Neck, chest and shoulder difficult case

alison m

Dec 29, 2020
I wonder if you guys can help. I have a really tricky case!

Female 48 year old patient had an implantable cardio defibrillator done in August. No physio referral until December into cardiac rehab where I picked her up. Lots of stress and psychological stuff going on understandably.

Longitudinal scar in anterior lateral chest wall about rib 2 to 4 - very very tight and sensitive. Lateral scar running under left arm around level of ribs 4/5/6 - again very very sensitive and tissues look bunched upwards here.

In sitting, centre of mass is pulled forwards and as we have extremely gradually improved her trunk extension it appears her neck is pulled forwards markedly and all the work going on at the lower cervical spine to extend trunk/head. Very painful. If she tries to extend her trunk and neck, it pulls heavily on her upper back and shoulder girdles and brings tears to the eyes.

Left shoulder:
forward flexion 80 degrees - limited by pain anteriorly (pecs/ant arm) and also pain in left ribs round scar area.
abduction: 80 degrees - same limitations!
Apleys: very very painful either direction, always complains of same pain.
Unable to weightbear through the arm in sitting, standing leaning on a plinth to lateral or front.

Unable to tolerate ANY hands on at the trunk/around the scars. Gets hot and faint (blood pressure is ok) like symptoms of original cardiac issue.

Been trying to do relaxation and helps a bit but any position I put her in she breathes very shallowly upper chest. Cannot tolerate lying down as when sits back up, goes into extremely flexed position. Says this happens every time lies down. Sleeps on right side with lots pillows supporting but still in agony.

She can move the trunk away from the arm on standing to sitting with the hands on a chair with a high plinth front to a point. She couldn't get her hand flat on wall to weightbear through it.

If she puts her hand in her coat she looks pretty comfortable in abducting the arm for this when she does a functional movement.

After watching the upper limb RTP and after some helpful emails from Dave, I am thinking perhaps her scalenes are under a lot of tension and she cannot protract/elevate her ribs. Perhaps working in standing on her neck upper cervical flexion and attempting some long relaxed breaths out, attempting to perhaps breathe in after with some very minor protraction/elevation of the ribs - trying to let go of the scalenes a bit and perhaps breathe out into a scalene stretch (eyes/head rotated down to side)? I'm wondering if I can get her upper trunk/head into more neutral she might be able to tolerate a more "open" chest position and balance her head better, before progressing to upper limb work. Also looking at breathing out and relaxing in the treatment positions.

What do you think? I'd be most grateful. She is getting pretty fed up and I feel limited.

Thanks so much.
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