/

Ma1111al Th<'rapr ° ''I), 42 45

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do,:I0.10541111a1h.2002.0473 . . . ao1 ■ No ■ @o1,i ■ oT•

Clinicai note

The e~ect of postoperative ataralgesia by manual therapy after pulmonary

resection

F. Hirayama*. Y. Kageyama*, N. Urabe*, H. Senjyut

*Department o.f Tlwracic Surgery , Numazu ,i/y Hospital , Japan , t Departrnent of Physical Therapy, The School
of Healtl, S~iences, Nagasaki U11il'ersi1y , apa,
(/J~rroc,pn

SUMMAR:. ........ I JrUNftll.......____ , was applied to control pain persisting for more thanJ
"Tj_~ week followmg posterolateral thoracotomy, and its cfficacy for thc allcviation of pain was invcstigated.
Eight paticnts who underwent posterolateral thoracotomy and lung rcsection for cancer (n - 7) or emphyscma \ C. e.
(n - 1) rcceived manual therapy to incised musclcs and the musclcs inscrting into the ribs in the affectcd arca for an ~~:,
average of 17 days postoperatively. ºwr;;s:e-kfstiwe1 f!FtlrNPM::lSebriw were uscd. Treatment was continued
-fi>.~ -.tHbc irtsndtY e4'19twtw1rs:fricli90::ffdtniettf:fterWUxel abwbk:hdbeetlieekfnlat,tirrhofritewh?
~-e' W ,;. 1 .çggyp;.mlet«tà Treatment was performed ~ Paio scverity was
measured using a visual analog scale (V AS) (0-1 O). Before the first trcatment thc VAS was sct at 10 and changcs
1
crc obscrved before and after the treatment as well as over time. After three scssions ali patients1 ~
1
of the .
1
a dccrease in ain from 10 to an avera e of 1.9 (range 1.3-2.6). OJ ~o., (O~~
Manual therapy was therefore found to be effective for pain control aftcr posterolateral thoracotomy. #_ r>· ~ I )
~ _§_ © 2003 Elsevier Science Ltd. Ali rights rescrved. ½~35:0 ~~: ":S,.J-''º
,,,,.._~ °'R

-~s ~ " t i \ Q b ~ .._ Q.\.u\.o)
INTRODUCTION
Most patients have frequent episodes of postopera-
tive pain after undergojng major operatjons suçh as
lung resection or esophagectomy via a postero!atera!
,e,, thoractomy (Griffith et ai. 1995). Because of limita-
tjon of mo-vement óf the arms and thoracic.cage in an
attempt to prevent pain, shortening of the muscles
5 and secondary restriclion of range of motion may
E C occur. The pain is not _always complet~ly con_trolled
8
8 9 1W"}pidural anaesthesta or by admm1strat1on of
$~ P~ ~ ates or anti-inflammatory agents. Transcutaneous
e~ trica! .nerve stünu)ation ITENS) (John 1990;
i8~-
Rgbinson 1996) also shows no analgesic effeçt on
~ o
4: (:) ""I
@
~- ------ ------ -----
Received: 7 February 2002
r
severe pain alter posterolateral thoracotomv (Bene-
detti et ai. 1997). Mãnual therapy is used for the
tJprma!ization of muscle contraction and for increas- ~o:o~
(.ing range of motion1;; and its efficacy has been ""'.,.
demonstrated following orthopaedic surgery and in
diseases of lhe central nervous system (Craig& Yoi-
chiro 1997; Bang & Oeyle 2000; Deyle et ai. 2000).
flowever, the apelication of manual therapy in th~
general thoracic field has not been reported. j~ '2..
The authors assumed that shortening of the incised -
muscles was one cause of pain after posterolateral ©
~QIDY- ln lhe present study, a phYsio1~t ➔ ~ . e !1_
(PT) used the m"!!!'!'!fti'molCtellhnignmnd:tba ..q, ~ -t,â
$tf@bielidft9hnioJMtl9rJAAal 1,-he;.igju;red::JllllMs in
l:hcrrt l l a d ~,l:lw::wgjpppin.w ,,.,.._ l •
liliiPP"P'itttF- This muscle therapy, a form of manual l • Ali
e li;,,,

Re,,ised: 1 June 2002 therapy, was found to be effective in eight patients ~

- • Ac<:epte.d: 16 July 2002 with postoperative pain that had persisted despite \) ~e~~o 1
L---1 Fiai Hirayama PT, Departriient of Thoracic Surgery, Numazu severa! attempts at pain control via other methods. ·
City Hospital, Japan. Yosbihiko Kageyama MD, Department of

if,
Thoracic Surgery, Numazu City Hospital, Japan, Norikazu Urabe
MD, Department of Thoracic Surgery, Numazu City Hospital. MATERIALS ANO METHODS
Japan, Hideaki Senjyu PbD, Dcpartment of Physica l Therapy, The
Schoo l of Hcalth Scienccs, Nagasaki University, Japan.
,~§ ~ Correspondence to: FH, Department of Thoracic Surgery,
Numazu City Hospital, Hideaki Senjyu 550 Harunoki, Higashi-
Batients: The patients studied at the Department of
:r~ ." shiiji, Numazu, Shizuoka 410-0302, Japan.
l'horacic Surgery of Numazu City Hospital com-

a :o í Tel: 8155924 5100; Fax: 81 55 924 5133;

E-mail: fumichan23 (â,hotmail.com
prised eight patients with persist'ent wound pain àt 14
day's postoperatively from among 45 patients who

li 42
 M11nm1l therapy afler pulmonary resection 43

T1ble 1. PatienL, charnctcristics

No. Sex Age Disease Surgery Postoperative days to first treatment

2
F
M
34
70
,,,,.,=, ~
Pneumothornx emphysema
Right lowcr l~bectomv
Wedge resecllon
10
10
3 F 51 Len lower lobectomy 6
4 M 48 ,,,,~,m
Lung cancer \ :Right upperlÕ!iectÕmy 17
5 F 70 Lung ca ncer ·, Right lower lobêctomy 24
6
7
F 73 Lung cancer 'l /8 , Lefl lower lo@iec:~y 54
M 51 Lung cancer Right upper o 6
8 F 64 Lung cancer Right upper lobectomy li
M = malc. F = female.

from April 1999 to March 2000 underwent postero-
lateral thoracotomy -at the levei of the fiflh or sixth
rib for Jung cancer or persistent pneumothorax
(Table 1). They included three males and five females
with a median age of 57.4 years,Ci!'t)I~~ ~
Treatme111 : From an average of 17 days post-
operatively. manual therapy was started at a fre-
quency of once a week, and three sessions were
performed . The muscles trea ted were serratus ante-
rior and latissimus dorsi, which were cut during
surgery, as well as rectus abdominis. externai oblique,
by extension of the lumbar spine and flexion of lhe
shoulder to 180º on the operated side. When the
subject was unable to achieve 180º shoulder flexion,
cushions were placed near the head of the patient, lhe
arms were placed on the cushions and the shoulder
position at which lhe patient showed no increased
• muscle tone due to pain was selected. Then, the PT
r
11p 11 1 : u.pc-w.w:illlffiÍdi@Dnfer':jq , e 1 .._ .
.., 1 ·s i ~ (Figs. 1 and 2). "-" ~\<.C.iO~
The rectus abdominis and externai oblique muscles ~dõ
showed induration and pain when pressure was

t ahd pectoralis major. which were attached to the ribs

affected by thoracotomy. At the time manual therapy
was applied, eight pa\jents were rece1vmg oral
apphed near thejr pelvic insertions, especially along
the mner border oi lhe anterior superior iliac spine.
Smce the serratus anterior showed the greatest
analgesics. NSAID.® sensitivity to pressure among the trea ted muscles,
Positioning of tl,e patient: Appropriate positions
were selected so that the muscles treated were placed
on a slight stretch and the @ltfist' w·r ; •

Treatment teclmiques: Th,. '.P"?§Z f · •ina tech-

nigue. which is used R!"ll efartw....,. to improve
muscle tone and muscle oedema, and lhe stretching
techniqlfe (for evaluation of changes in muscle t~
0 g [were applied. The pressure-friction technique in-
13 . volved application of l?e friction s9 that the thm~bs
5
i ·5 ~ reached the deepest pomt when pres-sure was apphed
,. ~ ~ -8 to a fixed posi~io~ on the pati~nt. ~werienx:s~á
o ~6 u T 1ZliilW4:Íf-tfitftfl:'!lerestrroo1:900PIPBIPSiy;osma
·:\ i \ • 11 fire The minimum intensity at which lhe
~ -::,. () patient felt pain was generally used as a guide for the
v -~ \ ;,;~ unount of pressure apphed. The fi nal decision was Fig. 1 Treatment of rectus abdominis and externai oblique.
% i >< made on the basis of informa tion obtained by
assessment of the response at the sites where pressure
was a pplied during treatment (changes of muscle tone
-t- and reduction of oedema), as well as lhe systemic
response (autonomic responses such as sweating and
p1loerect1on). Therefore, the pressure applied cannot
be expressed quantitatively. Before, du ring, and after
manual therapy. extensibility of the injured muscles
was examined by passive movement up to the limit of
motion for lhe related joint, so that lhe effects of J
t hera py could be evalua ted. ~
fü,~·tus ª ?~ominis, ext~rnal oblique, ~nd serra~11s ~
1• ; ~1
QJ
anten or: Imtta lly, the pallent was placed m the
1;1ii .•. i i:hs +r,aii&iíW tíw._.. _.l
f~ ~
E n'l ; ] •iiéêkiWp.A The rectus abdominis, externai
oblique and serratus anterior ffl#fffi)f§ tyf§@ ±P d d Fig. 2 Trealment of serratus anterior.

ca~ 11·1 2/JOJ E/seric•r Scienc1• Lltl. Ali ri/!,hts ri•sen•etl. Manual Tl11'rapy (l lHJJ / 8( / J, 42 45
 =~=.~:~:~ ~~~ ·::: ~~ wr a: ~H
_.,
'!!'
ad..l,__J
~
_..i.. 1- -
:a•.!~.:ffiJAAUiiiiwuuni. lmmedialely o - - - - The patient's arms were allowed to hang
after lhe firsl apphca11on of lhe pressure-friclion .f downwards on eilher side of lhe bed. Nexl. lhe PT
"'
,8 f2
f
a
~~hniq~e, ~xioo,w s• 1~ b
applied lhe 4Ustll &ittftiw tnbsiwt fg fhr l liri
!""◄ IMí!U'ffie..i l\.ffic..iu@#U ln@j@~ wue deseintMOde;,-,; g lbwtl a.- (Fig. 4). Recause
f
o
ç; f"
~ !
~IMUlQ~ ~ 1füs muscle was mc1sed during surgery, lhe lechnique il ~
~ector~lis maj~r: I_nilially, lhe pa1ien1 was placed in .b was not applied . for one finger breadlh ab_ove and ~ f
W#l-,,W ,Ui§!lfb Wjm~~ }·Q below the operal1ve wound. When lhe lechmque was .__J
~ O I I J Pecloralis major was placed on
slrelch w11h lhe lumbar spine in lhe exlended posilion
l
applied, this muscle showed the least sensitjyjty to
pressure.
and lhe shoulder on lhe operated side in an
inlermediate posilion between internai and externai
rotations with 90º abduction. Then, lhe PT applied ASSESSMENT ~
the ru-...aííwioo4iiifuõiíusssMS4w@ee• -0
!
(Fig. 3). The muscle A visual analog scale (VAS) (Huskisson 1974) was
was sensitive to pressure, especially ai its attachment used 10 evaluate the severity of pain. The sites of pain
to lhe clavicle. lmmediately after lhe first application were confirmed immediately before applicalion of
of lhe pressure-friclion lechnique, · f ppj@AAM: t
manual lherapy and lhe prelreatment pain was
WHl:W:lPto~ddcarja,i-4:-asq é ~ defined as IOon the VAS. lmmedialely after manual
6
l lOIMWl!:rttclmi911@1? 'l'l)bwt li • • ~ E therapy. changes ofthe pain ai each site were assessed
,.....iee a•.llii-MtM. Ofrom the VAS. The changes of pain day by day were
T Latissimus dorsi: Inilially, the palient was placed in b also assessed by the pat1ents and recorded once a day
MP r·ilÀ-9M@iMWr:9!,,i.he,,preooqljabyeJm11. 1·~
Lalissimus dorsi WiHWê:fffOOa:Wád:MW11tríio&junmf l
until the next treatmenb.
.
f .ó"
RESULTS j'..,.lf
Five patients had pain i11 lhe precordial ~egion, four _Ar ,... 4>'
had pain in lhe lateral chest wall, and s1x had back R' ,. .,_,
Rain (including patients with pain in more lhan oné '- +
regio!!!). The course after trealment was similar in ali
paiíents. lmmedialely after manual therapy, a
qnarked reducti?n ~n pai_n was confirm~d in tbe O.~~ ~
trealed re ions\ · ~ he am worsened a am_ o~ da ? .J. p ~ 4
2 or 3 afler lrealn'fcnl, with subseguent allevialJOn oí p>'
~ en changes in the severity ?f pain
on complelion of lrealmenl were assessed usmg lhe
VAS, a reduction in pain from a V AS of I O
Fig. 3 Trealment of peclralis major. (pretreatment) to a 1.§C0re of 2-4.6 was noted afler
lrealmenl (Fig 5). 'tl tCl'I ~ 2. oq c.pc:5:::.)

DISCUSSION

The results of this study show the effecl of manual

therapy for postoperalive pain following thora~ot-
omy for lung reseclion. Transcut~neous ~lectncal
nerve stimulation is oflen effec11ve m reducmg post.,
operalive pain, and was effective when used alone to
1rea1 mild pain caused by video-assisted thoracoscopy (©.b
_
(Benedetti 1997). It also showed an effecl when used
concomilantly with analgesics _for mild-to-moderate 7C~M
pain caused by muscle-sparmg lhora~otomy or J'l) $1.bg'nMq
sternolomy (Benedetti 1997). However, 11 has been
Fig. 4 Trealmenl of latissimus dorsi. reporled lhat TENS is nol effective againsl severe

Manual Therapy ( 2/)(}J J 8 ( I ) , 42 45 1n 2003 El.«•vier Sci('llce Ltd. Ali rig/11.1· n•s,•ri·rtl.

Anterior chest pain
10 - - - - - - - - - - - - - - - - ,
ê if9@ljlentmô"'eb 6 1 1 1 o .
!'O
Q)
.§.
• 5
VI
~ ) was ooted from lhe fourth dayJ
o'----------------'
♦ 1st ♦ 2nd ♦ 3rd treatment
Fig. 5 Rcduction in pain wilh m:mu:11 thernpy ( 10 = worsl,
O= none).
í pain caused by posterolateral thoracotomy (Benedelli
1997).
The authors have found that one cause of pain after
posterolateral thoracotomy is stress on muscles
incised during lhe operalion or on muscles allached
to lhe ribs that are affected by thoracotomy. ln this
series of patients the manual therapy applied was
based on the hypothesis that shorlening of these
muscles was involved in causing such pain. It has been
reporled that reactions to opioids such as endorphins
lhal suppress pain are deeply involved in pain
inhibition. To obtain the analgesic effects of opioids
for muscle pain, a physiological response lo simu)u-
tion of the skin and deep lissues is necessary., .and
intermittent stimulation by manual therapy is effective
for inducing this physiological response (Lewis et ai.
1980). This therapy not only appears to stimulate the
secretion of pain-suppressing substances and thus
alleviates pain, bul also improves the local circulalion
(Dawson & Hudlicka 1993). reduces muscle spas~
and helps to normalize muscle contractility.
Treatmen t was performed once a week for a total
of three sessions. When lhe severi ty of pain expressed
on the VAS scale was monitored over time, there was
a significant reduction in pain to 2-4.6_afte r lreat-
ment. compared with a score of I Oon lhe VAS before
treatment . suggesting the efficacy of manual therapy.
(n 2()()3 El.1·evier Science Ltd. Ali rights reserved.
M:muul thernpy uftcr pulmom,ry rescction 45
This therupy
'tMFWª · ··
. em3:::rbs
wrl±btfl'tf:Ml4:[s
. , and a
aee•~1 ~l\tl~
A '
. 1 la ~
@Mvi:optilíta The reason for this is thal pain [~ Ji
açtually increased in severity at 2=3 days after manual
'??.) therapy in mosl patients, while alleviation of the pain ( 'il".~
'!>30)
The authors believe that results of this observa-
lional study indicate lhe need for further investiga-
tions in lhe form of a randomized controlled clinicai t l"C- ~ a
triai.
Acknowledgements
Wc wish to cxpress our sinccre lhanks to Sue Jenkins, GradDip-
Phys, PhD, School of Physiolherapy, Curtin University of
Technology, Pcrth, Western Austrnlia, for her editoriul assistance.
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