Exercise & Physiotherapy
For most individuals with Pectus Excavatum, the disorder is completely cosmetic and has no real medical ramifications. The only real issue stems from the sunken sternum, which produces an unappealing appearance to the chest. However, the resulting physiological effects of this can be significant; the physiological effect can be enough to deter many from unveiling their chest and upper body, resulting in such individuals avoiding some social activities such as swimming or going to the beach. Whilst it is possible to fix the problem at its source with surgery, most people are not prepared to take the risks and issues associated with surgery in order to resolve something which is purely cosmetic. As a result, many of those with cosmetic Pectus Excavatum turn to non surgical alternatives. Moreover, many of those seeking non surgical treatment paths turn to exercise an physiotherapy in order to help alleviate their condition.
The underlying principle supporting the use of exercise and physiotherapy is similar to that of many of the non surgical treatment methods. The human skeletal structure is ‘plastic’ by nature in that it can be altered slightly by the strengthening and weakening of muscles. This for instance is one of the main contributing factors in the contraction and treatment of scoliosis (a spinal alignment disorder). Essentially it is possible to target and strengthen muscles in the chest, back and shoulders in order to alter the alignment and appearance of the chest and sternum. There are several core exercises, stretches and massage techniques which can be used to target the necessary muscles. There are copious variations of each of these, and many of these variations can be found in the exercise directory.
When improving your pectus excavatum through exercise it is important to create an exercise program which targets the following:
- 1. To increase the mobility and flexibility of the spine and chest wall.
- 2. To lengthen any tightened and shortened structures.
- 3. To strengthen muscles in elevating and expanding the depressed chest wall.
- 4. To restore normal posture.
The first two areas are to mobilize the articulating joints and to lengthen any tight soft tissue around the chest wall so that less impedance will be encountered during the elevation of depressed chest.
An Example Daily Routine
1. Forward arm stretching in pone kneeling
The patient is positioned in an inclined prone kneeling position with hands stretching forward and supported by wall bar (about 2 to 3 feet high from ground) Slowly lower his upper body and press his scapula (are around underarms) towards the floor. Experience the stretch feeling around the underarm and shoulder. Hold 8 seconds (may get a deep breathe and hold to increasingly stretch the chest wall) and release. Repeat for 20 times and 4 sessions per day.
Purpose: Stretch all anterior chest wall muscles especially pectoralis major (main pec muscles) and extend the upper back.
2. Upper trunk rotation – standing
The patient is to stand side on to a wall. The hand closest to the wall is put on the wall a bit higher than the shoulder level. The patient?s pelvis turns to the opposite side while still leaving the hand fixed on the wall. A stretch is felt at the anterior shoulder and upper chest wall.
Hold 8 second, then release and return to the original position. Take a rest and repeat on the other side. Repeat for 20 cycles and 4 sessions per day.
Purpose: Rotation gives the greatest range of movement for thoracic vertebrae (fancy word for spine) allowing stretch to ligaments, muscles and joints around the chest wall in a different direction.
3. Upper trunk side flexion – sitting
The patient is seated on a chair. Side bend to one side with the opposite hand crossing over the head to another side. A stretching feeling is felt on the other side of trunk. Hold 8 seconds (may get a deep breathe and hold to increasingly stretch the chest wall) and then return to the original position. Take a rest and repeat on the other side. Repeat for 20 times and 4 sessions per day.
Purpose: Similar to the 2nd exercise
1. Weight lifting in stretch supine – lying
The patient is positioned in supine with the upper trunk on a small foam roll around 2 to 3 inches in diameter (if patient can?t tolerate, just lie flat). The arms are put in an upward stretched position. The hands should hold on a fixed wall bar or hardly movable weight about 10 inches from the surface of the bed (pillows may be used to support the weight) . Deeply inspire and exert maximal force in lifting the wall bar or weight. Hold 8 seconds and relax. Repeat 10 times as 1 lot. Take rest then and repeat another 2 lots performing a total of 30 repetitions and 4 sessions per day.
Purpose: By the technique of ?reverse origin and insertion?, the arms are being fixed and the anterior chest wall is lifted up mainly by the pectoralis major and minor. Maximal force exertion allows recruitment of surrounding respiratory muscles for training. The foam roll under the upper to middle part of the trunk exerts postero-anterior force to the thoracic spine helping in extension, which mobilizes and corrects any unnatural bends in the back (poor posture related usually). The depressed chest will also be ?opened? up facilitating the elevation of the chest wall. Arms, being in a mid-length muscle range, are capable to exert the greatest force to elevate the depressed chest. Tone of pectorlis major is built up for better posture and outlook.
2. Upper trunk extension in prone – lying
The patient is positioned in prone lying with one or two pillows under the tummy (avoiding the lower anterior chest pressing on the pillow, area where lungs and heart are keep pillow lower down) . The hands are placed behind the head. The feet may be fixed on wall bar. Deeply inspire and extend the upper trunk with arms arching back. Stay and hold 8 seconds and then relax. Repeat 10 times as 1 lot. Take rest then and repeat another 2 lots. Perform a total of 30 repetitions and 4 sessions per day.
Purpose: The strengthened upper back muscles help to balance the improved muscle force of the anterior chest wall muscle. This prevents the development of Poor back posture due to strong anterior muscle pull and keeps a good posture.
3. Push up
The patient is positioned in prone lying and both hands are used to push up his body. The level of difficulty depends on the actual ability of the patients (1st level ? upper trunk pushed up, 2nd level ? whole body pushed up in one piece, 3rd level ? push and clap both hands in mid air). Start with the 1st level and when the patient is able to finish the level easily, he may proceed to next level). Repeat 10 times as 1 lot. Take rest and then repeat another 2 lots performing a total of 30 repetitions and 4 sessions per day.
Purpose: The exercise aims at general strengthening of the chest wall. Moreover, the high intensity but low frequency impacting force may be advantageous to stimulate remodeling and shaping of the chest wall deformity. Bone mineralization may also be enhanced.
4. Hands up and down movement behind and by the sides of body (with theraband or stretchy rope/velcro)
The patient is positioned sitting or standing with both arms in a stretched position. Each hand holds one end of a the band or a spring (resistance should be set at 10 repetitive maximum, RM, i.e. the resistance that one can perform 10 repetitions but no more). Then stretch the theraband and maintain the elbows straight . Slowly put the hands behind and pass by the sides of body and then down below buttock. After 3 seconds rest, the hands slowly go up and along the same track to the starting position. Repeat 10 times as 1 lot. Take rest and then repeat another 2 lots performing a total 30 repetitions and 4 sessions per day.
Purpose: The exercise is used to strengthen the neck, shoulder, upper back and anterior upper chest muscles. It can be treated as a kind of stabilization exercise to the upper thorax.
There are numerous massage techniques which can be applied to aid in the treatment of Pectus Excavatum. These typically target the back and spine in an attempt to increase flexibility and loosen the muscles to allow for a greater and more natural range of motion, helping to improve posture and the appearance of pectus excavatum.