mobilization with movement P/A was performed with the patient in sidelying performing open book stretches into my pisiform and 5th metacarpal. She was concentrating on proper breathing during this time. After several minutes of this, her complaints reduced to 5/10. She stated the sidelying open book exercises were difficult to perform repeatedly throughout the day. This was changed to mid range rotation left in sitting.


Day 4: Sx rated 6/10, no longer sharp with breathing, but still painful. Trunk rotation DP, mod loss, right FN. Cervical ROM FN in all planes. Started with IASTM to involved ribs and thoracic paraspinals left > right. Performed diaphragm and QL release, both of which were very painful. I regressed each technique to light release of the bony contours of the 12th rib anteriorly to latero-posteriorly. She was then able to tolerate diaphragm release and QL release. Upon leaving Sx were rated 2/10.


Day 5: 7 days later, as patient was sick between visits. Overall rated 2-4/10, displays much less apprehension to movement. Trunk rotation left now DN, mild loss, right FN. Reviewed diaphragmatic breathing, which the patient had stopped when she started feeling better. Diaphragm and QL releases were progressed with rotational movement to the left. She rated complaints as 1/10 upon leaving.


The patient returned with main complaints of her ankles having an RA exacerbation. She was referred for a Paleo consultation with a colleague in the hopes that it would help with some of her chronic pain and auto-immune issues. She was educated on continued HEP and will call upon completion of her consultation.


Discussion: Breathing is just as important as postural correction. Instruction on diaphragmatic breathing helped her not only relax, but helped her to self mobilize her ribs and increase thoracic rotation. This was also helped with diaphragm and QL releases. 


A DipMDT told me the McKenzie Institute performed an internal study on outcomes. They noticed improved outcomes for daily visits versus spaced out visits; this was prompted by the faculty noticing they had better outcomes when instructing courses, where the patients came back daily, versus clinically, they may come every other day or more. Seeing an acute presentation daily for the first 3-4 visits really helps with reinforcement of HEP and improves outcomes dramatically in a short period of time. Patients in severe pain do not mind coming in daily for 2-3 visits if they are convinced you can help them.