A patient was admitted to our cardiorespiratory department on January 2019 to start a rehabilitation program. The patient (54 years old, male, white race and retired) with an active lifestyle (daily walks) and no particular dietary alterations, no significant genetic alteration known and without comorbidity. The patient had undergone an artificial heart transplant, HeartMate III LVAD as a bridge to candidacy, 5 years before undergoing a heart transplant. The reasons for this artificial heart are related to continuous heart failure, due to previous inoperable stenoses (stenosis on small caliber coronaries) and a probable previous infant rheumatic disease.
In the months leading up to heart transplant surgery, the patient had been treated with antibiotics to reduce the infection derived from the drive line: Corynebacterium striatum and Staphylococcus aureus. The patient was also positive by rectal swab for Acinetobacter baumanii. The patient underwent a heart transplant in November 2018.
In the postoperative course, cordarone was used for supraventricular tachyarrhythmias that were resolved. The first three biopsies revealed a gradual improvement. The first endomyocardial biopsy (EMB) revealed a moderate grade rejection (2R) treated with methylprednisolone. The second EMB revealed lymphoid aggregates in 2/3 of the fragments, with mild rejection (1R). The third EMB showed a mild rejection (type 1) on two fragments. The following two EMBs revealed no evidence of rejection. In our department, clinical examinations as the echocardiography showed a small amount of pleural effusion, a normal left ventricular size and a preserved ejection fraction; minimal pericardial effusion. The electrocardiogram signaled a right bundle branch block with a heart rate of 90 beats per minute, a blood pressure level of 135 over 85 (135/85) and an oxygen saturation of 97%. Blood tests reported a low white blood cell count (3.18), a low lymphocyte count (0.74) and a postoperative anemia (hematocrit =29,1 and hemoglobin =9,6), hepatic and renal function gradually improved, gamma glutamyl transferase (30), bilirubin (0.75) and creatinine (1.74). Radiographs showed elevation of the left hemidiaphragm associated to the mild left pleural effusion, partially organized in the posterior basal area, in absence of signs of overload (Figure 1).
The pharmacological treatment in our department was as follows: Furosemide Teva 25 mg (1 tablet); Augmentin 1 g (3 tablets); 100 mg acetylsalicylic acid (1 tablet); KCL retard 600 mg (2 tablets); magnesium 2,25 g (2 sachets); Myfenax - mycophenolate mofetil 500 mg (2 tablets); Natecal 600 mg +400UI (1 tablet); omeprazole 20 mg (1 tablet); Sandimmun 100 mg (2 tablets); Stilnox 10 mg (1 tablet); Zoloft 50 mg (1 tablet).
Laboratory tests showed no glycemic abnormalities or elevated glycate values, as well as no abnormal thyroid function. The patient did not carry out tests such as electromyography, as the motility of the limbs did not present anomalies. Routine examinations, such as X-rays or MRI, did not show any somatic or neurological structural anomalies. From the examinations carried out by the psychologist (Coping Orientation for Problem Experiences, Medical Outcomes Study Short-Form 36, Hospital Anxiety and Depression Scale), no behavioral or mood anomalies emerged.
The patient was unable to perform physiotherapy (gymnastics and exercise bike) because he complained of a neuropathic pain in the mediastinum, in an undefined area on the left side of the sternum (by 4th to 6th rib), compounded by breathing, limb movements and trunk rotations. His VAS pain assessment was 8, during movement and with forced breathing. The breastbone was perfectly closed. A cotton pad on the painful sternal area was used to evaluate superficial stimulation discrimination and epicritic sensitivity; a pin for pain assessment was used with slight pressure on the painful area; for the thermal sensitivity we used a test tube with hot water (40-50 C), passing it on the sore skin. The patient had an unaltered sensitivity, in the absence of allodynia, hypoalgesia, hyperalgesia or hypoesthesia. The patient always scored 8 to the numeric rating scale, which means the presence of pain during the evaluations. The patient gave his informed consent for the publication of the pictures and the treatment. The institutional approval was not required and it was not necessary to publish the case report. It was decided to administer ibuprofen 600 mg for 2 tablets a day. After a week, the VAS score fell to 7, but he still could not do physiotherapy.
Considering the positive results of the previous trial and a previous case report on the reduction of pain in patients suffering a sternotomy, we decided to submit the patient to the same number of sessions, that is, an OMT session for 5 days. Considering that the 5 diaphragms involve the body system in a more global way, it was decided to opt for the latter strategy.