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Physiotherapy Theory and Practice
An International Journal of Physical Therapy
ISSN: (Print) (Online) Journal homepage: www.tandfonline.com/journals/iptp20
A preoperative use of manual therapy in a patient
with idiopathic pulmonary fibrosis awaiting lung
transplant: a case report
Beth Moody Jones, Adam Walsh & Kathy Lee Bishop
To cite this article: Beth Moody Jones, Adam Walsh & Kathy Lee Bishop (26 Apr 2024):
A preoperative use of manual therapy in a patient with idiopathic pulmonary fibrosis
awaiting lung transplant: a case report, Physiotherapy Theory and Practice, DOI:
10.1080/09593985.2024.2343046
To link to this article: https://doi.org/10.1080/09593985.2024.2343046
Published online: 26 Apr 2024.
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CASE REPORT
A preoperative use of manual therapy in a patient with idiopathic pulmonary
brosis awaiting lung transplant: a case report
Beth Moody Jones PT, DPT, EdD
a
, Adam Walsh PT, DPT
a
, and Kathy Lee Bishop PT, DPT, FNAP
b
a
Division of Physical Therapy, Department of Orthopaedics, University of New Mexico, Albuquerque, NM, USA;
b
Division of Physical Therapy,
School of Medicine, Emory University, Atlanta, GA, USA
ABSTRACT
Introduction: This case report describes the outcomes of a patient with idiopathic pulmonary
brosis (IPF) treated with manual therapy (MT) in an outpatient physical therapy setting. IPF is
a life-threatening interstitial lung disease, often requiring lung transplant for prolonged health
related quality of life and survival. There is little literature to support use of MT for IPF.
Clinical Findings: The patient was a 66-year-old male with IPF and on the Organ Procurement and
Transplant Network (OPTN). The patient was dependent on oxygen and referred to physical
therapy with neck pain, shoulder pain, and headaches. Evaluation revealed impairments classied
as thoracic hypomobility paired with upper extremity referred pain, shoulder impairments and
neck pain. Headaches were classied as cervicogenic in nature.
Outcomes: Improved objective measures of cardiovascular function and quality of life pre- and
post- transplant were observed in this patient after 14 treatment visits.
Discussion: The utilization of MT appeared to address the patient’s impairments, improved quality
of life, improved pulmonary function and improved transplant outcomes.
ARTICLE HISTORY
Received 30 September 2023
Revised 15 March 2024
Accepted 8 April 2024
KEYWORDS
Impairment-based
classification; thoracic spine;
physical therapy; pulmonary
function
Introduction
Despite decades of research, idiopathic pulmonary
fibrosis (IPF) remains a therapeutic enigma, the patho-
genesis is unknown, and the prognosis is poor (Hanson,
Winterbauer, Kirtland, and Wu, 1995; Nathan et al.,
2011; Oldham and Noth, 2014; Raghu et al., 2011;
Song et al., 2019). IPF is considered a progressive and
life-threatening interstitial lung disease (ILD) character-
ized by scarring of the lungs and exertional dyspnea
(Raghu et al., 2011). With the exception of a few phar-
macological options, there have been limited recent
changes in the treatment of IPF, with transplant being
the ultimate treatment option (Pleasants and Tighe,
2019). Lung transplantation is considered an accepted
treatment option for patients with chronic end-stage
lung disorders including IPF (Kistler, Nalysnyk,
Rotella, and Esser, 2014).
There are currently no clinical practice guidelines
for rehabilitation in lung transplant candidates and
recipients (Wickerson et al., 2016); however, physical
therapy (PT) has been shown to be an important part
of a pre- and post-operative pulmonary rehabilitation
(PR) program with most chronic lung diseases
(Corhay, Dang, Van Cauwenberge, and Louis, 2014).
Current guidelines recommend aerobic, resistance,
and flexibility training for patients pre and post lung
transplant (Spruit, Janssen, Franssen, and Wouters,
2009; Wickerson et al., 2016). Research on PR benefits
for patients with ILD including IPF, however, is lim-
ited (Dowman, Hill, Holland, and Holland, 2021;
Kenn, Gloeckl, and Behr, 2013; Nolan et al., 2022;
Panchabhai, Abdelrazek, and Bremner, 2019).
Optimal timing and components of PR for IPF are
still unknown and require further elaboration
(Dowman, Hill, Holland, and Holland, 2021; Kenn,
Gloeckl, and Behr, 2013; Panchabhai, Abdelrazek,
and Bremner, 2019; Spruit, Janssen, Franssen, and
Wouters, 2009). Typically, a combination of aerobic
testing, muscle function, and physical activity assess-
ment is used to evaluate exercise capacity and function
in lung transplant candidates and recipients (Spruit,
Janssen, Franssen, and Wouters, 2009). Further devel-
opment of standardized physical function measures
that can predict post-transplant outcomes are neces-
sary (Wickerson et al., 2016). Outcomes used post-
transplant include days on mechanical ventilation,
length of hospital stay, survival, and aerobic exercise
capacity, including six-minute walk distance (6MWD)
and the Upper Limb Exercise Test (Spruit, Janssen,
Franssen, and Wouters, 2009; Wickerson et al., 2016).
CONTACT Beth Moody Jones PT, DPT, EdD bmjones@salud.unm.edu Division of Physical Therapy, University of New Mexico, MSC09 5230, 1 University
of New Mexico, Albuquerque, NM 87131, USA
PHYSIOTHERAPY THEORY AND PRACTICE
https://doi.org/10.1080/09593985.2024.2343046
© 2024 Taylor & Francis Group, LLC
Currently, the American Association of Cardiovascular
and Pulmonary Rehabilitation (AACVPR) does not
include manual therapy (MT) within the definition of
PR (Spruit, Janssen, Franssen, and Wouters, 2009).
However, literature supports that increased mobility of
the thorax can improve pulmonary function, supporting
a possible inclusion of thoracic MT as an addition to PR
(Hwangbo, Hwangbo, Park, and Lee, 2014). Systematic
reviews in 2018 and 2019 of randomized controlled trials
(RCT) utilizing MT with COPD patients demonstrated
low quality of evidence (Galletti, Mcheileh, Hahne, and
Lee, 2018; Simonelli et al., 2019). In a prior review of MT
with patients with COPD, there was no consistency in
either the direction or magnitude of change after inter-
vention across a range of lung function measures
(Heneghan, Adab, Balanos, and Jordan, 2012). Galletti,
Mcheileh, Hahne, and Lee (2018) reported “in people with
COPD, MT (either with or without PR) improved func-
tional exercise capacity, but had no effect on lung func-
tion, or health related quality of life (HRQL).” While PT is
pursued pre and postoperatively for exercise prescription
as part of PR, rarely is PT directed at thoracic mobility
issues that may occur with progressive lung disease
(Florian et al., 2013; Spruit, Janssen, Franssen, and
Wouters, 2009; Wickerson et al., 2016).
Thus, the purpose of this case report is to demon-
strate the management and outcomes of a patient with
IPF who presented to an outpatient PT clinic with initial
reports of neck pain, shoulder pain, and headaches
while awaiting lung transplant. Through utilizing the
impairment-based classification for thoracic spine pain
disorders in the treatment of this patient and using
conventional orthopedic and manual therapy techni-
ques, this report illustrates the secondary improvement
in quality of life, lung function, decreased hospitaliza-
tion, and early recovery following lung transplantation
in this patient (Kenn, Gloeckl, and Behr, 2013).
Informed consent to report this case was obtained and
the rights of subjects were protected.
Case description
The patient was a 66-year-old adult male, dependent on
oxygen with IPF and secondary neck and shoulder pain
and cervicogenic headaches (Headache Classification
Committee of the International Headache Society
[IHS], 2018). He reported being diagnosed with IPF
approximately one year prior to this PT evaluation and
was listed on the Organ Procurement and Transplant
Network (OPTN) wait list for a single lung transplant.
A complete medical timeline can be seen in Figure 1.
The patient’s primary goal for PT was to be able to
function with less pain and decreased headaches to
allow improved function in concentration, sleeping,
recreation and self-care. The patient reported an unre-
markable medical history up until this recent diagnosis
Figure 1. Patient reported medical history timeline. B: Bilaterally; CXR: Chest Roentgenogram; CT: Computerized Topography; D/C –
Discharge/Discontinue; DLCO: Diffusing Capacity of Lungs for Carbon Monoxide; ECG: Electrocardiogram; FEV1: Forced Expiration Volume in
1 Second; FVC: Forced Vital Capacity; IPF: Idiopathic Pulmonary Fibrosis; L: Left; LL: Left Lobe; MW: Minute Walk (Distance Walked % of
Expected 6MW Distance calculated on age/gender/height - https://www.mdcalc.com/calc/3983/6-minute-walk-distance); O2: Oxygen; PFT:
Pulmonary Function Test; PNA: Pneumonia; POD: Post-Operative Day; PRP: Pulmonary Rehabilitation Program; PT: Physical Therapy; R: Right;
RML: Right Middle Lobe; R/O: Rule Out; VAT: Video Assisted Thoracotomy; S/S: Signs & Symptoms; UIP: Usual Interstitial Pneumonia.
2B. MOODY JONES ET AL.
of IPF. He enjoyed playing golf for recreation, however,
he had greater difficulty recently due to his neck and
shoulder pain.
Examination
The patient reported “shooting pain and tingling into
the left upper extremity and constant neck pain” (2016
patient interview with BM Jones; unreferenced). These
symptoms worsened with left shoulder movement and
occured regardless of activity level. His pain originally
started insidiously six months prior in the region of the
cervicothoracic (CT) junction, gradually peripheralizing
to the left (L) shoulder.
The treating physical therapist completed all standard
sections of an outpatient orthopedic evaluation and con-
sidered differential diagnoses to confirm the patient’s
impairments were of a musculoskeletal origin. The iden-
tified patient impairments included: limited active range
of motion in the left shoulder, restricted passive mobility
of the left glenohumeral joint (GHJ), decreased lower
rib excursion with diaphragmatic breathing with
a compensatory breathing pattern using accessory mus-
cles assessed via manual palpation and incentive spirom-
eter, poor posture (head forward and rounded
shoulders), reproduction of headache symptoms with
suboccipital musculature palpation, and structural
impairments of the ribs linked to the CT junction.
A list of full evaluation findings can be found in Table 1.
Diagnosis
The patient was classified into a clinical framework using
the classification method described by Olson (2015). The
patient was classified into three out of the six impairment
levels: (1) thoracic hypomobility with upper extremity
referred pain, (2) thoracic hypomobility with shoulder
impairments, and (3) thoracic hypomobility with neck
pain. The headache was classified as cervicogenic accord-
ing to the International Health Society Headache
Classification schema (2018). Clinical reasoning ruled
out the differential diagnoses of radiculopathy, sub-
acromial pain syndrome (SPS) and adhesive capsulitis
(Table 1). Radiculopathy and SPS were ruled out due to
negative clinical prediction rules (Park et al., 2005;
Waldrop, 2006). Adhesive capsulitis was ruled out due
to the lack of a capsular pattern and inconsistent capsular
limitations (Manske and Magee, 2021).
Intervention
The primary problems addressed by the physical
therapist included: (1) difficulty breathing due to
IPF causing increased use of accessory respiratory
muscles leading to chronic CT junction pain, (2)
decreased function in bilateral upper extremities,
and (3) headaches. These primary problems
restricted the patient’s participation in his recrea-
tional activities. Long term goals included: (1)
improve diaphragmatic breathing pattern to reduce
excessive use of accessory respiratory muscles, (2)
improve posture and alignment in the upper thoracic
region to reduce neurodynamic restrictions and pain,
and (3) improve function.
Initial interventions included patient education
focused on anatomy, proper body mechanics and pos-
ture, and diaphragmatic breathing without compensa-
tory accessory motion. Treatment included manual
therapy and therapeutic exercise for encouraging thor-
acic mobility and improved diaphragmatic excursion, as
well as headache reduction. Aerobic activity and other
general conditioning exercises were already a part of his
normal fitness routine and completed independently
outside of the therapy sessions. A thorough scope of
findings and treatment for each visit can be found in
Appendix A.
The manual therapy techniques to the spine and rib
cage consisted of thoracic thrust and non-thrust manip-
ulation, CT junction thrust and non-thrust manipula-
tion, rib mobilization, muscle energy techniques to the
cervical spine and soft tissue release, including the sub-
occipital cervical and thoracic regions. GHJ mobiliza-
tion were specifically focused on inferior glide and gen-
eral stretching for shoulder internal rotation (IR) and
elevation. Neural mobilization was directed at the med-
ian and radial nerves.
MT is considered a safe and useful treatment, with
the most common benign adverse effects of MT direc-
ted at the spine being a temporary increase in discom-
fort, stiffness, or headache (Swait and Finch, 2017). MT
has been shown to be safe and effective in those with
chronic lung disease (Clarke, Munro, and Lee, 2019)
and have no additional adverse effects or increased risk
of adverse effects compared to a healthy population
(Roh, Kim, Jung, and Wieland, 2021; Swait and Finch,
2017). With no conclusive predictive factors estab-
lished for patients who are at increased risk of an
adverse effect to MT (Paanalahti et al., 2014; Swait
and Finch, 2017; Walker et al., 2013), the utilization
of MT in this patient, even in light of the presenting
comorbidities, was considered to be a safe treatment
intervention.
The patient’s outpatient PT frequency ranged from
0 to 1 ×/week across a span of 37 weeks totaling 14
visits until discharge from PT prior to a lung transplant
PHYSIOTHERAPY THEORY AND PRACTICE 3
surgery. See Appendix A for a complete timeline of
treatment sessions throughout the plan of care. The
patient demonstrated increased oxygen saturation
(SpO
2
) after most PT treatments while maintaining
the same amount of supplemental oxygen throughout
the span of PT treatment. The patient’s SpO
2
was
recorded and is illustrated in Figure 1.
Two months prior to receiving a lung transplant the
patient relocated states and was discharged from PT.
Outcomes/results
The following goals were successfully achieved: (1)
improved diaphragmatic breathing pattern to reduce
excessive use of accessory respiratory muscles (2)
improved posture and alignment in the upper thoracic
region to reduce neural tension (3) decreased pain (4)
decreased headaches and (5) increased function. The
standard outcome measure used in this outpatient
rehabilitation facility was CAREConnections
TM
,
Table 1. Patient evaluation.
Comorbidities IPF, HTN, history of GERD, pre-diabetes, CAD, neuropathy, R parotidectomy, H/O infected gall bladder, AF,
polypoid adenoma, Indirect hyperbilirubinemia likely related to Gilberts disease, blood clot L hand and
R forearm, BMS LCA 80% blockage; H/O whiplash 30 years prior
Labs Lung biopsy year 2, See Figure 1 for PFT results
Medications Gabapentin, Tylenol with codeine 3, Benzonatate, Omeprazole, Cozaar
Social History H/O tobacco use, quit 30 years ago, lives with his wife
Prior Level of Function Active golfer who enjoyed working on cars, racing, hiking, traveling
Reason for visit Neck and shoulder pain – insidious onset. See pain chart for location. His pain makes it difficult to fall asleep
and he awakens with pain. Pain is worse with movement. He describes pain as shooting pain at cervical
thoracic junction that sends tingling pain into left upper extremity. His neck hurts constantly with
intermittent issues in shoulder and UE.
Objective findings ●Posture: Forward head with elevated 1st and 2nd ribs on R.
●Functional deficits: Limitations in personal care, sleeping, concentration and presence of headaches
(see Table 2). Continues to play golf even with pain.
●ROM: Shoulder elevation in sitting R 140°, L 125°. Shoulder IR in supine R 40°, L 10° with pain.
Shoulder B – ER > 90°. Restricted inferior glide in L GH joint. Cervical ROM WFL.
●Strength: Strong and pain-free throughout BUE.
●Neurological: Bilateral positive ULNT median. No changes in reflexes, sensation, or strength. Spurling’s
test is negative.
●Palpation: Pain in left serratus posterior superior region. Pain and increased tone in right scalene
muscles.
●Special tests: Speeds test is negative. Empty can test is positive on the L.
●Spinal mobility: Bilateral stiffness at CT junction and throughout T1-T6 levels. Generalized stiffness
noted in entire thoracic cage including rib mobility.
●Diaphragmatic breathing: Unable to get a good deep diaphragmatic breath using the incentive
spirometer or with manual resistance.
Clinical Reasoning/ Differential diagnosis ●Cervical spine is clear for radiculopathy: no neurological signs and negative CPR.
●Neurodynamic changes could be due to changes in posture from declining pulmonary function and
shoulder pain.
●Negative SPS CPR. Positive empty can test appears to be false positive.
●GH issues appear to be capsular in nature and responded well to joint mobilizations and exercises.
●Declining pulmonary function could explain increased tone of accessory respiratory muscles and
stiffness at cervical thoracic junction and thoracic cavity.
Problems (1) Difficulty breathing due to pulmonary fibrosis causing increased use of accessory muscles possibly
leading to chronic CT junction pain and stiffness and thoracic cage stiffness.
(2) Decreased function in bilateral upper extremities with possible GH joint capsular restriction.
(3) Neurodynamic tension bilaterally.
(4) Hypomobility of thoracic cage and spine.
(5) Decreased function (see Table 2).
Goals (1) Improve diaphragmatic breathing to allow improved expansion of thoracic cavity, better profusion,
decreased overutilization of accessory muscles.
(2) Improve posture and alignment of cervical – thoracic spine to improve function of upper extremities.
(3) Improve neural dynamic mobility.
(4) Return to normal pain free golf.
(Continued)
4B. MOODY JONES ET AL.
which measures subjective functional ability of the
cervical/thoracic region and is reported in Table 2.
CAREConnections
TM
has a similar MCID (7) to the
neck disability index (NDI) (Hoekstra, Deppeler, and
Rutt, 2014). A visual analog scale (VAS), as a part of
CAREConnections
TM
was used to record pain changes
and goniometric measurements were used to assess
range of motion changes. The outcomes over the
treatment period are illustrated in Appendix A. The
patient also achieved his goal of playing symptom free
golf until required to stop one month before his
transplant.
Table 1. (Continued).
Initial Treatment
(see Appendix A for detailed description of
other treatment sessions)
(1) Patient education and manual instruction in diaphragmatic breathing while utilizing incentive
spirometer for biofeedback.
(2) Manual therapy for the following:
a. GHJ inferior glide.
b. Soft tissue releases to scalene muscle, serratus posterior superior, cervical and thoracic extensor
musculature.
c. Neural dynamic mobilization for median nerve.
d. Rib non-thrust manipulations with breathing.
e. Prone CT thrust manipulation technique.
f. Prone P/A non-thrust manipulation throughout thoracic spine grade 3.
g. Supine thoracic thrust manipulation to upper thoracic spine from T2-T6.
(3) Home exercise program
a. Side lying “bow and arrow” for thoracic rotation 5 repetitions bilaterally, twice daily.
b. Side lying GHJ circumduction with thoracic rotation on L 5 repetitions twice daily.
c. Diaphragmatic deep breathing utilizing manual biofeedback along with incentive spirometer
feedback 5 times a day for 5 repetitions.
d. Use of foam roller perpendicular to thoracic spine for thoracic extension, twice daily for
3–5 repetitions up and down thoracic spine.
e. Use of foam roller for pectoralis opening lying parallel on the foam roller, twice daily for
3–5 minutes or as tolerated.
f. Ipsilateral cervical rotation with shoulder ER followed by reciprocal motion on the contralateral
side, “Egyptian,” 5 repetitions twice a day.
AF: atrial fibrillation; B: bilaterally; BMS: bare metal stent; CAD: coronary artery disease; CPR: clinical prediction rule: CT cervical thoracic; ER: external rotation;
GERD: gastrointestinal reflux disease; GH: glenohumeral; GHJ: glenohumeral joint; H/O: history of; HTN: hypertension; IPF: idiopathic pulmonary fibrosis; IR:
internal rotation; L: left; L: lumbar; LCA left coronary artery; P/A: posterior/anterior; PFT: pulmonary function tests; R: Right; ROM: range of motion; SAPS: sub-
acromial pain syndrome T: thoracic; UE: upper extremity.
Table 2. CARE connections cervical/thoracic form.
FUNCTIONAL INDEX
Choose one answer in each section that
best describes your condition. 6 items in
each category
graded 0–5, 5 = full function Initial evaluation
Interim
4 months post initial evaluation
Discharge
7 months post initial
evaluation
Walking 5 – “symptoms do not prevent me
walking any distance”
5 5
Work 5 – “I can do as much work as I want
to”
5 5
Personal care 4 – “I can manage all personal care
with some increased symptoms”
5 4 – “I can manage all
personal care with some
increased symptoms”
Sleeping 3 – “My sleep is disturbed (1–2 hours
sleepless)”
3 – “My sleep is disturbed (1–2 hours
sleepless)”
5 – “I have no trouble
sleeping”
Recreation/sports 5 – “I am able to engage in all my
recreational/sports activities without
increased symptoms”
4 – “I am able to engage in all my
recreational/sports activities with
some increased symptoms”
5
Concentration 4 – “I can concentrate fully when I want
to with slight difficulty”
5 – “I can concentrate fully when I want
to with no difficulty”
5
Headaches 2 – “I have moderate headaches which
come frequently”
4 – “I have slight headaches which come
less than 3 per week”
5
Reading 5 – “I can read as much as I want
without increased symptoms”
5 5
Driving 5 – “I can drive my car or travel without
any extra symptoms”
5 5
Lifting 5 – “I can lift heavy weights without
extra symptoms”
4 – “I can lift heavy weights, but it gives
me symptoms”
5
Total Up to 50 points
x 2 = % Function
43 × 2 = 86% 45 × 2 = 90% 49 × 2 = 98%
VAS (10 cm) 4 1.9 0
%: percent; VAS: visual analog scale.
PHYSIOTHERAPY THEORY AND PRACTICE 5
The patient received pulmonary function tests (PFT)
throughout his care leading up to the lung transplant and
after the surgery. The patient’s outcomes of forced vital
capacity (FVC) and diffusing capacity of carbon monox-
ide (D
LCO
) are illustrated in Figure 2. The patient’s FVC
had been steadily declining over the ten months prior to
this PT intervention going from 59% to 46% as seen in
Figure 3. The patients FVC at time of initiation of this
therapy was 46%. His FVC measured at the time of dis-
charge had stabilized and improved to 50%. The minimal
clinically important difference of FVC in a population
with IPF is between 2% and 6%, making the patient’s
FVC improvement of 4% in a gray area of being clinically
meaningful (du Bois et al., 2011). Taking into considera-
tion a 13% decline in the 10 months prior to initiation of
therapy, the authors suggest that the improvement of 4%
in FVC over the course of treatment is clinically
meaningful.
Hospital admission for the lung transplant and
events during admission are according to patient report.
The patient was in the Intensive Care Unit post-
operative day one (POD1) and by POD2 the patient
was off mechanical ventilation and out of bed. The
patient reported ambulation on POD3 and was trans-
ported to a Progressive Coronary Care Unit on POD4.
The patient’s supplemental oxygen use was discontin-
ued at rest on POD7. The patient was discharged home
on POD10. His total hospital length of stay (LOS) was
ten days status post a single lung transplant, nearly
2.5× shorter than average (Florian et al., 2013).
Patient perspective
The patient continued to participate in golfing much
longer than expected pre-transplant. Approximately half-
way through PT treatment, the patient reported improved
pulmonary function with both lung capacity and
perfusion, crediting the improvements to the
outpatient PT treatment. The patient described
a conversation he had with his surgeon during a pre-
operative appointment. He informed his surgeon of his
outpatient PT treatment and reported his surgeon “was
pleased with the mobility in his chest.” The patient
reported that “after the transplant, many people would
feel as though they could breathe better, however, their
lung was too big for their chest” (2016 patient interview
with BM Jones; unreferenced). This patient stated he
never felt that his lungs were too big for his chest. The
patient stated he felt he “was well prepared for the lung
transplantation and recovered well” (2016 patient inter-
view with BM Jones; unreferenced). He also reported that
his surgeon was significantly impressed with his ease of
recovery and was curious about the manual therapy he
had received.
Discussion
This case report reflects the intervention of MT aimed to
improve thoracic hypomobility in a patient with IPF.
While PT has been shown to be an important part of
a pre- and post-operative PR program with most chronic
lung diseases (Corhay, Dang, Van Cauwenberge, and
Louis, 2014) there is limited evidence of the utilization
of MT in patients with IPF. Using a classification method
of practice, the therapist categorized this patient with
cervicogenic headaches and the primary glenohumeral
and cervical complaints into an impairment classification
of thoracic hypomobility with upper extremity referred
pain, shoulder impairments and neck pain; all while
considering the co-morbidity of the underlying cardio-
pulmonary disease process.
The proposed mechanism in which MT provided the
patient with symptomatic relief and objective
75%
80%
85%
90%
95%
100%
5 6 7 8 9 10 11 12
SpO2
Visit number
Patient SpO2Before & After Physical Therapy
Intervention
Before After
Figure 2. Patient SpO
2
before and after physical therapy intervention.
6B. MOODY JONES ET AL.
improvement is multifactorial. The classical theory of MT
improving joint mobility via a mechanical response to
intervention has merit, as numerous studies have shown
increases in joint mobility (Beneck, Kulig, Landel, and
Powers, 2005; Cramer et al., 2012) and a positive influence
on chest wall compliance (Wall, Peiffer, Losco, and Hebert,
2016) after MT to the spine. While this increase in mobility
plays an important factor in patient outcomes, central and
peripheral neurophysiological mediated mechanisms also
play a large role in patient outcomes post MT intervention.
MT has been shown to decrease inflammatory biomarkers,
increase markers of cellular repair, inhibit nociceptive
transmission in the spinal cord, and enhance muscle
activation (Crane et al., 2012; Dishman, Burke, and
Dougherty, 2018; Kingston, Claydon, and Tumilty, 2014;
Lohman et al., 2019; Muth, Barbe, Lauer, and McClure,
2012; Teodorczyk-Injeyan, McGregor, Triano, and
Injeyan, 2018). It is impossible to attribute a percentage
of patient improvement to mobility improvements versus
the neurophysiological effects of MT. Any MT interven-
tion will result in both proposed mechanisms of improve-
ment in patient outcomes, thus the importance of the
specific mechanism of how MT improves patient out-
comes is minimal. Specific to this patient, the improve-
ment in joint mobility through the thoracic spine and
ribcage after MT treatment likely increased the compliance
of his thoracic cavity, thus decreasing subjective symptoms
and increasing objective findings such as FVC.
Therapeutic exercises prescribed to this patient were to
reinforce the improvements MT provided and likely con-
tributed to the patient’s successful outcome.
Decreased survival or predicted mortality in IPF is
associated with decline of FVC by 5–10% (Florian
et al., 2013). According to Song et al. (2019),
the percent predicted D
LCO
and FVC are key inde-
pendent prognostic indicators of IPF. In this case
report, stabilization and improvement of FVC, lack
of decline in the D
LCO
, decreased pain, improved
mobility, and increased ability to participate in golf
were all observed in this patient prior to his lung
transplant. According to Florian et al. (2013), when
looking at the effects of PR on survival rate post-
transplant the average days in hospital for IPF lung
transplant patients who underwent PR prior to trans-
plant was 23 (19–33) days with the average ICU stay
being 6 (4.5–13) days. His ICU and hospital LOS were
significantly lower than average for a single transplant
in those with IPF who had participated in PR (Florian
et al., 2013).
The following are potential limitations of this retro-
spective case report. This is a single case report of
a patient with IPF responding to orthopedic MT.
Measurements and outcomes relied on the availability
and accuracy of medical records and patient self-
reporting. Finally, improvements in lung transplant out-
comes may have been due to multiple factors including,
but not limited to, pulmonary rehabilitation and medi-
cations that were not fully described here. In this case,
the addition of MT to the patient’s treatment program
seems to have influenced the patient outcomes, though
no causation can be concluded from a singular case
report. Further research is warranted to establish a link
between MT and outcomes, including FVC, in those
with IPF.
The purpose of this case report was to describe the
successful treatment of an individual with IPF utilizing
a manual therapy approach. While the utilization of
manual therapy for neck and shoulder pain has been
40%
50%
60%
70%
80%
30 26 23 22 20 19 15 13 *9 6 1 2 3 8
Predicted Percent Value
Months Pre/Post Lung Transplant
Patient Pulmonary Function Tests FVC DLCO
Figure 3. Pulmonary function tests. FVC: Forced Vital Capacity (Liters) % Predicted; D
LCO:
Diffusing Capacity of Carbon Monoxide
(ml/min/mmHg) % Predicted; *: Recommended Lung Transplant; - - -: Received Single Lung Transplant; □: Received Outpatient
Physical Therapy.
PHYSIOTHERAPY THEORY AND PRACTICE 7
well established, there is no literature, to the authors’
knowledge, on the utilization of manual therapy for pre-
operative care in individuals with IPF or results of pre-
operative manual therapy on post-operative lung trans-
plant outcomes (Chaibi, Stavem, and Russell, 2021;
Hidalgo et al., 2017; Miller et al., 2010) This case report
suggests that MT as an aspect of physical therapy care
improved outcomes and function post-transplant for
this patient with IPF.
Physical therapists often serve as the entry point in the
health care system for evaluation and treatment (Bernard
Becker Medical Library Digital Collection, 2009). A patient
with a cardiopulmonary diagnosis, such as IPF, is rarely
referred to an outpatient orthopedic PT practice for
shoulder or neck pain. This case is an example of the
potential benefits of a merger of specialty of practice; that
of manual orthopedic PT and cardiopulmonary PT.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Funding
The author(s) reported there is no funding associated with the
work featured in this article.
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PHYSIOTHERAPY THEORY AND PRACTICE 9
Appendix A. Individual Treatment Sessions
Treatment
session
Treatment week (months
prior to surgery) Subjective Assessment Treatment Outcomes
1 2 (9) Using oxygen daily now. Neck felt better after
initial treatment for 2 days. UE felt better for
one day. No pain in UE unless he tries to
induce it.
●ROM GHJ L IR; 10 degrees
●Tightness in pectoralis minor L
●Continued stiffness in thoracic
spine.
●Neural tension test positive for
median and radial nerves.
●Reviewed goals with spirometer.
●GHJ inferior glide.
●Thrust manipulation to upper thor-
acic spine.
●Non-thrust mobilization to entire
thoracic spine and ribs.
●Soft tissue manipulation to posterior
CT junction and L pectoralis minor.
●Neural dynamic flossing to median
nerve and radial nerves.
ROM GHJ L IR: 45 degrees without
pain. Decreased pain in thorax.
2 4 (8.5) Pulmonary function test 6 days ago was poor.
Will now be on call for transplant with team
out of state. Has been told if he does not get
the transplant, he has only 2 years to live.
Feels 80–90% better in his shoulder. Neck still
hurts all the time but overall 80% better. Not
needing as much ibuprofen for pain.
●Able to reach behind his back
with his L UE now.
●Restricted elevation of rib 6
B with inspiration.
●Stiffness in thoracic cage and
spine continues.
●Neural tension test positive for
median and radial nerves.
●GHJ inferior glide.
●Thrust manipulation to upper thor-
acic spine.
●Non-thrust mobilization to entire
thoracic spine and ribs.
●Rib mobilization with breathing to
rib 6 B prone.
●Soft tissue manipulation to posterior
CT junction.
●Neural dynamic flossing to median
and radial nerves.
Improving function and decreasing
pain. Rib 6 moving with breathing
and less pain with mobilization of
thoracic cage.
3 5 (8.25) Shoulder is feeling better, he went out to hit golf
balls. Had some dizziness with this activity
but no pain.
●Improved mobility in thoracic
spine and in the ribs.
●SpO2 was only 88% at start of
visit but patient wanted to con-
tinue because he felt that PT
helped his breathing.
●UE is doing well with increased
function in ADLs.
●Reassess neural dynamics with
no restriction upon
reassessment.
●Thrust manipulation to upper thor-
acic spine in supine with cavitation.
●Non-thrust mobilization to entire
thoracic spine and ribs.
●Soft tissue manipulation to posterior
CT junction.
Feels like he can breathe better.
Treatment to thoracic cage may be
improving his oxygenation and
ability to breath. PT will start to
monitor SpO2 before and after each
visit.
4 6 (8) Feeling pretty good. No complaints. ●SpO2 before treatment 93%.
●Reassess neural dynamics with
no restriction upon
reassessment.
●Thrust manipulation to upper thor-
acic spine.
●Non-thrust mobilization to entire
thoracic spine and ribs.
●Soft tissue manipulation to posterior
CT junction.
SpO2 97% after therapy.
Able to reach with L UE to upper
lumbar region now without pain
(Continued)
10 B. MOODY JONES ET AL.
Treatment
session
Treatment week (months
prior to surgery)
Subjective Assessment Treatment Outcomes
5 13 (7) Will be having another pulmonary test to see if
he is a candidate for transplant. Having some
neck pain again. Asked for strengthening
exercises to rotator cuff.
●SpO2 before treatment 89%. As
he reclined for treatment it
dropped to 84% and patient put
on O2 at 3 L. SpO2 then leveled
off at 92% and treatment was
continued.
●Increased stiffness was noted at
T2-T4.
●Reassess neural dynamics with
no restriction upon
reassessment.
●Thrust manipulation to upper thor-
acic spine.
●Non-thrust mobilization to entire
thoracic spine and ribs.
●Soft tissue manipulation to posterior
CT junction.
●GHJ L grade II inferior glide.
●Added side lying ER in 90–90 for ER
to HEP with 2-pound dumbbell.
SpO2 92% after therapy. Improved
mobility in spine and decreased
pain in shoulder and CT junction
after treatment.
6 14 (6.5) Having a cardiac catheterization tomorrow.
Began new medication – pirfinadone 3×
a day. Continues with HEP daily as he is able.
●SpO2 82% Wants to continue
PT. Pulmonary team aware of
decline.
●Still with radial nerve ULTT but
median nerve is improved.
●GHJ joint inferior glide limited.
●Thrust manipulation to upper thor-
acic spine.
●Non-thrust mobilization to entire
thoracic spine and ribs.
●Soft tissue manipulation to posterior
CT junction.
●GHJ inferior glide
●Neural dynamic flossing to radial
nerve.
SpO2 92% after therapy.
Continues to feel like he can
breathe better after treatment.
7 15 (6.25) Feeling so much better. Feeling “great.” Cardiac
catheterization was last week and all went
well.
Awaiting transplant.
●SpO2 before treatment 98%.
●No pain in shoulder with
motion.
●Has reached 2000 level on his
incentive spirometer.
●Able to deep breath with infer-
ior ribs movement.
●Mild tightness in B scalene
muscles.
●L GHJ elevation to 159 degrees.
●Tightness in L pectoralis major
and teres major muscles.
●Tissue release to pectoralis major
and teres major in supine.
●Non-thrust mobilization to entire
thoracic spine and ribs.
●Soft tissue manipulation to posterior
CT junction and scalenes.
SpO2 97% after therapy.
Able to elevate shoulder and have full
SHJ ER without pain.
8 19 (5.25) Has been doing well and did not feel the need to
come in. Pain in L shoulder continues
occasionally. Meeting the transplant team in
a few weeks. Still playing golf. Using 2 L of
oxygen daily. Lifted the garage door open
and it took 5 minutes to recover. Had
a pulmonary function test and his lung
capacity and profusion was improved. Patient
credits PT with this change. He no longer has
any nerve pain. His golf game has improved
with more ROM with his swing.
●SpO2 95%.
●L GHJ elevation 155, IR 25.
●Mild decreased inferior glide.
●Improved mobility of ribs with
breathing.
●Rib 5 B is lacking movement and
elevation with inspiration.
●Reassess neural dynamics with
no restriction upon
reassessment.
●GHJ inferior glide
●Thrust manipulation to upper thor-
acic spine.
●Non-thrust mobilization to entire
thoracic spine and ribs.
●Soft tissue manipulation to posterior
CT junction.
●Rib mobilization with breathing to
rib 5 B prone.
SpO2 96% after treatment.
GHJ IR 45 degrees.
(Continued)
PHYSIOTHERAPY THEORY AND PRACTICE 11
Treatment
session
Treatment week (months
prior to surgery)
Subjective Assessment Treatment Outcomes
9 23 (4.5) Went to transplant team and was presented for
lung transplant. Surgeon in transplant
hospital is “pleased” with his mobility in his
chest was. Patient is feeling good, and is
playing golf. Continues to have pain with GHJ
IR while reaching behind his back.
●SpO2 94% with 2 L oxygen.
●Stiff, elevated and restricted 1st
and 2nd ribs B and throughout
T2-T5.
●Pain 1.9 on VAS.
●CAREConnections
TM
90%
●Reassess neural dynamics with
no restriction upon
reassessment.
●GHJ inferior glide.
●Thrust manipulation to upper thor-
acic spine.
●Non-thrust mobilization to entire
thoracic spine and ribs.
●Soft tissue manipulation to posterior
CT junction.
●Non-thrust mobilization with
breathing to rib 1 and rib 2 B supine.
SpO
2
96% after treatment.
CAREconnections
TM
:
improved 4%- improved
concentration and headaches.
Reports some decreased ability to
lift heavy weights and golf.
10 26 (4) Feeling 80% better. Shoulder is only painful at
end ranges now. Continues to have CT
junction stiffness. Still able to hit 2000 on the
incentive spirometer.
●SpO2 94% no oxygen.
●Mild restriction in ribs 3 & 4 B.
●Mild tightness of posterior cer-
vical muscles B.
●Good mobility at GHJ and with-
out pain at full ER
●Reassess neural dynamics with
no restriction upon
reassessment.
●Thrust manipulation to upper thor-
acic spine.
●Non-thrust mobilization to entire
thoracic spine and ribs.
●Soft tissue manipulation to posterior
CT junction.
●Soft tissue releases to upper cervical
spine along semispinalis capitus.
SpO2 98% after treatment.
11 27 (3.75) Is being presented this week to transplant team
for activation.
●SpO2 93% before (without
oxygen).
●Pain-free GHJ ER.
●Mild tightness continues in
B scalenes.
●Some stiffness in T5-T6.
●Tightness of posterior cervical
muscles continues.
●Reassess neural dynamics with
no restriction upon
reassessment.
●Thrust manipulation to upper thor-
acic spine.
●Non-thrust mobilization to entire
thoracic spine and ribs.
●Soft tissue manipulation to posterior
CT junction.
●Soft tissue releases to upper cervical
spine along semispinalis capitus.
SpO2 96% after treatment.
12 28 (3.5) Was listed on the transplant list and will be
activated July 1. No complaints. Shoulder and
neck and feeling better.
●SpO2 97%.
●GHJ ROM L ER 90 degrees, IR 48
degrees, elevation 145 degrees.
●Improved breathing and mobi-
lity of lower rib cage.
●Improved forward head.
●No pain in cervical region.
●Decreased mobility at T5 and T6
with restricted flexion rotation
and side bending to the L at T5
and to the R at T4.
●Reassess neural dynamics with
no restriction upon
reassessment
●Thrust manipulation to T4 and T5
thoracic spine.
●Non-thrust mobilization to entire
thoracic spine and ribs.
Nearing 100% of initial goals. Will hold
PT unless patient has recurring
symptoms.
13 37 (2) Returns for DC prior to leaving for transplant
hospital. (note: transplant occurs in 2 months)
●All goals met.
●Independent and able to con-
trol pain and has full mobility.
●CAREConnections
TM
98%.
●Pain 0 on VAS.
●General review of home program.
●Non-thrust mobilization to entire
thoracic spine and ribs.
CAREconnections
TM
now 12%
improved with only one area
selected under personal care. DC PT.
12 B. MOODY JONES ET AL.
