Diagnosis and treatment of musculoskeletal chest pain: design of a multi-purpose trial

Abstract

BackgroundAcute chest pain is a major health problem all over the western world. Active approaches are directed towards diagnosis and treatment of potentially life threatening conditions, especially acute coronary syndrome/ischemic heart disease. However, according to the literature, chest pain may also be due to a variety of extra-cardiac disorders including dysfunction of muscles and joints of the chest wall or the cervical and thoracic part of the spine. The diagnostic approaches and treatment options for this group of patients are scarce and formal clinical studies addressing the effect of various treatments are lacking.Methods/DesignWe present an ongoing trial on the potential usefulness of chiropractic diagnosis and treatment in patients dismissed from an acute chest pain clinic without a diagnosis of acute coronary syndrome. The aims are to determine the proportion of patients in whom chest pain may be of musculoskeletal rather than cardiac origin and to investigate the decision process of a chiropractor in diagnosing these patients; further, to examine whether chiropractic treatment can reduce pain and improve physical function when compared to advice directed towards promoting self-management, and, finally, to estimate the cost-effectiveness of these procedures. This study will include 300 patients discharged from a university hospital acute chest pain clinic without a diagnosis of acute coronary syndrome or any other obvious cardiac or non-cardiac disease. After completion of the clinic's standard cardiovascular diagnostic procedures, trial patients will be examined according to a standardized protocol including a) a self-report questionnaire; b) a semi-structured interview; c) a general health examination; and d) a specific manual examination of the muscles and joints of the neck, thoracic spine, and thorax in order to determine whether the pain is likely to be of musculoskeletal origin. To describe the patients status with regards to ischemic heart disease, and to compare and indirectly validate the musculoskeletal diagnosis, myocardial perfusion scintigraphy is performed in all patients 2–4 weeks following discharge. Descriptive statistics including parametric and non-parametric methods will be applied in order to compare patients with and without musculoskeletal chest pain in relation to their scintigraphic findings. The decision making process of the chiropractor will be elucidated and reconstructed using the CART method. Out of the 300 patients 120 intended patients with suspected musculoskeletal chest pain will be randomized into one of two groups: a) a course of chiropractic treatment (therapy group) of up to ten treatment sessions focusing on high velocity, low amplitude manipulation of the cervical and thoracic spine, mobilisation, and soft tissue techniques. b) Advice promoting self-management and individual instructions focusing on posture and muscle stretch (advice group). Outcome measures are pain, physical function, overall health, self-perceived treatment effect, and cost-effectiveness.D...

Clinical characteristics, myocardial perfusion deficits, and clinical outcomes of patients with non-specific chest pain hospitalized for suspected acute coronary syndrome: A 4-year prospective cohort study

“…As part of a larger trial addressing sub-classification and treatment of patients with NSCP [15][16][17], the baseline evaluation was carried out during August 2006 to April 2008 at a CPU at a 1000-bed urban, university hospital serving approximately 300,000 inhabitants. This unit receives patients with suspected ACS and patients with other acute cardiac conditions.…”

Presentation of Coronary Artery Disease in a Chiropractic Clinic: A Report of 2 Cases

“…41 The lack of a definitive diagnosis can also lead to inappropriate investigations and management, with further anxiety and time lost from work. 42 Stochkendahl et al (2008) 43 suggest that a chiropractor may be able to identify and triage a subset of patients with chest pain predominantly of musculoskeletal origin among patients who are discharged from acute chest pain clinics with no apparent cardiac condition. The current study also demonstrates that a chiropractor may assist in the diagnoses of patients who are experiencing cardiac-related chest pain, not just noncardiac chest pain as in the former study.…”

Thoracic spine pain

“…Истинная корешковая боль встречается редко, под маской «межреберной невралгии» обычно скрывается скелетно-мышечная боль, иррадиирующая на переднюю поверх-ность грудной клетки и имеющая склеротомный, а не ней-ропатический характер [5,10,13,15,22,23].…”

“…Ниже и выше уровня блокирования сустава нередко определяется рефле-кторный спазм мышцы, выпрямляющей позвоночник. Боль провоцируется при глубокой пальпации соответствующего дугоотростчатого сустава [11,13,[22][23][24].…”

“…Боль при этом тупая, мозжащая, иногда глубо-кая с ощущением жжения, усиливается при форсированном дыхании, кашле, нередко иррадиирует по ходу межреберно-го промежутка и по передней поверхности грудной клетки, при сдавлении грудной клетки, пальпации в проекции ре-берно-поперечных и реберно-позвоночных суставов, на 2-3 см кнаружи от остистых отростков [11,13,23].…”