ORIGINAL ARTICLE Integrated Physical Therapy Intervention for a Person With Pectus Excavatum and Bilateral Shoulder Pain: A Single-Case Study Paul K. Canavan, PhD, PT, Larry Cahalin, MS, PT ABSTRACT. Canavan PK, Cahalin L. Integrated physical therapy intervention for a person with pectus excavatum and bilateral shoulder pain: a single-case study. Arch Phys Med Rehabil 2008;89:2195-204. Objective: To examine the effects of an individualized physical therapy (PT) program for a subject with pectus exca- vatum and bilateral shoulder pain. Design: Single-case study of a man diagnosed with moder- ate-to-severe pectus excavatum and constant bilateral shoulder pain. Exercise tolerance was measured through the Bruce pro- tocol and home exercise log, pulmonary function, ventilatory muscle strength, echocardiography, chest wall and abdominal excursion, self-perception of pectus excavatum, and a variety of anthropometric and volumetric tests before and after PT. Setting: University laboratory. Participant: A 22-year-old man. Intervention: A 3-month PT program including breathing exercises and therapeutic exercises. Main Outcome Measures: Exercise tolerance, ventilatory muscle strength, chest wall and abdominal excursion, self- perception of the pectus excavatum, and other anthropometric and volumetric tests. Results: The most striking anthropometric and volumetric test change was the pectus severity index (in H 2 O), which decreased from 50 to 20mL H 2 O (60% change). The subject reported no shoulder pain at rest and with recreational activity after 8 weeks of intervention. Conclusion: An individualized PT program provided mini- mal-to-moderate improvements on many characteristics of pec- tus excavatum. Bilateral shoulder pain was eliminated. An individualized PT program integrating cardiopulmonary and musculoskeletal interventions that is provided to other patients with pectus excavatum may provide similar results. However, PT provided to younger patients with the pectus excavatum may be of even greater benefit because of a less mature skel- eton. Further investigation of the effects of PT intervention provided to younger and older persons with the pectus exca- vatum is needed. Key Words: Exercise tolerance; Rehabilitation; Shoulder pain. © 2008 by the American Congress of Rehabilitation Medi- cine and the American Academy of Physical Medicine and Rehabilitation P ECTUS EXCAVATUM IS ONE of the most common anomalies of childhood. It occurs in approximately 1 in every 400 births. 1 Pectus excavatum has also been described as funnel chest. Pectus excavatum is a depression of the sternum and the center of the rib cage causing an inward deformity. Pectus excavatum has been associated with true physiologic impairment and reduced exercise capacity, predominately be- cause of impaired cardiovascular performance rather than ven- tilatory limitation. 2 The cardiovascular impairments are pri- marily caused by constrained diastolic filling from the pectus excavatum. The severity of pectus excavatum is often deter- mined with the PSI, which is quotient of the transverse width of the chest by the vertebral-sternal distance. A PSI greater than 4 is indicative of severe pectus excavatum, which may significantly limit filling within the cardiac chambers because of skeletal compression of the pectus excavatum. Idiopathic pectus excavatum may be associated with a vari- ety of lung function abnormalities such as lower airway ob- struction and reduced lung capacities. 3 Symptoms of pectus excavatum have been described to include easy fatigability, dyspnea with mild exertion, pain in the anterior chest, and tachycardia becoming increasingly severe during the adoles- cent years and remaining throughout adult life. 1 However, there has been no evidence of significant worsening of lung function with development from childhood to early adulthood in persons with pectus excavatum (5–19y). 3 Persons with pectus excavatum may also experience deficits with upper-extremity strength and psychologic issues such as self esteem and self-efficacy. It has been previously reported that PT for patients with pectus excavatum without postural impairments is not necessary with the exception of postopera- tive pulmonary care. 4 Many people with pectus excavatum exhibit postural deviations as well as other orthopedic-related complaints such as shoulder pain. Rehabilitation for people with pectus excavatum should incorporate the integration of cardiopulmonary and orthopedic PT because a significant neg- ative correlation between thoracic kyphosis angle and inspira- tory capacity, vital capacity, and lateral expansion of the thorax has been shown to exist. 5 Furthermore, postural positioning can From the Department of Physical Therapy, Northeastern University, Boston, MA. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organi- zation with which the authors are associated. Reprint requests to Paul K. Canavan, PhD, PT, Dept of Physical Therapy, North- eastern University, 6 Robinson Hall, Boston, MA 02115, e-mail: p.canavan@neu. edu. 0003-9993/08/8911-00279$34.00/0 doi:10.1016/j.apmr.2008.04.014 List of Abbreviations FEV 1 forced expiratory volume in 1 second FVC forced vital capacity MEP maximal expiratory pressure MIP maximal inspiratory pressure MMT manual muscle testing PSI pectus severity index PT physical therapy QOL quality of life ROM range of motion RPE rating of perceived exertion VAS visual analog scale 2195 Arch Phys Med Rehabil Vol 89, November 2008