This was an interesting patient case study. I was wondering if I missed any special questions and what the origin of this patient’s symptoms.
Subjective: The patient is a 61 year old female with a chief complaint of right chest pain of insidious onset a couple years ago. Patient states that her pain encompasses her right ribcage; from her clavicle to 12th rib and sternum to the spinal cord. The patient mentions that the pain is 6/10 and feels as though there is a lot of pressure on her chest and similar to the feeling of someone having punched her. Pt states that at its worst her pain reaches 10/10 and has gone to the emergency room due to the pain. She mentions that the pain has been worsening and fears a flare up of 10/10 which occurred a couple years ago. The patient states that the pain worsens with physical activity such as walking, stair climbing, etc. She states that she feels her breathing increase dramatically, increased perspiration, and a rapid heart rate. She mentions that the symptoms may linger for a couple hours after the onset. She reports right sided cervical pain and a history of migraines, a history of right sided lower back pain and sciatica that started in 1999, and a left sided meniscal repair. She states that there may be a correlation between the chest pain and her cervical pain but does not see a correlation between the chest pain and the LBP/sciatica. The patient had MRI’s completed on the chest, x-rays, and blood work. All tests were negative on abnormal findings. She was referred with the diagnosis of right chest wall pain by a physician and was told by another physician that she has myofascial syndrome by another physician. She mentions that she is on several prescribed medications (about 5-6 types) for pain management, cholesterol, blood pressure, etc. She mentions that she would like to be weaned off of her pain medication and was prescribed another less strong medication and reduced the dosage of the stronger medication. She went through physical therapy in the past and stated that she recalls receiving ultrasound to her chest which reduced her symptoms to manageable levels. She mentions that she had a recent flare up of discomfort around the time of her meniscal repair surgery. The patient lives at home and her three grandchildren are always present (males ages 19, 20, and 21) to help care for her. She works as an accountant and will not be working for the next month due to symptoms.
Objective:
- Observation: Posture – forward head, protracted shoulders, hyperkyphotic upper thoracic spine, and limited lumbar lordosis; Breathing – paradoxical breathing (chest breathing only)
- Palpation: Tenderness at right chest wall (unable to reach R1 upon palpation), cervical paraspinals, right upper trap, thoracic paraspinals, psoas, quadratus lumborum, and diaphragm.
- Joint mobility: Not assessed due to hypersensitivity
- Manual Muscle Test: Not assessed due to hypersensitivity
- Neuro Exam: Not assessed due to hypersensitivity
- Special Tests: BP = 131/82; no audible sounds of pulse in the abdomen, no rebound tenderness
Treatment:
- Soft Tissue Massage: Left side-lying – thoracic paraspinals and right ribcage to R1; Supine – abdomen; all of which caused increases in discomfort
- Deep Breathing: reeducation on breathing with one hand on chest and one on stomach which also became her HEP.
It seems to me that the patient is expressing signs of chronic pain. Her sympathetic is in overdrive and causing her to be hypersensitive. The side-lying soft tissue massage caused tearing of the eyes which is not so much due to pain but more due to her sympathetic system. I plan to calm down her sympathetic system with more breathing reeducation, visualization, abdominal STM, foot rolling on lacrosse ball, and slight stretching. I am concerned that there may be more going on with the patient such as a systemic issue even though she has been to 3-4 physicians for the problem and all medical tests were negative. Are there other areas I should assess or special questions to ask? Or am I on the right path and she is suffering from chronic pain?
FirstAscent Physical Therapy 
Update on the patient’s follow up treatment after her evaluation:
The patient stated that her symptoms had flared up after the evaluation. She mentions that her symptoms took about 2 days to calm down. She was able to work on deep breathing at home and presents with improvement with her ability to complete the task. The patient was treated with soft tissue massage to the abdomen, right iliopsoas, right upper trapezius, right pectoralis major, and right upper extremity. She presented with improvement with deep breathing. Her Ther-Ex consisted of abdominal bracing, single knee to chest stretching, supine scapular retractions, upper trapezius and levator scapulae stretching, and foot rolling on the plantar aspect of her feet. The patient also received a trial of light therapy to the thoracic spine, right ribcage and upper trapezius.
Update #2: Patient was seen for her third visit. She mentions that she had a reduction in symptoms after her last treatment but states that her symptoms became exacerbated later that night while washing the dishes. The patient’s treatment on the third visit consisted of soft tissue massage to the extremities to R1 starting at the distal limbs and progressing to the proximal aspect then soft tissue massage at the right abdominal region to R1 for 1-2 minutes with guided imagery and visualization techniques. The patient states that her symptoms calmed down a bit from manual therapy. She was instructed to complete the same Therapeutic Exercises she has been completing and again treated with light therapy to areas of discomfort. She had mentioned that the light therapy had helped with her discomfort. She presented with improvement with her ability to complete diaphragmatic breathing.
This sounds like a complicated patient case for physical therapy. Few questions, how did you do light therapy with her? Do you think she may need nerve block? obviously PTs cannot do it but everything is on one side.
These are all great questions. We have a laser/light therapy device at the clinic. We completed a number of intervals at her most tender areas and at the thoracic spine. I dont know if a nerve block would be necessary. It wouldn’t correct the problem but more mask it. We were taking an approach to reduce the sympathetic nervous response.