Research

Management of Non-cardiac Chest Pain With Chiropractic Care: A Case Report and Brief Review

Stephen R. Cooper, DC

 

Mark T. Pfefer, RN, MS, DC

 

author email    corresponding author email   

Topics in Integrative Health Care 2011, Vol. 2(3)   ID: 2.3005



Published on
October 7, 2011
Text Size:   (-) Decrease the text size for the main body of this article    (+) Increase the text size for the main body of this article
Share:  Add to TwitterAdd to DiggAdd to del.icio.usAdd to FacebookAdd to GoogleAdd to LinkedInAdd to MixxAdd to MySpaceAdd to NewsvineAdd to RedditAdd to StumbleUponAdd to Yahoo

Abstract

Objective: The purpose of this report is to discuss the outcome of a patient with non-cardiac chest pain treated with chiropractic spinal manipulation combined with instrument-assisted soft tissue mobilization.

Introduction: Chest pain is the fourth most common presentation in emergency rooms in the United States. The direct and indirect costs of chest pain are high in terms of disability, medication, repeated hospital admissions and physician visits, and costly diagnostic procedures.

Clinical features: The case of a 45 year-old male presenting to a chiropractic clinic with complaints of chest pain is discussed. Although the source of this chest pain was likely non-cardiac, cardiac risk factors were present and were addressed as well.

Intervention and outcome: The patient was treated with manual thoracic spinal manipulation and instrument-assisted soft tissue mobilization with complete resolution of chest pain at 3 weeks and no chest pain at 1 month and 3 month follow-up visits. Conservative cardiac prevention approaches were encouraged with good outcome.

Conclusion: This case points out the promising role the combination of chiropractic manipulation and instrument-assisted soft tissue mobilization may have in the management of non-cardiac chest pain arising from musculoskeletal dysfunction.

Introduction

Chest pain is the fourth most common presentation in emergency rooms in the United States.1 The direct and indirect costs of chest pain are high in terms of disability, medication, repeated hospital admissions and physician visits, and costly diagnostic procedures.2,3
 
This condition is troubling, and sometimes confounding, for both the patient and the physician.  Although myocardial infarction (MI) and cardiac chest pain must be the first consideration, a substantial number of cases of chest pain are sometimes called non-cardiac chest pain, pseudoangina, or atypical chest pain.4,5  Non-cardiac chest pain is defined as chest pain with no history or findings of cardiac disease or of unknown etiology.  In a retrospective case-control study, Blacklock4 found that in 50% of the cases of chest pain, the origin was undetermined 6 months post-follow up. 
 
Non-cardiac chest pain presents in a similar manner to cardiac chest pain but is often of indeterminate origin, much to the chagrin of the physician and patient.5  Locke et al6 found that 23% of American adults aged 25-74 years had non-cardiac chest pain.  Eslick and Talley reported similar findings in Australia.5  Baldi and Ferrarini7 noted that, “between 10 and 50% of patients with anginal pain who are referred for arteriography are found to have normal coronary arteries.”  These studies demonstrate significant medical resources being allocated toward non-cardiac chest pain.  Further, Smith et al8 state,

“Current techniques for accurately evaluating and triaging chest pain presenters are inadequate, and risk-driven liberal administration policies contribute substantially to an estimated cost of $10 to $13 billion per year to rule out MI in low-risk patients…”

 
Non-cardiac chest pain not only impacts hospital resources, but also severely impacts the quality of life of sufferers.  Eslick et al9 reported that 36% of non-cardiac chest pain sufferers indicated they had a much lower quality of life.
 
Many possible etiologies have been suggested for non-cardiac chest pain such as gastroesophageal origin,4-7,9 psychiatric origin,4,5,9,11-16 musculoskeletal or biomechanical origin 4,5,8,17-21 and drug abuse.22 
 
Chest pain may be a sequel to psychiatric conditions such as anxiety disorders, somatoform disorders, affective disorders, and depressive episodes.13-16  Of the implicated anxiety disorders, panic appears to be the most prevalent.14
 
Some disagreement remains regarding the most frequent cause of non-cardiac chest pain.  Some authors maintain gastroesophageal reflux disease (GERD) is the most common cause of non-cardiac chest pain,5,6,9,16 whereas others lean toward musculoskeletal causes.8,17-20  However unlike GERD, which is a singular condition, musculoskeletal involvement is a group of conditions that may lead to non-cardiac chest pain.  Conditions included in the musculoskeletal group are intercostal myalgia, bruising, fractured rib, sprain/strain, costochondritis, chest wall syndromes, thoracocostal subluxation, myofascial pain, among others.8,17-21
 
Musculoskeletal origin non-cardiac chest pain is a relatively common occurrence.18  Svavarsdottir and coworkers18 studied 186 patients entering a health care center with chest pain.  They found that 48.9% of patients were diagnosed with musculoskeletal pain, 17.9% with heart disease, and 9.5% had undiagnosed chest pain. 18  Triano et al19 discuss anatomical and neurological mechanisms leading to non-cardiac chest pain.
They state, 19

“…anterior chest pain…forms the bulk of any referred pain associated with these articulations [costovertebral joints].  Disorders affecting the first and second CV [costovertebral] joints may result in accompanying arm pain conveyed via Kuntz’s nerve…which reflects a linkage with the brachial plexus from the first and/or second intercostal nerve.” 

 
Erwin et al20 investigated the musculoskeletal mechanisms previously reported and conclude, “The anatomic findings of this study suggest that the costovertebral joint is a likely, although perhaps often unrecognized, candidate that may be responsible for the generation of atypical chest pain…” Further, they state that failure to recognize this condition may lead to unnecessary costs and distress on the part of the patient. 20
 
One of the treatments showing promise for non-cardiac chest pain of musculoskeletal origin is chiropractic manipulation.19-21,24-26 In fact, Mennell26 reported on the treatment of chest pain by manipulation as early as 1948.  Recent case studies19,21,24,25 suggest that manipulative therapies will be an important area of research in the future of treatment for musculoskeletal atypical chest pain.
 
A promising adjunct to spinal manipulation is instrument-assisted soft tissue mobilization (IASTM).27,28,29,30  Little research has investigated the combination of spinal manipulation and IASTM although it is feasible that accelerated healing and decreased treatment visits might be possible with this approach. 
 
The purpose of this report is to discuss the outcome of a patient with non-cardiac chest pain treated with chiropractic spinal manipulation combined with instrument-assisted soft tissue mobilization.

Clinical Features

A 45 year-old healthy-appearing male reported to a chiropractic clinic with primary complaint of chest pain. He described this as pain and tightness in the left side of the chest with radiation of pain into his left arm. His pain started insidiously two months earlier with no history of prior similar episodes and no recent trauma. His pain was described as constant low-grade pain with intermittent episodes of much sharper pain and tightness. He stated that he was active, running two times per week (1 to 2 miles) and did state that he had done some house painting around the time that his chest pain began but did not feel that it was definitely directly related to the onset of chest pain.  The patient expressed significant concern that his pain was related to a cardiac cause as his father had died suddenly at age 68 due to myocardial infarction. The patient has never smoked and his other history was non-contributory to the current episode.
 
The patient was concerned about the possibility of a cardiac condition and had consulted a cardiologist, at the recommendation of his primary care physician. His lipid profile demonstrated elevated total cholesterol with moderately elevated LDL and decreased HDL subfractions. His triglycerides were within normal range. He was evaluated with ECG and stress echocardiogram, which was considered normal. He was referred for a multislice computed tomography exam of his heart that demonstrated the presence of calcium, which was defined as medium risk. He had no history of hypertension so his cardiologist recommended a 3-month trial of dietary changes along with a recommendation to add additional days of exercise. His cardiologist told him he would likely need to start statin therapy to reduce his cardiac risk if the dietary changes and exercise were not adequately helpful. 
 
Physical exam revealed no neurologic deficit and the patient appeared healthy but slightly overweight (206 lbs; 6 feet tall) with a BMI of 28. His waist circumference was 38 inches. His blood pressure was within normal range (128/80) but his pulse was elevated at rest (88/minute). The lungs were clear and the pulse was regular. Exam of the abdomen was unremarkable. Palpation of the thoracic spine revealed passive joint restriction and marked tenderness at T6, T8 and T 12. Manual pressure near the inferior angle of the left scapula along the course of the latissimus dorsi muscle and the teres minor muscle as both muscles attach to the humerus appeared to provoke the chest pain and provoked apparent referral of pain down the left arm in the ulnar distribution.  The patient stated this pain was consistent with the “chest” pain he was feeling during the last two months. 
 
The impression was that the chest pain was primarily non-cardiac in origin and a trial of chiropractic care was planned. The patient consented to a short trial of chiropractic care after an explanation of the proposed treatment, possible risks and other treatment options were explored.

Intervention and Outcome

The patient was treated with manual spinal thoracic manipulation and instrument-assisted soft tissue mobilization. He was seen twice per week for 3 weeks with significant improvement after 3 visits and full resolution of his chest pain at the 6th visit.  He was seen for a follow-up visit 1 month later with continued resolution of chest pain and was seen 2 months later with no complaints of chest or arm pain. 
 
At the third visit, the patient asked about his cardiac risk factors and what would be recommended from a chiropractor. The chiropractor encouraged the patient to try to be more active, getting some exercise for at least 30 minutes every day and to cut down on carbohydrates and eat more vegetables and fruits. The patient stated that he was motivated to do this as he had witnessed his father die prematurely due to cardiac disease. At the one month follow-up visit, the patient had lost 6 pounds. He was given encouragement to continue with his exercise and dietary recommendations. At 3 months, there was slight improvement in his lipid profile such that his cardiologist told him he would allow him 3 more months to assess further changes associated with his lifestyle modification. Additional outcomes are not available at this time.

Conclusion

This case points out the promising role the combination of chiropractic manipulation and instrument-assisted soft tissue mobilization may have in the management of non-cardiac chest pain arising from musculoskeletal dysfunction. Additionally this case highlights the role a chiropractor can play in conservative primary and secondary prevention of cardiac disease.
Share:  Add to TwitterAdd to DiggAdd to del.icio.usAdd to FacebookAdd to GoogleAdd to LinkedInAdd to MixxAdd to MySpaceAdd to NewsvineAdd to RedditAdd to StumbleUponAdd to Yahoo

References

1.   

Nourjah P. National hospital ambulatory medical care survey: 1997 emergency department summary. Advance data from vital health statistics, No. 304. Hyattsville, MD: National Center for Health Statistics, 1999.



2.   

Potts SG, Bass CM. Psychosocial outcome and use of medical resources in patients with chest pain and normal or near-normal coronary arteries: a long-term follow up study. Q J Med 1993; 86:583-93.



3.   

Selker HP. Coronary care unit triage decision aids: how do we know they work? Am J Med 1989;87:491-2.



4.   

Blacklock SM. The symptom of chest pain in family practice. J Fam Pract 1977; 4:429-33.



5.   

Eslick GD, Talley NJ. Non-cardiac chest pain: squeezing the life out of the Australian healthcare system? MJA 2000; 173:233-4.



6.   

Locke GR, Talley NJ, Fet S, et al. Prevalence and clinical spectrum of gastroesophageal reflux in the community. Gastroenterology 1997;112:1448-56.



7.   

Baldi F, Ferrarini F. Non-cardiac chest pain: a real clinical problem. Eur J Gastroenterol Hepatol 1995; 7:1136-40.



8.   

Smith M, Ellerbrock DC, Khorshid D, Hadley S. Retrospective study of chest pain cases presented to a chiropractic teaching clinic: a preliminary feasibility study. J Neuromusculoskeletal Sys 2000;8:67-75.



9.   

Eslick GD, Coulshed DS, Talley NJ. Review article: the burden of illness of non-cardiac chest pain. Aliment Pharmacol Ther 2002;16:1217-23.



10.   

Pellicano R, Durrazzo M, Oliaro E, et al. The role of gastroesophageal reflux disease in chest pain. J Cardiovasc Surg;2002; 43:553-7.



11.   

Potokar JP, Nutt DJ. Chest pain: panic attack of heart attack? Int J Clin Pract 2000;54:110-4.



12.   

Ho KY, Kang JY, Yeo B, Ng WL. Non-cardiac, non-oesophageal chest pain; the relevance of psychological factors. Gut 1998;43:105-10.



13.   

Clouse RE, Carney RM. The psychological profile of non-cardiac chest pain patients. Eur J Gastroenterol Hepatol 1995;7:1160-5.



14.   

Potts SG, Bass CM. Psychological morbidity in patients with chest pain and normal or near-normal coronary arteries: a long-term follow up study. Psychol Med 1995;25:339-47.



15.   

Serlie AW, Erdman RA, Passchier J, Trijsburg RW, et al. Psychological aspects of non-cardiac chest pain. Psychother Psychosom 1995;64:62-73.



16.   

Richter JE. Investigation and management of non-cardiac chest pain. Baillieres Clin Gastroenterol 1991;5:281-306.



17.   

Levine P. Musculoskeletal chest pain in patients with “angina”: a prospective study. South Med J 1989;82:580-5.



18.   

Svavarsd0ttir AE, Jonasson MR, Gudmundsson GH, Fjeldsted K. Chest pain in family practice: diagnosis and long-term outcome in a community setting. Can Fam Physician 1996;42:1122-8.



19.   

Triano JJ, Erwin M, Hansen DT. Costovertebral and costotransverse joint pain: a commonly overlooked pain generator. Top Clin Chiropr 1999;6:79-92.



20.   

Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther 2000;23:395-403.



21.   

Johnson HH. Thoracocostal subluxation syndrome: an often overlooked cause of chest and arm pain. Chiropr Tech 1995:7:134-8.



22.   

Disla E, Rhim HR, Reddy A, Karten I, Taranta A. Costochondritis: a prospective analysis in an emergency department setting. Arch Intern Med 1994;154:2466-2469.



23.   

Guerot E, Sanchez O, Diehl JL, Fagon JY. Complications aiguës das l’usage de cocaïne [Acute complications in cocaine users]. Ann Med Intern 2002;153:1S27-31.



24.   

Polkinghorn BS, Colloca CJ. Chiropractic management of chronic chest pain using mechanical force, manually assisted short-lever adjusting procedure. J Manipulative Physiol Ther 2003;26:108-15.



25.   

Haneline MT. Chest pain in chiropractic practice. J Neuromusculoskeletal Sys 2000; 8:84-88.



26.   

Mennell JM. Manipulation and treatment of pain in the chest. NZ Med J 1948;48:586-98.



27.   

Looney B, Srokose T, Fernandez-de-las-Penas, Cleland J. Graston instrument assisted soft tissue mobilization and home stretching for the management of plantar heel pain: a case series. J Manipulative Physiol Ther 2011;34:138-42.



28.   

Hammer WI, Pfefer MT. Treatment of a case of subacute lumbar compartment syndrome using the Graston Technique. J Manipulative Physiol Ther 2005;28:199-204.



29.   

Hammer W. The use of transverse friction massage in the management of chronic bursitis of the hip and shoulder. J Manipulative Physiol Ther 1993;16:107-11.