Dr. Nuss's Pectus Excavatum Exercise Suggestions

extracted from Dr.Donald Nuss's writings

Regardless of how long you or your child has to wait before corrective surgery for PE, exercises which improve posture and breathing are very important! And after surgery they play an essential part in achieving and maintaining the best correction possible. The following program comes from Dr. Donald Nuss, who uses a unique corrective method he developed over years of surgery at Children's Hospital of the King's Daughters, in Norfolk, Virginia. He explains why these are so important in a guide he hands to his young patients and their families. Because information on appropriate exercise for those with PE and those after PE correction is hard to find, we present Dr. Nuss's recommendations for you here.

 Before Surgery

"Patients with pectus excavatum frequently have a posture which accentuates the pectus excavatum. The typical 'pectus posture' includes forward-sloping shoulders, a kyphotic [hunched] thoracic spine, and a protuberant abdomen. This posture undoubtedly makes the pectus look worse than it is. A mild pectus may, therefore, appear to be severe simply because the posture is so poor. Whether this posture plays any role in the worsening of a mild pectus is uncertain.

"The purpose of the exercise program is to get the patients to straighten their thoracic spine and pull their shoulders back and develop a 'military' or 'marine boot camp' posture.

"All exercise is good because it improves muscular tone. Even exercises such as running are good because they make the patient stand up straight (nobody runs in a hunched position) and make the patient breathe deeply, and give the patient a sense of well-being. This applies to other sporting activities including soccer, etc.

"The first step is to obtain both the patient's and the parents' cooperation. Unless they are motivated to do the exercises, one is wasting his time. The best way to do this is to show them in front of a mirror how improving the posture improves the appearance of the chest.

"Exercise #1: Sacrospinalis Exercise:

Hands are placed behind the head and fingers interlocked. The elbows are pulled back (extended) as much as possible and the head needs to remain extended. This posture causes the chest to fill out anteriorly. Once the posture has been properly attained, the patient then bends from the hips forward down to a horizontal position, holds it for a second or two, and then straightens back up again. It is very important that during the exercise the elbows are maintained in the original extended position. Also, the neck should not be flexed during this procedure. In other words, when the patient reaches the horizontal position, his spinal cord should be a straight line and not flexed at the cervical [neck] region. The patient should do this exercise 25 times. The purpose is to strengthen the sacrospinalis muscles and to pull the shoulders back.

"Exercise #2: Strengthening of Pectoralis Muscles:

"A) The patient should do 25 push-ups. B) The patient lies on his back on the floor with is arms at right angles to his body. Place a small weight in each hand and, keeping arms straight, bring them together in the midline. The patient should do this exercise 25 times.

"Exercise #3: Chest Expansion:

"The patient breathes in as deeply as possible, pulling shoulders back as he/she inhales. The patient holds breath for as long as possible with chest pushed out anteriorly. This should be done with the patient standing up straight and shoulders back. As the patient breathes in, he should be encouraged to see how long he can hold his breath in this position. This exercise should be repeated 20 times.

"Total exercise time should be no more than 10 minutes. The patient should be encouraged to perform these exercises immediately upon arising out of bed in the morning and prior to going to bed in the evening. Patients who have a poor posture are also encouraged to wear a figure-of-eight brace (clavicular brace) to pull the shoulders back.

"During the day the patient should be active, playing a variety of sports as mentioned above. Motivation is extremely important and it is vital that the patient be monitored on a regular basis or he will lose interest. Taking an interest in the patient's sporting activities not only helps motivate the patient but also helps establish good rapport.

"An exercise program like this will not cure a severe degree of pectus excavatum. However, a poor posture will make even a good surgical result look bad, and vice-versa."

After Surgery

Dr. Nuss emphasizes the following exercises to help improve and maintain optimal chest expansion and posture AFTER corrective surgery:


"The most important exercise is deep breathing with breath holding while standing up straight with the shoulders pulled back. I recommend to my patients that they do this exercise the first thing in the morning as soon as they get out of bed, and the last thing at night before they get into bed. It is very important that the exercise be done regularly, or it will have no benefit whatsoever. With the shoulders pulled back and the chest pushed forward as much as possible (military style), the patient inhales to maximum capacity and holds the breath for as long as possible. After exhaling and taking a few normal breaths, the process is reperated ten times. The idea behind this exercise is to expand the chest as much as possible using physiologic methods.

"It is well known that older patients who develop pulmonary emphysema develop a barrel-shaped chest. It is interesting that this occurs long after the skeleton has matured and calcified, since most of these patients are in their 40s, 50s and 60s.

"A second exercise which is designed to strengthen the sacrospinalis or back muscles involves putting the hands behind the head with the elbows pulled well back, then flexing at the hips to a horizontal position, keeping the head horizontal and not flexed. Once the horizontal position is reached, the patient then straightens up again. This is repeated 25 times, morning and evening.

"I would strongly recommend swimming, particularly back stroke, as a regular exercise. Walking and particularly running also help to produce good muscle tone, good posture, and deep breathing.

"Most patients who have pectus excavatum have a classic posture with forward-sloping shoulders, curved spine and a protuberant belly. Improving the posture usually does wonders for their appearance."


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