Chest pain in patients with COPD: the fascia's subtle silence

Beyond breathing: Systematic review of global chronic obstructive pulmonary disease guidelines for pain management

CONTEXT

Patients with chronic obstructive pulmonary disease (COPD) experience pain as both symptom and comorbidity. There has been no evaluation of the recommendations for pain management in updated clinical practice guidelines (CPGs).

OBJECTIVES

Update the evidence on pain management, determine alignment of pain management recommendations with best-practice, and advocate for optimal pain management in patients with COPD.

METHODS

PubMed, Guideline International Network, Guideline Portal, Agency for Healthcare Research and Quality, National Institute for Healthcare Excellence, Scottish International Guidelines Network, Institute of Medicine, grey literature, national websites, and bibliographies were searched. CPGs available online for stable COPD produced by organizations representing reputable knowledge of COPD management were included. CPGs unavailable online, not translatable into English, or not including techniques within the defined scope were excluded. Researchers performed frequency counts for the verbatim terms "pain," "physical activity," "exercise," "rehabilitation," "physical therap(ist)/(y), "physiotherap(ist)/(y)," recorded context, and collected recommendations for pain management/treatment when present.

RESULTS

Of 32 CPGs, 24 included "pain" verbatim. Of these, 13 included recommendations for pain treatment/management. Common recommendations included opioids, pharmacological management, further medical assessment, and surgical intervention. Two CPGs referred to palliative care, one CPG discussed treating cough, and one discussed massage, relaxation, and breathing.

CONCLUSIONS

Pain management recommendations vary and are not aligned with evidence. Pain should be addressed in patients with COPD, whether directly or indirectly related to the disease. Reduction of variability in pain management and the disease burden is necessary. Pain management should include referrals to providers who can maximize benefit of their services.

The Importance of the Diaphragm in Neuromotor Function in the Patient with Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is a constant and chronic narrowing of the respiratory airways, with numerous associated symptoms, not always related to the pathological adaptation of the lungs. Statistical projections show that COPD could become the third leading cause of death globally by 2030, with a significant increase in deaths by 2060. Skeletal muscle dysfunction, including the diaphragm, is one of the causes linked to the increase in mortality and hospitalization. Little emphasis is given by the scientific literature to the importance of the diaphragm towards functional neuromotor pathological expressions. The article reviews the adaptation of the skeletal muscles, with greater attention to the adaptations of the diaphragm, thereby highlighting the non-physiological variations that the main respiratory muscle undergoes and the neuromotor impairment found in COPD. The text could be an important reflection from a clinical and rehabilitation point of view, to direct greater attention to the function and adaptation of the diaphragm muscle.

Clinical and Psychological Impact of Chronic Pain in People with Chronic Obstructive Pulmonary Disease

Purpose

The presence of pain can be associated with an exaggerated negative cognitive and emotional response, leading to worsening of existing symptoms. This study aimed to describe the multifaceted impact of chronic pain on cognition, emotional and physical health in people with chronic obstructive pulmonary diseases (COPD) and to explore the clinical impact of pain.

Patients and Methods

A prospective, cross-sectional multicenter study was carried out in 68 people with COPD (COPD group) and 65 community-dwelling age-matched participants (control group). Participants were assessed for the presence of chronic pain, pain location, intensity and catastrophizing, pain-related fear (kinesiophobia), anxiety and depression, physical activity, and sleep duration. The COPD group also completed assessments of dyspnea, exercise tolerance (6-minute walk distance [6MWD]), and activities of daily living (ADL).

Results

The prevalence of pain was higher in the COPD group (85% vs 51%, p<0.001). The COPD group reported pain located in neck/shoulder, upper back, thorax and upper limbs, while the control group had more pain in the lower back. Pain catastrophizing and kinesiophobia were reported by 28% and 67% vs 9% and 42%, in the COPD and control groups respectively (both p<0.05). People with COPD and pain (n=58) reported greater dyspnea (p<0.001), and impairment in ADL (p<0.05), and lower 6MWD and physical activity (both p<0.01) compared to COPD participants without pain (n=10).

Conclusion

This study demonstrated that, compared to community-dwelling participants, there is a higher prevalence of chronic pain in people with COPD. Pain combined with dyspnea may impact adversely on cognitive function and lead to anxiety and depression, as well as greater impairment in exercise tolerance, physical activity, and ADL. These results suggested that it is necessary to assess the symptoms of chronic pain and inflect in chronic pain coping strategies.

The relationship between vertebral deformities and thoracic arthropathy with back pain in Chronic Obstructive Pulmonary Disease

OBJECTIVES

The aim of the study was to investigate the relationship between back pain and thoracic vertebral deformities and arthropathy in patients with COPD who underwent thorax CT scans to screen for lung nodules and cancer.

MATERIALS AND METHODS

The data of patients who underwent thoracic CT and pulmonary function tests (PFTs) between July 2019 and February 2020 were retrospectively reviewed. The patients were divided into two groups: the COPD (n = 64) and control groups (n = 101), according to the PFT results. The CT images were evaluated for vertebral deformities, osteoporosis and thoracic vertebral joint arthropathy, and the Spinal Deformity Index (SDI) was calculated.

RESULTS

Back pain was detected in 43.7% of the COPD patients and 20.9% of the controls. The patients with COPD had significantly higher rates of costotransverse, intervertebral, facet joint arthropathy, and osteoporosis than did the control group (P < .001). The OR analyses showed that the presence of a vertebral deformity (OR 4.42, 95% CI 2.26 - 8.63, P < .001), of facet joint arthropathy (OR 3.6, 95% CI 2.83-4.58, P < .001), and of costotransverse arthropathy (OR 2.20, 95% CI 1.47-2.77, P < .001) were associated with the presence of back pain. Although a strong positive correlation was found between the SDI and pain score, a moderate negative correlation was found between the FEV1% values and pain score.

CONCLUSIONS

Back pain was present in patients with COPD and was related to vertebral deformities and facet and costotransverse joint arthropathy. Additional studies are required to clarify the relationships of back pain with musculoskeletal system diseases, including cervical and lumbar spine arthropathy and vertebral deformities.

Functional evaluation of the diaphragm with a noninvasive test

Cardiac surgery with median sternotomy causes iatrogenic damage to the function of the diaphragm muscle that is both temporary and permanent. Myocardial infarction itself causes diaphragmatic genetic alterations, which lead the muscle to nonphysiological adaptation. The respiratory muscle area plays several roles in maintaining both physical and mental health, as well as in maximizing recovery after a cardiac event. The evaluation of the diaphragm is a fundamental step in the therapeutic process, including the use of instruments such as ultrasound, magnetic resonance imaging (MRI), and computed axial tomography (CT). This article reviews the neurophysiological relationships of the diaphragm muscle and the symptoms of diaphragmatic contractile dysfunction. The authors discuss a scientific basis for the use of a new noninstrumental diaphragmatic test in the hope of stimulating research.

Prevalence and risk factors of musculoskeletal pain in patients with chronic obstructive pulmonary disease: A systematic review

OBJECTIVES

This systematic review aimed to discuss the prevalence and the risk factors of the musculoskeletal pain in chronic obstructive pulmonary disease (COPD).

DATA SOURCE AND STUDY SELECTION

Four databases were analysed (Scopus, PubMed, Cochrane and EMBASE). We excluded systematic reviews, meta-analyses, conference abstracts and case reports. Two authors independently checked for the eligibility of the relevant articles. The risk of bias was evaluated using the Newcastle Ottawa Quality Assessment Scale and the Joanna Briggs Institute critical appraisal checklist. The selection and evaluation of studies followed the PRISMA guidelines.

RESULTS

Twenty studies were retrieved, including from 21 to 7952 patients with COPD. The prevalence of pain was highly heterogeneous across studies: 7-89.7%. Pain was mostly reported in the lumbar (7-69%) and cervical spine (11-48.3%) and the chest (44-82.8%). The main risk factors for developing pain were old age, sex (female), level of physical activity (low) and comorbidities.

CONCLUSION

Pain is a very common symptom in patients with COPD. Despite this, few clinical trials have investigated the pain. It appears to be located primarily in the lumbar, cervical and thoracic regions and facilitated by being a female, a low level of physical activity, comorbidity(ies) and old age.

Symptom severity is associated with signs of central sensitization in patients with asthma

INTRODUCTION

Asthma is characterized by recurrent episodes of wheezing, dyspnoea, chest tightness and cough. In addition to respiratory symptoms, previous studies have reported the presence of pain.

OBJECTIVE

To analyse the nociceptive processing of young adults with well-controlled asthma.

METHODS

A cross-sectional case-control study was performed. Patients diagnosed with persistent well-controlled asthma were recruited from the 'Complejo Hospitalario Universitario' (Granada). Main outcomes included pain processing, measured by the pressure-pain thresholds (PPTs) and temporal summation and latency of pain; symptoms, including cough (Leicester Cough Questionnaire) and dyspnoea (Borg scale); and catastrophic cognitions about breathlessness, assessed by the Breathlessness Catastrophizing Scale (BCS).

RESULTS

Seven-two participants were finally recruited in our study. Patients with asthma presented lower pressure thresholds (p < 0.05) and significant differences in latency and summation tests. These patients also presented a greater cough level, with significant differences in all subscales (p < 0.05). Significant differences were also found in the BCS between groups (p < 0.001).

CONCLUSION

Our results show a decrease of PPTs and a greater pain intensity in latency and summation tests, suggesting an abnormal pain processing in patients with asthma.

Osteopathic Palpation of the Heart

In the panorama of scientific literature, there is a paucity of literature on how to palpate the heart area in the osteopathic setting and relevant indications on which palpatory sensations the clinician should perceive during the evaluation. The article reviews the fascial anatomy of the heart area and the heart movements derived from magnetic resonance imaging (MRI) studies and describes the landmarks used by the cardiac surgeon to visualize the mediastinal area. The text sets out possible suggestions for a more adequate osteopathic palpatory evaluation and describes any tactile sensations arising from the patient's chest. To the knowledge of the authors, this is the first article that seeks to lay solid foundations for the improvement of osteopathic manual medicine in the cardiology field.

Ambient air quality and the risk for Chronic Obstructive Pulmonary Disease among Metro Manila Development Authority traffic enforcers in Metro Manila: An exploratory study

Background

Air pollution and poor ambient air quality are significantly related to multiple health risks. One associated disease is chronic obstructive pulmonary disease (COPD), a preventable disease with several contributing factors and one of the leading causes of morbidity/mortality locally and globally. A potentially high-risk population are traffic enforcers who are constantly exposed to air pollution. In the Philippines, the MMDA has the widest coverage in traffic management. The study determined the risk of COPD among Metro Manila Development Authority (MMDA) traffic enforcers in relation to ambient air quality level, as well as identified other factors that increase the risk of developing COPD.

Methods

Fifty-two MMDA traffic enforcers deployed in PM_2.5 air quality sensor areas in Metro Manila from 2016 to 2018 were recruited through stratified sampling. The International Primary Airways Guidelines (IPAG) questionnaire was utilized to measure risk of COPD. Respiratory health and working history were obtained through questionnaires. Department of environment and natural resources provided PM_2.5 ambient air quality data which aided in the construction of the Exposure-Month Index. Ordinal logistic regression was used to examine the association of PM_2.5 together with the relevant factors and the risk of COPD.

Results

We found statistically significant associations between PM_2.5 and COPD among high risk category [odds risk (OR): 1.24, 95% confidence interval (CI): 1.07-1.44]. Age (Moderate, OR: 1.16, 95% CI: 0.98-1.38 and High, OR: 10.06, 95% CI: 4.02-25.17) and chest pain (Moderate, OR: 68.65, 95% CI: 1.71-2.75 × 10³) were potential risk factors, whereas body mass index (BMI) (OR: 0.05, 95% CI: 0.01-0.53) exhibited protective effect.

Conclusions

Exposure to PM_2.5 was associated with an increased risk of COPD among high-risk category MMDA traffic enforcers. Age and chest pain were potential risk factors to risk of COPD, whereas BMI exhibited a potential protective effect. Results of this study can be used for clinical management of high-risk populations, such that of MMDA traffic enforcers.

Pain Prevalence, Localization, and Intensity in Adults with and without COPD: Results from the Danish Health and Morbidity Survey (a Self-reported Survey)

Introduction

Pain is a clinical complication to chronic obstructive pulmonary disease (COPD) that interferes negatively with physical activity level (PAL), quality of life (QOL) and pulmonary interventions. Yet, research in pain characteristics including prevalence, localization, and intensity in people with COPD are sparsely researched.

Aim

To investigate self-reported pain prevalence, localization and intensity of pain in people with and without COPD, and to investigate the association between pain intensity and PAL among participants with COPD.

Methods

Data were derived from the Danish Health and Morbidity Survey in 2017. The study population was restricted to individuals aged ≥35 years. Data included pain intensity assessed on the Numeric Rating Scale (NRS) and localization, PAL, QoL, sleep disturbance, comorbidities, sociodemographic and behavioral factors.

Results

In all, 528 participants with COPD and 8184 participants without COPD (51% females, mean ±SD age 67.1±11.4 years) were analyzed. Pain prevalence within the past 14 days was significantly higher in participants with COPD vs nonCOPD (72.7% vs 57.7%, p<0.001) and mainly located in the limbs, thorax, and lower back. COPD was associated with the prevalence of chronic pain (≥6 months) (OR: 2.78, 95%CI: 2.32; 3.34, p<0.001). Participants with COPD reported a higher pain intensity compared to those with nonCOPD with a mean difference of 1.04 points (95%CI: 0.75; 1.32, p<0.001) on the NRS. In the adjusted multiple logistic regression analysis, pain intensity was negatively associated with odds of being physical active (OR: 0.72, 95%CI: 0.61; 0.85, p<0.001).

Conclusion

Pain is more prevalent in people with self-reported COPD. After adjustment for age and gender, COPD was associated with an elevated pain intensity. Sleep disturbance and multimorbidity had the most pronounced impacts on pain intensity in the multiple linear regression model. In participants with COPD, increased pain intensity was negatively associated with being physically active.

COPD is Associated with Higher Prevalence of Back Pain: Results of a Population-Based Case-Control Study, 2017

Objective

We aimed to assess whether patients suffering from COPD have a higher prevalence of chronic back pain (neck and low back pain) than age-, sex-, and residence-matched non-COPD controls. We also aimed to identify which variables are associated with chronic neck pain (CNP) and chronic low back pain (CLBP) among COPD patients.

Methods

We carried out a retrospective case-control study using data obtained from the Spanish National Health Survey conducted in 2017.

Results

We analyzed data from 1034 COPD and 1034 matched non-COPD controls. The prevalence of CNP and CLBP was 38.20% and 45.16%, respectively, among COPD patients and 22.82% and 28.34% for non-COPD controls, respectively (p<0.001 for both). Multivariable analysis showed that COPD patients had a 1.62-fold (95% CI 1.50-1.74) higher risk of CNP and a 1.83-fold (95% CI 1.73-1.91) higher risk of CLBP than non-COPD controls. Experiencing one type of pain greatly increased the risk of having the other. Factors associated with the presence of both types of pain among COPD patients included female sex, "fair/poor/very poor" self-rated health, migraine or frequent headache and use of pain medication. Being aged from 70 to 79 years was a risk factor for CLBP, and suffering from a mental disorder was a risk factor for CNP.

Conclusion

The prevalence of CNP and CLBP was significantly higher among COPD patients than among non-COPD controls after adjusting for age, sex and other relevant clinical variables. Our findings add new data to the knowledge of chronic pain in COPD patients.

Changes in and predictors of pain and mortality in patients with chronic obstructive pulmonary disease

This longitudinal study of patients with chronic obstructive pulmonary disease (COPD) aimed to investigate changes in pain characteristics (i.e., occurrence, intensity, and interference) and covariates associated with pain from study enrollment to 12 months, and to investigate if the different pain characteristics were associated with 5-year mortality. In total, 267 patients with COPD completed questionnaires five times over 1 year. The mean age of the patients was 63 years (standard deviation: 9.0), 53% were women, and 46% had very severe COPD. Median number of comorbidities was 2.0 (range: 0-11) and 47% of patients reported back/neck pain. Mixed models and Cox regression models were used for analyses. In total, 60% of the patients reported pain at baseline, and 61% at 12 months. The mixed model analyses revealed that those with better forced expiratory volume in 1 s (% predicted), more comorbidities, only primary school education, and more respiratory symptoms reported significantly higher average pain intensity. Moreover, those with more comorbidities, more respiratory symptoms, and more depression reported higher pain interference with function. At the 5-year follow-up, 64 patients (24%) were deceased, and the cumulative 5-year mortality rate was 22% (95% confidence interval [19-25]). Older age, lower forced expiratory volume in 1 s (% predicted), and higher pain interference at enrollment were all independently and significantly associated with higher 5-year mortality. Our findings show that many patients with COPD have persistent pain, and awareness regarding comorbidities and how pain interferes with their lives is needed.

The Five Diaphragms in Osteopathic Manipulative Medicine: Neurological Relationships, Part 2

The main objective of the osteopath and that of osteopathic manipulative medicine (OMM) is to create space between the different tissues. The sliding capacity of the various tissue layers and between the different body components, up to the possibility of movement between cells is the salutogenic stimulus to allow the circulation of fluids, the biochemical exchange, and the adequate management of the multiple internal and external stimuli that perturb the body living. Movement is allowed by space and space is life. In this second part, the exposure of the anatomical neurological relationships of the five diaphragms continues, highlighting the relationships of the thoracic outlet, the respiratory diaphragm, and the pelvic floor. Finally, there will be clinical reflections to further corroborate the existence of the anatomical continuum and to lay the scientific foundations for an OMM approach to body diaphragms.

Chronic Obstructive Pulmonary Disease: Proprioception Exercises as an Addition to the Rehabilitation Process

Respiratory rehabilitation in patients with chronic obstructive pulmonary disease (COPD) is recognized as a cornerstone for the therapeutic path. Physiotherapy involves physical activity with aerobic and anaerobic exercises, which can improve the patient's symptomatic picture, such as motor function, emotional status (depression and anxiety), and improve the pain perception. The training of proprioception is not included in the structure of the exercises proposed by the Global Initiative for Chronic Obstructive Lung Disease (GOLD). The training of proprioception is a very useful strategy for stimulating the cerebellum, a neurological suffering area in patients with COPD. The cerebellum sorts information about pain and emotions, as well as motor stimuli. The article discusses the need to introduce proprioception in respiratory rehabilitation protocols, highlighting the neurological relationships with the management of comorbidities.

The Five Diaphragms in Osteopathic Manipulative Medicine: Myofascial Relationships, Part 1

Working on the diaphragm muscle and the connected diaphragms is part of the respiratory-circulatory osteopathic model. The breath allows the free movement of body fluids and according to the concept of this model, the patient's health is preserved thanks to the cleaning of the tissues by means of the movement of the fluids (blood, lymph). The respiratory muscle has several systemic connections and multiple functions. The founder of osteopathic medicine emphasized the importance of the thoracic diaphragm and body health. The five diaphragms (tentorium cerebelli, tongue, thoracic outlet, thoracic diaphragm and pelvic floor) represent an important tool for the osteopath to evaluate and find a treatment strategy with the ultimate goal of patient well-being. The two articles highlight the most up-to-date scientific information on the myofascial continuum for the first time. Knowledge of myofascial connections is the basis for understanding the importance of the five diaphragms in osteopathic medicine. In this first part, the article reviews the systemic myofascial posterolateral relationships of the respiratory diaphragm; in the second I will deal with the myofascial anterolateral myofascial connections.

Prevalence and Characteristics of Pain in Patients of Chronic Obstructive Pulmonary Disease: A Cross-Sectional Study in China

The purposes of this study were to: (1) study the prevalence of pain in patients with mild-to-very severe chronic obstructive pulmonary disease (COPD) in China; (2) compare the differences in pain characteristics between stable COPD and acute exacerbation of COPD (AECOPD); (3) explore the clinical associations with pain in those with COPD. This cross-sectional study was conducted in China from October 24, 2017, to January 11, 2019. A face-to-face interview was conducted to collect data. The Chinese version of the brief pain inventory (BPI-C) was applied to investigate the pain characteristics in patients with COPD. Of the 901 patients in this study, 226 (25.1%) patients reported pain problems. The prevalence of pain in patients with mild to very severe COPD was 32.9%, 23.9%, 25.2%, and 23.5%, respectively (p = 0.447). According to the BPI-C results, 31.3% (31/99) of patients reported pain of AECOPD, compared to 24.3% (195/802) of stable COPD (p = 0.13). Reported pain intensity and pain interference evaluated by the BPI-C were significantly higher in AECOPD than stable COPD (p < 0.001, p < 0.05, respectively). Those with body mass index (BMI) ≥ 24kg/m² or COPD assessment test (CAT) score > 20 were significantly more likely to have pain problems than BMI < 24kg/m² (aOR = 1.568, a95IC = 1.132-2.170, p = 0.007) or CAT ≤ 20 (aOR= 1.754, a95IC = 1.213-2.536, p = 0.003). Pain was common in patients with both stable COPD and AECOPD. AECOPD patients had a significantly higher pain intensity than stable COPD. Overweight and CAT > 20 were significantly related to higher prevalence of pain.

The Fascial Breath

The word diaphragm comes from the Greek (διάϕραγμα), which meant something that divides, but also expressed a concept related to emotions and intellect. Breath is part of a concept of symmorphosis, that is the maximum ability to adapt to multiple functional questions in a defined biological context. The act of breathing determines and defines our holobiont: how we react and who we are. The article reviews the fascial structure that involves and forms the diaphragm muscle with the aim of changing the vision of this complex muscle: from an anatomical and mechanistic form to a fractal and asynchronous form. Another step forward for understanding the diaphragm muscle is that it is not only covered, penetrated and made up of connective tissue, but the contractile tissue itself is a fascial tissue with the same embryological derivation. All the diaphragm muscle is fascia.

Biotensegrity or Fascintegrity?

The biotensegrity view of the living is a theoretical model and there is no mathematical study in vitro or in vivo that demonstrates its validity, taking into account the presence of liquids (blood, lymph, water), the tension produced by nerves and blood vessels, just as the displacement of the viscera and their resistances and contractions are not taken into consideration. The concept of cellular transduction is reviewed as it is the key to understanding if the passage of different mechanical information occurs only through solid structures, such as the cytoskeleton, or even liquid and viscous. The article focuses on reviewing the weaknesses of the biotensegrity model in the light of new scientific information, trying to coin another term that better reflects the dynamics of living: fascintegrity.

The Other Side of the Fascia: Visceral Fascia, Part 2

In osteopathic clinical practice and in the teaching of osteopathic medicine, the visceral manipulation approach is included. The knowledge that some viscera satisfy the definition of fascial tissue will allow the osteopath to improve its practice. In the second part of the article, we will give a conclusive definition of fascia, and we will explain the embryological development of the heart and how the fascial tissue can be subject to manual treatment. This text is the first in the international scientific field that discusses the inclusion of some viscera in the context of what is considered fascia, through our committee for the definition and nomenclature of the fascial tissue of the Foundation of Osteopathic Research and Clinical Endorsement (FORCE).

The Diaphragm Muscle Manual Evaluation Scale

This is a technical report describing how to use the Manual Evaluation Diaphragm (MED) scale, the only evaluation scale in the world to generate a value for the mobility of the main respiratory muscle. In a previously published paper, we described how the areas of the diaphragm should be palpated correctly because a valid manual diaphragmatic evaluation was lacking in the literature. The MED scale emerged as a logical consequence of manual palpation, to provide reference values and allow comparisons between the assessments of different health professionals in multidisciplinary teams. The scale is the first non-instrumental approach to obtaining data on diaphragm function and provides parameters by which the effects that a therapeutic approach has on the diaphragm can be measured.

Lymphatic Pump Manipulation in Patients with Chronic Obstructive Pulmonary Disease

Patients with chronic obstructive pulmonary disease (COPD) show a persistent local and systemic inflammatory pattern which stimulates negative remodeling of the airways. Globally, chronic respiratory disease is the third leading cause of death. One of the rehabilitative strategies used to improve the symptoms of COPD patients is the use of lymphatic pump manipulation; this procedure aims to reduce the concentration of pro-inflammatory substances. However, research results relating to this technique are contradictory. This article reviews the mechanisms that determine lymphatic flow, lymphatic lung anatomy, and the lymphatic response to respiratory pathology. Also highlighted is the manual approach to the mediastinum which can be used to improve the lymphatic and inflammatory response in COPD. Finally, new manual strategies have been discussed with which lymphatic flow in patients with COPD can be improved.

Non-Cardiac Chest Pain: A Review of Environmental Exposure-Associated Comorbidities and Biomarkers

The prevalence of non-cardiac chest pain (NCCP) ranges from 13-33%. A majority of those presenting with a chief complaint of chest pain are found to have a diagnosis of NCCP. Aerodigestive diseases are a cause of NCCP, and billions of dollars are spent annually on the treatment of NCCP. Furthermore, NCCP can cause significant psychological stress. NCCP is commonly diagnosed when patients have chest pain despite a normal cardiac evaluation. The leading cause of NCCP is gastro-oesophageal reflux disease (GORD). GORD should be suspected in patients who report a history of acid regurgitation, cough, dysphagia, and bloating. Another common cause of NCCP is obstructive airway disease (OAD). A thorough history and review of the symptoms should be performed for those with suspected NCCP, especially because of the contributing end organs. It is known that environmental exposures can commonly cause GORD and OAD; however, NCCP has not been fully explored in the context of environmental exposure. Patients with a history of exposure to particulate matter can develop environmental-exposure-associated GORD and coexisting OAD. This narrative review aims to provide a practical overview of NCCP, its causes, their relation to environmental exposure, and associated biomarkers. The authors used a PubMed search that spanned 2003-2018 to accomplish this. Additionally, this review provides a broad overview of biomarkers of GORD-associated NCCP and OAD-associated NCCP due to environmental exposure.

The Awareness of the Fascial System

Fascia is a cacophony of functions and information, a completely adaptable entropy complex. The fascial system has a solid and a liquid component, acting in a perfect symbiotic synchrony. Each cell communicates with the other cells by sending and receiving signals; this concept is a part of quantum physics and it is known as quantum entanglement: a physical system cannot be described individually, but only as a juxtaposition of multiple systems, where the measurement of a quantity determines the value for other systems. Fascial continuum serves as a target for different manual approaches, such as physiotherapy, osteopathy and chiropractic. Cellular behaviour and the inclusion of quantum physics background are hardly being considered to find out what happens between the operator and the patient during a manual physical contact. The article examines these topics. According to the authors' knowledge, this is the first scientific text to offer manual operators’ new perspectives to understand what happens during palpatory contact. A fascial cell has not only memory but also the awareness of the mechanometabolic information it feels, and it has the anticipatory predisposition in preparing itself for alteration of its natural environment.

Frontiers in fascia research

Basic sciences are the backbone of every clear understanding of how the body is composed and how different structures and functions are connected with each other. It is obvious that there is a huge variability in human beings - not only in terms of the outer appearance such as measurements of height, weight, muscle mass and other physical properties, but also with respect to metabolic and functional parameters. This article highlights recent developments of research activities in the field of fascia sciences with a special emphasis on assessment strategies as the basis of further studies. Anatomical and histological studies show that fascial tissue is highly variable in terms of density, stiffness, and other parameters such as metabolic and humoral activity. Moreover, it encompasses nerves and harbours a system of micro-channels, also known as the primo vascular system. As ultrasound is a widely available method, its use is appealing not only for imaging of fascial structures, but also for thorough scientific analysis. Unlike most other imaging technologies, US has the advantage of real-time analysis of active or passive movements. In addition, other assessment methods for fascial tissue are discussed. In conclusion, fascial tissue plays an important role not only in functional anatomy, but also in evolutionary and molecular biology, sport, and exercise science as well as in numerous therapeutic approaches. A high density of nerves is found in fascial tissue. Knowledge of individual characteristics, especially by visualizing with ultrasound, leads to personalized therapeutic approaches, such as in pain therapy.