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

Assessment of Body Posture of Children With Chest Pain

Objective: An increase in the appearance of chest pain among children is observed globally. The authors present various reasons for their appearance. As can be seen from numerous observations, the majority of cases are not related to the pathology of the circulatory system. Increasingly, studies on the causes of chest pain in children show their association with musculoskeletal disorders. Aim: of the work was assessment of body posture in children with chest pain using the Diers Formetric 4D system. Methods: The study involved a group of 184 female and male children, aged 7-12 years. The study group consisted of 64 patients with chest pain. The children from this group were diagnosed with functional chest pain by a cardiologist. The control group consisted of 120 patients without chest pain. The study included the assessment of body posture using the DIERS Formetric system. Results: The analysis of the results obtained during the study showed that among the children with chest pain, there are statistically significant irregularities in the parameters determining body posture compared to the control group. Comparing the study group with the control group, there is a statistically significant difference in the lateral deviation of VPDM (rms) (mm) (p = 0.001). Both children from the test group aged 9-10 and 11-12 obtained higher results than their peers from the control group. In the group of the youngest children in terms of the lateral deviation of VPDM (rms) (mm), increasing the number of children under study would contribute to significant differences in this variable. In the study group, among children aged 9-10 years, there were also statistically significant abnormalities regarding trunk imbalance and pelvic skewness compared to the children of the same age in the control group. Conclusions: Irregularities in the parameters determining body posture may cause chest pain in children.

Emergency Department Clinician Experiences and Perceptions Regarding Noncardiac Chest Pain: A Cross-Sectional Survey

OBJECTIVES

The objectives of this study are to report the responses of emergency department (ED) clinicians regarding the characteristics and management of patients with noncardiac chest pain (NCCP) and to explore clinician experiences with the current standard of care and whether nonpharmacologic or nonsurgical referral options would be considered.

METHODS

A cross-sectional survey was delivered to 40 ED clinicians from hospitals in Winnipeg, Manitoba from 2012 to 2013. Data were reduced descriptively and thematically summarized to assess the characteristics of patients with NCCP along with the responses of ED clinicians regarding the management of NCCP.

RESULTS

The survey response was 27 (67.5% response rate). They reported that patients with NCCP comprised a considerable amount of ED care and are a variable and heterogeneous population. Respondents agreed (63.0%) that onsite and on-call providers for NCCP referral would assist in patient management. Further, ED clinicians (66.7%) would consider referring patients with NCCP to a nonpharmacologic, nonsurgical clinical research study.

CONCLUSION

Clinicians in this study wanted better access to on-site referrals and outpatient clinics for patients experiencing NCCP after discharge and would consider nonpharmacologic or nonsurgical referral.

Cost-effectiveness of chiropractic care versus self-management in patients with musculoskeletal chest pain

Aims

To assess whether primary sector healthcare in the form of chiropractic care is cost-effective compared with self-management in patients with musculoskeletal chest pain, that is, a subgroup of patients with non-specific chest pain.

Methods and results

115 adults aged 18–75 years with acute, non-specific chest pain of musculoskeletal origin were recruited from a cardiology department in Denmark. After ruling out acute coronary syndrome and receiving usual care, patients with musculoskeletal chest pain were randomised to 4 weeks of community-based chiropractic care (n=59) or to a single information session aimed at encouraging self-management as complementary to usual care (n=56). Data on resource use were obtained from Danish national registries and valued from a societal perspective. Patient cost and health-related quality-adjusted life years (QALYs; based on EuroQol five-dimension questionnaire (EQ-5D) and Short Form 36-item Health Survey (SF-36)) were compared in cost-effectiveness analyses over 12 months from baseline. Mean costs were €2183 lower for the group with chiropractic care, but not statistically significant (95% CI −4410.5 to 43.0). The incremental cost-effectiveness ratio suggested that chiropractic care was cost-effective with a probability of 97%, given a threshold value of €30 000 per QALY gained. In both groups, there was an increase in the health-related quality of life, and the mean increases were similar over the 12-month evaluation period. The mean differences in QALYs between the groups were negligible.

Conclusions

Chiropractic care was more cost-effective than self-management. Therefore, chiropractic care can be seen as a good example of a targeted primary care approach for a subgroup of patients with non-specific chest pain.

Trial registration number

NCT00462241.

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

OBJECTIVE

The purpose of this report is to describe 2 patients with coronary artery disease presenting with musculoskeletal symptoms to a chiropractic clinic.

CLINICAL FEATURES

A 48-year-old male new patient had thoracic spine pain aggravated by physical exertion. A 61-year-old man under routine care for low back pain experienced a secondary complaint of acute chest pain during a reevaluation.

INTERVENTION AND OUTCOME

In both cases, the patients were strongly encouraged to consult their medical physician and were subsequently diagnosed with coronary artery disease. Following their diagnoses, each patient underwent surgical angioplasty procedures with stenting.

CONCLUSION

Patients may present for chiropractic care with what appears to be musculoskeletal chest pain when the pain may be generating from coronary artery disease necessitating medical and possibly emergency care.

Could the clinical interpretability of subgroups detected using clustering methods be improved by using a novel two-stage approach?

Background

Recognition of homogeneous subgroups of patients can usefully improve prediction of their outcomes and the targeting of treatment. There are a number of research approaches that have been used to recognise homogeneity in such subgroups and to test their implications. One approach is to use statistical clustering techniques, such as Cluster Analysis or Latent Class Analysis, to detect latent relationships between patient characteristics.

Influential patient characteristics can come from diverse domains of health, such as pain, activity limitation, physical impairment, social role participation, psychological factors, biomarkers and imaging. However, such ‘whole person’ research may result in data-driven subgroups that are complex, difficult to interpret and challenging to recognise clinically.

This paper describes a novel approach to applying statistical clustering techniques that may improve the clinical interpretability of derived subgroups and reduce sample size requirements.

Methods

This approach involves clustering in two sequential stages. The first stage involves clustering within health domains and therefore requires creating as many clustering models as there are health domains in the available data. This first stage produces scoring patterns within each domain. The second stage involves clustering using the scoring patterns from each health domain (from the first stage) to identify subgroups across all domains. We illustrate this using chest pain data from the baseline presentation of 580 patients.

Results

The new two-stage clustering resulted in two subgroups that approximated the classic textbook descriptions of musculoskeletal chest pain and atypical angina chest pain. The traditional single-stage clustering resulted in five clusters that were also clinically recognisable but displayed less distinct differences.

Conclusions

In this paper, a new approach to using clustering techniques to identify clinically useful subgroups of patients is suggested. Research designs, statistical methods and outcome metrics suitable for performing that testing are also described. This approach has potential benefits but requires broad testing, in multiple patient samples, to determine its clinical value. The usefulness of the approach is likely to be context-specific, depending on the characteristics of the available data and the research question being asked of it.

A randomized clinical trial of chiropractic treatment and self-management in patients with acute musculoskeletal chest pain: 1-year follow-up

OBJECTIVE

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.

METHODS

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).

RESULTS

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.

CONCLUSIONS

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

OBJECTIVE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

A case of pseudo-angina pectoris from a pectoralis minor trigger point caused by cross-country skiing

OBJECTIVE

The aim of this article is to illustrate the pectoralis minor muscle as a possible pain source in patients with anterior chest pain, especially those who are known to be beginner cross-country skiers.

CLINICAL FEATURES

A 58-year-old man presented with anterior chest pain and normal cardiac examination findings. Upon history taking and physical examination, the chest pain was determined to be caused by active trigger points in the pectoralis minor muscle.

INTERVENTION AND OUTCOME

The patient was treated with Graston Technique and cross-country skiing technique advice. The subject's symptoms improved significantly after 2 treatments and completely resolved after 4 treatments.

CONCLUSION

This case demonstrates the importance of differential diagnosis and mechanism of injury in regard to chest pain and that chiropractic management can be successful when addressing patients with chest wall pain of musculoskeletal origin.

Future developments in chest pain diagnosis and management

Much of the focus of research on patients with chest pain is directed at technological advances in the diagnosis and management of acute coronary syndrome (ACS), pulmonary embolism (PE), and acute aortic dissection (AAD), despite there being no significant difference at 4 years as regards mortality, ongoing chest pain, and quality of life between patients presenting to the emergency department with noncardiac chest pain and those with cardiac chest pain. This article examines future developments in the diagnosis and management of patients with suspected ACS, PE, AAD, gastrointestinal disease, and musculoskeletal chest pain.

An algorithm for the diagnosis and management of chest pain in primary care

This article focuses on the key clinical and investigatory features that help differentiate the multiple causes of chest pain in adults in assessment of patients with undifferentiated chest pain in primary care using history, physical examination, and basic initial investigations. The initial treatment of many of the causes is discussed. Some treatments not only relieve symptoms but also provide further diagnostic information based on the response to treatment. Guidance for referral for specialist assessment and further investigations is provided, but the diagnostic usefulness of these measures is not discussed.