Palpation for muscular tenderness in the anterior chest wall: an observer reliability study

Reliability of joint mobility and pain assessment of the thoracic spine and rib cage in asymptomatic individuals

Despite the importance of correctly diagnosing a spinal dysfunction, limited research exists related to physical therapists' ability to reliably identify a joint exhibiting signs of dysfunction. The purpose of this investigation was to determine the inter- and intra-examiner reliability of a thoracic spine and rib cage joint mobility and pain assessment between two experienced manipulative physical therapists. Nine healthy subjects (3 male, 6 female; ages 23-35) without history of mid- or low back pain participated. Posterior-to-anterior pressures were applied to the thoracic spine and rib articulations with anterior-to-posterior pressures applied to the costosternal joints of each subject by two examiners to evaluate joint mobility and pain provocation. Both examiners assessed all subjects twice and were blinded to subject identity. Kappa statistics were calculated using a strict and expanded definition of agreement to determine the between- and within-examiner reliability for each outcome. Intra-examiner reliability of joint mobility assessment ranged from slight to fair based on the strict agreement but improved to good when findings were compared across +/- 1 spinal/rib level. Pain provocation reliability increased to very good under the expanded agreement; however, this finding should be viewed with caution due to limited pain prevalence in the subject sample. Selected clinical prediction rules, applied to the care of individuals with back pain, characterize the patient's regional mobility simply as hypomobile, normal, or hypermobile; consequently, we feel the results of an expanded definition of agreement may be more appropriate for clinic practice. Further research is needed to determine the reliability in individuals with thoracic spine and rib cage symptoms.

Chest pain in focal musculoskeletal disorders

The musculoskeletal system is a recognized source of chest pain. However, despite the apparently benign origin, patients with musculoskeletal chest pain remain under-diagnosed, untreated, and potentially continuously disabled in terms of anxiety, depression, and activities of daily living. Several overlapping conditions and syndromes of focal disorders, including Tietze syndrome, costochondritis, chest wall syndrome, muscle tenderness, slipping rib, cervical angina, and segmental dysfunction of the cervical and thoracic spine, have been reported to cause pain. For most of these syndromes, evidence arises mainly from case stories and empiric knowledge. For segmental dysfunction, clinical features of musculoskeletal chest pain have been characterized in a few clinical trials. This article summarizes the most commonly encountered syndromes of focal musculoskeletal disorders in clinical practice.

Pressure pain sensitivity and hardness along human normal and sensitized muscle

The spatial distribution of pressure sensitivity and muscle hardness was examined on normal muscle tissue and muscle tissue after induction of delayed onset muscle soreness (DOMS). The pressure sensitivity and muscle hardness were assessed at nine sites on the tibialis muscle from the proximal to distal tendon on two separate days. In total 37 healthy volunteers participated in three experiments. In the first experiment pressure pain threshold (PPT) and pressure pain tolerance (PPTO) were assessed. Decreased PPT and PPTO were found on day 2, 7 days after day 1. Proximal and distal stimulation sites were harder compared to muscle belly sites. In a second experiment two different probe sizes were used. Variation in PPT between the nine sites was found for the large probe with muscle belly being less sensitive to pressure stimulation compared to proximal and distal sites. The most proximal stimulation site was harder compared to muscle belly sites. In a third experiment PPT and muscle hardness were assessed before and 48 h after eccentric exercise. PPT at two muscle belly sites was significantly decreased during DOMS. No specific sites were harder during DOMS, the average muscle hardness across sites was however significantly increased. Decreased PPT and increased muscle hardness did not correlate. In conclusion, within subjects the pressure sensitivity varies along the musculoskeletal unit. In DOMS, specific muscle belly sites were more sensitive to pressure stimulation. Muscle-tendon sites were harder compared to muscle belly sites.

Manual Therapy for Patients With Stable Angina Pectoris: A Nonrandomized Open Prospective Trial

OBJECTIVE

To examine if participants with chest pain originating from the spine would benefit from manual therapy.

METHODS

A nonrandomized, open, prospective trial was performed at a tertiary hospital. Patients who were referred for coronary angiography because of known or suspected stable angina pectoris were invited to participate in this study. A total of 275 took part, 50 were diagnosed as cervicothoracic angina (CTA)-positive (chest pain from the cervicothoracic spine) and 225 as CTA-negative. The intervention performed was manual therapy according to chiropractic standards. Patient self reported questionnaires at baseline and 4-week follow-up, including pain measured with an 11-point box scale, Short Form 36 (quality of life), and perceived improvement.

RESULTS

Approximately 75% of CTA-positive patients reported improvement of pain and of general health after treatment, compared with 22% to 25% of CTA-negative patients (P < .0001). Pain intensity decreased in both groups with consistently larger decreases for all measures of pain among CTA-positive patients. Short Form 36 scores increased in the CTA-positive group in 5 of 8 scales and remained unchanged in the CTA-negative group.

CONCLUSION

This study suggested that patients with known or suspected angina pectoris and a diagnosis of CTA may benefit from chiropractic manual therapy. Methodologically, sound randomized clinical trials are needed to corroborate our results.

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

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.