Case Study: Cystic Fibrosis – The Impact on Posture

Cystic Fibrosis is a hereditary disease caused by a faulty gene.  ‘This gene controls the movement of salt and water in and out of your cells, so the lungs and digestive system become clogged with mucus, making it hard to breathe and digest food’.  The symptoms can include poor lung function, repeated chest infections, poor digestion and hence nutrition, bowel problems and CF related diabetes.  In addition there is also a link to low bone density and low muscle mass.  Treatment includes medication, nutrition, exercises and physiotherapy.  The Physiotherapy aspect helps to build up the muscles that act on the lungs to help with clearing the mucus which in turn helps to minimise the lung infections as part of the treatment of the condition.

Patients with CF are also prone to postural issues, pain, osteopenia and osteoporosis.   This may be due to the low lean body mass, CF related diabetes, repeated infection the use of steroids in the treatment of CF or low bone density. Alongside the regular tests that are performed to measure these changes is there anything else that can be done to help delay the onset of pain and postural dysfunctions in CF patients? 

I had a client present to me about 2 months ago who was keen for two things.  One was to help delay the onset of lower back and postural problems as he was aware that this is something that impacts  sufferers of CF and secondly to help improve his mobility and therefore strength for his golf game.  A double challenge!


Can Patients with Cystic Fibrosis Benefit from Sports Massage?

Anyone who has studied Sports & Remedial Massage Therapy will know that some of our techniques e.g. tapotement are really helpful when applied over the thoracic region in helping to break up mucus which aids in the clearing of the chest but is there a way we can help in a more global way?  The muscles of breathing are vital to the mechanics of the body, bad breather, bad body mechanics.  So if a client with CF spends hours and hours in physiotherapy and training to improve the clearance of the lungs what happens to these muscles?  They become stronger and stronger, and as we often discuss in this forum, with strength you also need flexibility to produce power and efficiency.  If the muscles of breathing have become strong but short could they be causing postural imbalance that when coupled with the other risk factors of CF be increasing the risk of pain, stiffness and injury in our clients?  I believe they might.  Not only that but could we also improve the efficiency of the clients clearing by helping to improve the flexibility in these muscles?  I, for one, am very interested to find out.

Over 3-4 blog entries I am going to outline the treatment and findings of my client over a 6 month period so we can see what impact Soft Tissue Therapy has on his day to day life.  In this entry I am going to review the first assessment and treatment from earlier this summer.  The next instalment we will look at the progress after two months.


Highlights of Biomechanical Analysis

• Obvious ‘Sway Back’ Posture in standing position with a posteriorly tilted pelvis with slight rotation from left to right.

• Overly tight Pectorals, Intercostals and Abdominals have led to a weakening of the muscles in the Thoracic Spine Extensors with a lengthening and tautening of the lower back.  Right scapula is also winging.

• Hamstrings have become shortened and tight and the client complains of pain on hamstring stretching.

• My clients Glute Firing Pattern indicates a lack of glute activation and this is also clear on various glute strength tests performed.

For a more complete summary see Appendix A below.

Long Term Treatment Plan

To correct the ‘Sway Back’ posture in order to help delay any degeneration of the lumbar spine and to improve the clients power and quality of movement in the golf swing.  We aim to do this with a combination of soft tissue work and homecare exercise. 

Short Term Treatment Plan

In our first session we agree to focus on improving the flexibility of the breath related muscles that have become shortened and to start corrective work on the ‘Sway Back’ posture.    We work on releasing the Intercostals, Diaphragm, Obliques, Quadtratus Lumborum, Pectoralis Major and Minor, the Scalenes and neck extensors using a variety of soft tissue techniques.  In addition we work on my clients pelvic alignment by lengthening the hamstrings, offloading the psoas major and releasing the abdominal tension.

Homecare

It is vital that if we are to have a long term effect on my clients postural imbalances that he focuses on corrective homecare exercise and postural habits.    Our initial homecare plan consists of the following:

    •  Chest/Pec Stretching
    •  Scapula Setting Strength Exercises
    •  Hamstring Stretching & Foam Rolling
    •  Psoas and Hip Flexor strengthening
    • Glute Proprioceptive Work

My client will return for a second session in 3 weeks time and we aim for treatment to be every 3-4 weeks so we can track postural changes during this treatment plan.

This case has proved to be extremely interesting to me and I hope will be of interest to you as both therapists or as a sufferer of Cystic Fibrosis.

References:

What is Cystic Fibrosis?  http://www.cysticfibrosis.org.uk/about-cf/what-is-cystic-fibrosis

Postural Issues in Cystic Fibrosis: http://www.rbht.nhs.uk/patients/condition/cystic-fibrosis/cf-team/posture-issues-in-cf/

Relationship of skeletal muscle mass, muscle strength and bone mineral density in adults with cystic fibrosis:  http://www.ncbi.nlm.nih.gov/m/pubmed/10995596/

Appendix A: Biomechanical Summary of Client

Neck
• Slight Rotation to the Right and forward of midline by about 1.5 inches.
• Scalenes and SCM visibly strained.
• Cervical Neck Extensors short and tight.
• Cervical Range of Motion (ROM) to be tested in next session.

Shoulders
• Lack of lateral Rotation (right more restricted than left ) both sides due to tight medial rotators in particular tight Pectoralis Major.  Pec Minor Also short and Tight.
• Right Scapula Winging slightly.
• Lack of Scapular control on Right due to weakness in the mid & lower Trapezius, Rhomboids and Serratus anterior.  Serratus Anterior Rib attachments tender to touch on Right side.

Spinal Alignment
• Flattened Lumbar Spine region with a lack of rotation available in this area.
• Flexion through the Thoracic and Etension of the Cervical Spine.  Good Thoracic Rotation.
• On first assessment it looks like a mild ‘Sway Back’ Posture is present.
• Ribs compressed and with reduced mobility indicating tight intercostals.

Hips
• Posteriorly Tilted pelvis, more exaggerated on the Left than on the right.
• On assessment this looks to be caused by tight short and strong abdominals and hamstrings.
• Interestingly your glute firing pattern shows hamstring dominance over glute maximus.
• Weak and tender deep hip flexors (Psoas) and lower back.
• Quadratus Lumborum overly strained, tendons tender to touch.
• Tight Lateral Hip Rotators (Piriformis) right side.
• Test for Glute Strength and Hip Stability to be assessed in the next session.

Knees
• Extension restricted when hip flexed to 90 degrees indicating shortened hamstrings.
• Patella tracking to be tested in the next session.

Arms
• No ROM restrictions in wrists or elbows.

Ankles & Feet
• Good range of motion.  Slight restriction in Dorsi Flexion only.
• Right arch raised, left flattened.

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