Danish Medical Bulletin    |    Contact Front page  

 
Muskuloskeletal chest pain in patients with stable angina pectoris - diagnosis and treatment

Henrik Wulff Christensen  


  Download file   (3988 KB)

Accepted by: Health Sciences University of Southern Denmark
Defended on: April 26, 2004
Official opponents: Gert Brønfort , Hans Erik Bøtker , Peter Junker
Tutors: Poul Flemming Høilund-Carlsen , Torben Haghfelt , Claus Manniche

Published in the PhD Database: August 10, 2004


English abstract
This is a ph.d. -dissertation on diagnosis and treatment of chest pain from the musculoskeletal system in patients with known or suspected stable angina pectoris (AP), more definite named cervico-thoracic angina (CTA). The dissertation comprises 4 part projects (I-IV). The aim was to assess the reliability of different manual palpation methods for the detection of muscular tenderness in the thorax and biomechanical dysfunction in the spine (I-II). Additional, illustrate the occurrence of CTA in AP patients and describe the possible the diagnostic decision process based on the case history and clinical examination including manual palpation (III). Finally, it was examined if patients with a CTA positive diagnosis would benefit from manual treatment (IV).
In I and II we investigated the intra- and interobservatør reliability of 4 palpation methods in 85 patients. I part project III, 507 patients referred for coronary angiography (CAG) examined. Out of these 275 gave consent to participate. Myocardial perfusion imaging (MPI) was done to evaluate the perfusion of the myocardium and later CAG were done. The result was not communicated. The treatment part (IV) was done as a non-randomised trial where 50 patients with the diagnosis CTA were offered manual therapy. The studies showed, that it was possible to establish an examination program with low intraobserver variation, but with high interobserver variation except for paraspinal tenderness. Further, it was shown, that an experienced chiropractor, by systematic manual palpation of the spine and thorax in combination with a number of variables from the case history and the clinical examination, could identify a subgroup of AP patients with CTA, in the present material 18%. In this group we found normal myocardial perfusion in 80% compared with 50% in the CTA negative group. Finally, the non-randomised treatment series suggested that patients with suspected AP and a chiropractic-based diagnosis of CTA might benefit from manual therapy (IV). To sum up, the study gave the impression that musculoskeletal dysfunction can be a (contributory) cause of the chest pain in patients referred for further investigation of AP, and that manual therapy is a possible treatment offer to these patients.
The clinical consequences of the treatment trial cannot be concluded before we have long-term results and more controlled treatment trials.



Danish abstract
Emnet er diagnostik og behandling af såkaldte brystsmerter afledt fra det muskuloskeletale apparat hos patienter med kendt eller formodet stabil angina pectoris (AP), dvs. cerviko-thorakal angina (CTA). Formålet var at vurdere reproducerbarheden af forskellige manuelle palpationsmetoder til påvisning af muskulær ømhed i thorax og biomekaniske dysfunktioner i rygsøjlen. Desuden at beskrive forekomsten af CTA hos AP patienter og skitsere den diagnostiske beslutningsproces baseret på sygehistorie og klinisk undersøgelse inklusive palpation. Endelig at vurdere, om patienter med diagnosen CTA har gavn af manuel behandling.
Intra- og interobservatør variationen af 4 palpationsmetoder blev undersøgt hos 85 patienter. Ialt 275 patienter henvist til koronararteriografi (KAG) deltog i de kliniske studier. Der blev udført myokardiescintigrafi (MPI) til vurdering af myokardieperfusionen og senere KAG. Behandlingsdelen blev gennemført som et ikke-randomiseret forsøg. Det viste sig muligt at etablere et undersøgelsesprogram, hvormed en erfaren kiropraktor kunne identificere en undergruppe af AP patienter med CTA, ialt 18%. I denne gruppe havde 80% normal perfusion i myokardiet mod 50% af de CTA negative patienter. Den urandomiserede behandlingsdel viste, at AP patienter med den kiropraktiske diagnose CTA muligvis kan have gavn af manuel behandling. Projektet gav indtryk af, at det muskuloskeletal apparat kan være en (medvirkende) årsag til brystsmerter hos disse patienter, samt at manuel terapi muligvis er en behandlingsmulighed.