David Drummer, DPT, PRC

Patient Case Study: Shortness of Breath (04/18/2008)

Initial Visit

Subjective:
Patient is a 36-year old female who presents with a primary complaint of shortness of breath. She states she has experienced the S.O.B. sporadically for about three years, though it has recently become more regular. She says she smoked for twenty years, and that she quit about two years ago because of the S.O.B. When she first noticed the breathing problems, she says her first concern was cancer, though tests have shown her to be cancer free. The patient gave birth to her first child seven months ago, and has been suffering postpartum depression for which she has been prescribed Lexapro (antidepressant). She says the S.O.B. is worse when in a seated position and rotated to the right to feed her infant child. Upon questioning, the patient admits to experiencing occasional low back pain and occasional numbness/tingling between the scapulas.

Objective:
Left Right
Adduction Drop Test + -
SLR 70° 90°
FA IR 65° 50°
FA ER 35° 31°
Hruska Adduction Lift Test 3/5 2/5
HG IR 90° 45°
Apical Expansion with Contralateral Opposition Normal Limited
Spirometer Trial #1: 2920cc
Trial #2: 2900cc
Trial #3: 2880cc Normal Range: 2520cc

Assessment:
The patient is in a Left AIC/Right BC pattern…Forward torsion of the left innominate as indicated by: the positive left Adduction Drop Test, the decreased right HG IR, the left rib flair, and the limited right apical expansion with contralateral opposition. Ultimately she does not have a zone of apposition, and therefore is not breathing appropriately with her diaphragm. Patient needs a zone of apposition and improved right apical expansion. We will achieve this by first addressing her pattern which has oriented her sacrum and lumbar spine to the right, for which she is compensating by extending through her back and rotating to the left.

Treatment:
1. Sternal Positional Stretch (3rd Edition CD: Sagittal Anterior Neck Inhibition)
• To assist with opening the (right) chest wall for improved apical expansion

2. 90-90 Hip Shift with Hemibridge and Balloon (2nd Edition CD: Integration – Supine #6)
• We were able to:
o Activate the Left IC adductor
o Activate the Left Hamstring
o Assist with Right Apical Expansion
o Focus on Diaphragmatic Breathing

3. Standing Un-Resisted Wall Reach (2nd Edition CD: Integration – Standing #8)
• Done to help get (left) ribs down, round out the back and promote diaphragmatic breathing

Second Visit (2 1/2 weeks)

Subjective:
Pt reports that her breathing is much improved. She says she only notices the S.O.B. when she is nursing.

Objective:
Left Right
Adduction Drop Test - -
Hruska Adduction Lift Test 4/5 4/5
HG IR 90° 45°

Assessment:
Pt is still in a right BC pattern. She needs improved right apical expansion, and a zone of apposition.

Treatment:
1. Right Sidelying Apical Expansion with Balloon (2nd Edition CD: Integration – Sidelying #21)
• Done to promote right apical expansion and diaphragmatic breathing

2. All Four Intercostal/Lat Inhibition (3rd Edition CD: Frontal Right Intercostal Inhibition)
• To promote right apical expansion

3. MR:
• Left AIC, Superior T4
Note: Following these techniques, right HG IR improved to 60°
• Right Subclavius
Note: Following this technique, right HG IR improved to 90°

Third Visit (4 weeks)

Subjective:
Pt reports that she has not experienced any shortness of breath since her previous session.

Objective:
Left Right
Adduction Drop Test – –
Hruska Adduction Lift Test 4/5 4/5
Hruska Abduction Lift Test 4/5 4/5
HG IR 90° 90°
Apical Expansion with Contralateral Opposition Normal
Normal

Treatment:
The patient was instructed in three new exercises to compliment the progress we have made:

1. Right Sidelying Apical Expansion with Left Arm Reach and Left Adductor (2nd Edition CD: Integration – Sidleying #22)

2. Left Sidelying Thorax Opening with Arched Hemibarrel (3rd Edition CD: Frontal Right Intercostal Inhibition)
• We used 3-4 pillows instead of the hemibarrel

3. Standing Right Intercostal Inhibition in Left AFIR (3rd Edition CD: Frontal Right Intercostal Inhibition)