Cervicothoracic Angina Identified by Case History and Palpation Findings in Patients with Stable Angina Pectoris

doi:10.1016/j.jmpt.2005.04.002

Journal of Manipulative and Physiological Therapeutics

Volume 28, Issue 5, June 2005, Pages 303-311

https://doi.org/10.1016/j.jmpt.2005.04.002 Get rights and content

Abstract

Objective

To investigate the decision-making process of an experienced chiropractor in diagnosing noncardiac musculoskeletal chest pain of cervicothoracic angina in patients with stable angina pectoris, based on patient history and clinical examination. Secondly, to examine the possibility of obtaining an objective diagnostic rule tool for the identification of cervicothoracic angina and to validate the diagnosis of this disorder.

Methods

A nonrandomized prospective trial was performed at a university hospital. A total of 516 of 972 consecutive patients referred for coronary angiography because of known or suspected angina pectoris were asked to participate in the study. Of these, 275 gave informed consent to a standardized manual examination of their spine and thorax. Diagnoses of an experienced chiropractor on cervicothoracic angina patients. Myocardial perfusion imaging and coronary angiography were used for validation. A set of candidate variables from patient history and clinical examination were tested for their role in the decision-making process.

Results

Eighteen percent of the patients were diagnosed with cervicothoracic angina. Of these, 80% had normal myocardial perfusion compared to 50% of cervicothoracic angina–negative patients. The main determinants of the decision-making process could be identified.

Conclusion

An experienced chiropractor could identify a subset of patients with angina pectoris as having cervicothoracic angina. Systematic manual palpation of the spine and thorax could be used as part of the clinical examination together with basic cardiological variables to screen patients with chest pain allowing for improvements in referral patterns for specialist opinion or angiography. (J Manipulative Physiol Ther 2005;28:303-311)

Section snippets

Study Population

This study was conducted as a substudy of the Myocardial Ischemic Logistic Evaluation Study (MILES) project,¹⁶ the objective of which was to compare the results of myocardial perfusion imaging (MPI) and CAG in a prospective series of patients referred to a tertiary hospital for CAG because of known or suspected stable AP. A total of 516 of 972 consecutive patients participated in the MILES study. This initial selection was made from the referral letter based on predetermined exclusion criteria

Results

Eighteen percent of patients (n = 50) had CTA. The CTA-positive patients were significantly younger, had lower blood pressure, were more often referred from general practice than from local hospitals, and received less medication than the CTA-negative patients (Table 2). Of CTA-positive patients, 80% (n = 40) had a normal MPI compared to 50% of CTA-negative patients (P < .0001). Among CTA-positive patients, half (n = 5) of those with abnormal perfusion had fixed defects in contrast to 18% (n =

Discussion

This appears to be the first study to systematically examine the combination of case history and palpation findings as a tool for identifying musculoskeletal causes of chest pain. In our sample of patients with stable AP, this approach resulted in a separation of nearly 1 of 5 patients with suspected noncardiac musculoskeletal chest pain (CTA-positive) and 4 of 5 patients (CTA-negative) who are more prone to having either AP (ie, angina caused by myocardial ischemia) or chest discomfort due to

Conclusion

The results of this study suggest that an experienced chiropractor can fairly convincingly identify a subset of patients with angina pectoris as having CTA. Systematic manual palpation of the spine and thorax could be used as part of the clinical examination in combination with basic cardiological variables to screen patients with chest pain to allow for improvements in referral patterns for specialist opinion or angiography. The suggested decision tree may serve as an example of how to base

Acknowledgments

The authors greatly appreciate the secretaries Anne-Marie Møller and Bente Wichmann from the Department of Cardiology, the laboratory technicians of the “Heart Group,” physicians, head secretary Anette Albæk, laboratory technicians Karina Madsen and Tina Godskesen, and chief laboratory technician Mette Møldrup, Department of Nuclear Medicine, for their assistance with the production of this paper.

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A randomized clinical trial of chiropractic treatment and self-management in patients with acute musculoskeletal chest pain: 1-year follow-up
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We have previously reported short-term follow-up from a pragmatic randomized clinical trial comparing 2 treatments for acute musculoskeletal chest pain: (1) chiropractic treatment and (2) self-management. Results indicated a positive effect in favor of the chiropractic treatment after 4 and 12 weeks. The current article investigates the hypothesis that the advantage observed at 4 and 12 weeks would be sustained after 1 year. In addition, we describe self-reported consequences of acute musculoskeletal chest pain at 1-year follow-up.
In a nonblinded, randomized controlled trial undertaken at an emergency cardiology department and 4 outpatient chiropractic clinics, 115 consecutive patients with acute chest pain of musculoskeletal origin were included. After the baseline evaluation, patients were randomized to 4 weeks of either chiropractic treatment or self-management, with posttreatment questionnaire follow-up 52 weeks later. The primary outcome measures were change in pain intensity (11-point box numerical rating scale) and self-perceived change in pain (7-point ordinal scale).
Both groups experienced decreases in pain, positive global, self-perceived treatment effect, and increases in the 36-Item Short Form Health Survey scores. No statistically significant differences were observed between groups at the 1-year follow-up, and we could not deduce a common trend in favor of either intervention.
At the 1-year follow-up, we found no difference between groups in terms of pain intensity and self-perceived change in chest pain in the first randomized clinical trial assessing chiropractic treatment vs minimal intervention for patients with acute musculoskeletal chest pain. Further research into health care utilization and use of prescriptive medication is warranted.
Reconstruction of the decision-making process in assessing musculoskeletal chest pain: An exploratory study using recursive partitioning
2012, Journal of Manipulative and Physiological Therapeutics
Citation Excerpt :
Recursive partitioning allows researchers to include any number of predictor variables in their analysis, regardless of the number of observations, including even the special case of analyzing a data set that has more variables than observations. A comparison between our decision tree and the one published by Christensen et al,11 in 2005 reveals that many of the same indicators were highly associated with the MSCP diagnosis in both studies. Although they are based on data from 2 different populations, that is, 1 chronic and 1 acute chest pain population, both decision trees are linear without branches, and manual palpation of the neck and thoracic spine are major determinants for an MSCP-positive diagnosis.
The purposes of this study were to identify the most important determinants from the patient history and clinical examination in diagnosing musculoskeletal chest pain (MSCP) in patients with acute noncardiac chest pain when supported by a structured protocol and to construct a decision tree for identification of MSCP in acute noncardiac chest pain.
Consecutive patients with noncardiac chest pain (n = 302) recruited from an emergency cardiology department were assessed. Using data from self-report questionnaires, interviews, and clinical assessment, patient characteristics were associated with the MSCP diagnosis, and the decision-making process of the clinician was reconstructed using recursive procedures in the tradition of constructing Classification and Regression Trees.
Thirty-eight percent of patients had MSCP. There was no single determinant that predicted the condition completely. However, many items with high associations could be identified, mainly with high negative predictive value. The decision-making process was reconstructed giving rise to a 5-step, linear decision tree without branches.
Clinicians use a combination of indicators including systematic palpation of the spine and chest wall and items from the case history to diagnose MSCP. However, the high negative predictive values of the main determinants suggest that the MSCP diagnosis may be a diagnosis by exclusion.
Chiropractic treatment vs self-management in patients with acute chest pain: A randomized controlled trial of patients without acute coronary syndrome
2012, Journal of Manipulative and Physiological Therapeutics
Citation Excerpt :
The diagnosis of musculoskeletal chest pain was based on systematic patient assessment using a standardized protocol shown to have substantial interobserver agreement.17 The issue of validity of this diagnosis has been addressed previously by us in patients with stable angina pectoris in whom an experienced clinician could fairly convincingly identify a subset of patients with musculoskeletal chest pain.15 In the current study, positive response to treatment targeted at structures believed to be pain generators (muscles and joints of the cervicothoracic spine and chest wall) gave further support to the validity of the diagnosis.
The musculoskeletal system is a common but often overlooked cause of chest pain. The purpose of the present study is to evaluate the relative effectiveness of 2 treatment approaches for acute musculoskeletal chest pain: (1) chiropractic treatment that included spinal manipulation and (2) self-management as an example of minimal intervention.
In a nonblinded, randomized, controlled trial set at an emergency cardiology department and 4 outpatient chiropractic clinics, 115 consecutive patients with acute chest pain and no clear medical diagnosis at initial presentation were included. After a baseline evaluation, patients with musculoskeletal chest pain were randomized to 4 weeks of chiropractic treatment or self-management, with posttreatment questionnaire follow-up 4 and 12 weeks later. Primary outcome measures were numeric change in pain intensity (11-point box numerical rating scale) and self-perceived change in pain (7-point ordinal scale).
Both groups experienced decreases in pain, self-perceived positive changes, and increases in Medical Outcomes Study Short Form 36-Item Health Survey scores. Observed between-group significant differences were in favor of chiropractic treatment at 4 weeks regarding the primary outcome of self-perceived change in chest pain and at 12 weeks with respect to the primary outcome of numeric change in pain intensity.
To the best of our knowledge, this is the first randomized trial assessing chiropractic treatment vs minimal intervention in patients without acute coronary syndrome but with musculoskeletal chest pain. Results suggest that chiropractic treatment might be useful; but further research in relation to patient selection, standardization of interventions, and identification of potentially active ingredients is needed.
Historical overview and update on subluxation theories
2010, Journal of Chiropractic Humanities
This article presents a personal view of the historical evolution of theories of subluxation in the chiropractic profession.
Two major themes emerge from this review: those related to the mechanical behavior of the spine and those related to the neurologic implications of these mechanical issues. Chiropractic subluxation theory is one of the few health-related theories whereby these mechanical and neurologic theories have been unified into a comprehensive theory of disorder of spinal function. For this disorder, doctors of chiropractic have used the term subluxation. These theories, and their unification in the “subluxation concept,” have undergone evolution in the profession's history.
The “subluxation concept” currently faces challenges, which are briefly reviewed in this article. The only way forward is to strengthen our efforts to investigate the “subluxation concept” with high-quality scientific studies including animal models and human clinical studies.
Examination of musculoskeletal chest pain - An inter-observer reliability study
2010, Manual Therapy
Chest pain may be caused by joint and muscle dysfunction of the neck and thorax (termed musculoskeletal chest pain). The objectives of this study were (1) to determine inter-observer reliability of the diagnosis ‘musculoskeletal chest pain’ in patients with acute chest pain of non-cardiac origin using a standardized examination protocol, (2) to determine inter-observer reliability of single components of the protocol, and (3) to determine the effect of observer experience. Eighty patients were recruited from an emergency cardiology department. Patients were eligible if an obvious cardiac or non-cardiac diagnosis could not be established at the cardiology department. Four observers (two chiropractors and two chiropractic students) performed general health and manual examination of the spine and chest wall. Percentage agreement, Cohen's Kappa and ICC were calculated for observer pairs (chiropractors and students) and all. Musculoskeletal chest pain was diagnosed in 45 percent of patients. Inter-observer kappa values were substantial for the chiropractors and overall (0.73 and 0.62, respectively), and moderate for the students (0.47). For single items of the protocol, the overall kappa ranged from 0.01 to 0.59. Provided adequate training of observers, the examination protocol can be used in carefully selected patients in clinical settings and should be included in pre- and post-graduate clinical training.
Future Developments in Chest Pain Diagnosis and Management
2010, Medical Clinics of North America

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: Sources of support: Supported by the Nordic Institute of Chiropractic and Clinical Biomechanics, Odense, Denmark, and the Foundation for Chiropractic Research and Postgraduate Education, Denmark.

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Original ArticleCervicothoracic Angina Identified by Case History and Palpation Findings in Patients with Stable Angina Pectoris

Abstract

Objective

Methods

Results

Conclusion

Section snippets

Study Population

Results

Discussion

Conclusion

Acknowledgments

Prog Cardiovasc Dis

Am J Med

J Manipulative Physiol Ther

J Chronic Dis

Am J Cardiol

Pain

J Am Coll Cardiol

Part I. Examination of the patient: the history

Management of stable angina pectoris. Recommendations of the Task Force of the European Society of Cardiology

Eur Heart J

Patients with angina with normal and near normal coronary arteries: clinical and psychosocial state 12 months after angiography

BMJ

Chest pain in people with normal coronary anatomy

BMJ

Musculoskeletal chest wall syndromes in patients with noncardiac chest pain: a study of 100 patients

Arch Phys Med Rehabil

Rapid assessment of chest pain. Chest pain clinics may be one step forward, two steps back

BMJ

Non-cardiac chest pain: a useful physical sign?

Heart

Palpation of the anterior chest wall—an observer reliability study

J Manipulative Physiol Ther

Original Article
Cervicothoracic Angina Identified by Case History and Palpation Findings in Patients with Stable Angina Pectoris