8/24/2016
Osteopathic Care for Female Patients with Chest Pain Laura Griffin, D.O., FAAO Associate Professor and Chair Department of Osteopathic Principle and Practices University of Pikeville Kentucky College of Osteopathic Medicine President, American Academy of Osteopathy
Objectives • Review common etiologies of chest pain in females in a case‐based format • Discuss osteopathic considerations in the care of these patients • Review and practice easy OMT techniques useful in the everyday office setting
Why is this Important? • Incidence of chest pain of any etiology in primary care is under 1% • About 1‐2% of outpatient chief complaints (2005 American Family Physician) • Probably an under‐reported complaint
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Epidemiology of chest pain in primary care and Emergency Department settings Diagnosis
Primary care US
Primary care UK
Musculoskeletal condition
36%
29%
ER 7%
GI disease
19%
10%
3%
Serious cardiovascular disease
16%
13%
54%
Stable coronary artery disease
10%
8%
13%
Unstable coronary artery disease
1.5%
‐‐‐
13%
Psychosocial or psychiatric disease
8%
17%
9%
Pulmonary disease
5%
20%
12%
Nonspecific chest pain
16%
11%
15%
Differential Diagnosis by System • • • • • • •
Cardiac: Angina, MI, PE Musculoskeletal: Costochondritis/Tietze’s syndrome Pulmonary: Pneumonia, asthma Gastrointestinal: GERD Neurologic: Anxiety, intercostal neuritis Rheumatologic: Pericarditis or pleurisy 2° SLE, RA Somatic dysfunction
• It can be confusing because there can be musculoskeletal reflection of these processes leading you to believe the etiology is muculoskeletal
Cardiac: Angina • 44 yo Caucasian female presents for yearly well‐ check with no complaints • ROS: denies CP but says she feels like her bra is too tight with household exertion like vacuuming. Also has dyspnea but says it’s because she is “out of shape” • Onset is gradual, 5 minutes duration, resolves with rest, does not occur with rest • No change with respiration or position and not reproduced with palpation
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Cardiac: Angina • What are key features that make this suspicious for angina? • What are some possible physical exam findings?
Cardiac: Angina • Characteristics • Often diffuse and hard to describe. May be pressure (“feels like my bra is tight”) • May radiate into jaw and neck, radiating to the left upper chest • GRADUAL in onset and relief • If it only lasts a few seconds or longer than 30 minutes then less likely to be angina • Ass n/v. may feel like they need to belch • Not positional • Physical exam findings • Their chest pain should not be reproducible to palpation (unless related to somatic dysfunction) •
Referred pain via the cardiac viscero‐sensory reflex from the coronary arteries (angina)
• •
Refers out and down the inner surface of the arm and hand The above are classic pain distribution into dermatomes C8‐T3, especially when ventricle is involved With atrial involvement the pain is lower in the chest wall involving dermatomes T4‐6
•
Innervation: Intercostal nerves
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Sympathetic Chain • Sympathetic portion of the autonomic nervous system originates from T1‐ L2 • Cardiac: T1‐5 • Invested in fascia covering the anterior rib heads
Cardiac: NSTEMI • 62 you Caucasian female presents to ED with left‐sided chest pain, which is throbbing has been continuous for hours and is accompanied by nausea and dyspnea • PMHx: uncontrolled hypertension, hyperlipidemia, 1 ppd tobacco for 50 years • Pain relieved by NTG, EKG is normal sinus rhythm and negative for T wave or ST abnormality. Troponin was negative • Serial troponins were elevated but EKG’s remained without abnormalities • Cardiac cath revealed a lesion in the mid RCA which was stented • The patient tolerated the procedure well and was discharged to home.
Cardiac: NSTEMI • What are some key features that make this suspicious for NSTEMI? • What might be some expected physical exam findings?
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Cardiac: NSTEMI • Key features • Classic left sided chest pain with expected radiation patterns (discussed previously) • Associated SOB, nausea, diaphoresis • Lasting much longer than you anticipate for angina (>30 minutes) • Relieved with SL nitroglycerin • Positive troponins
Cardiac: NSTEMI • Physical exam findings • Again, pain should not be reproducible to palpation unless related to accompanying or secondary somatic dysfunction • Common Chapman’s point for myocardium • Myocardium – 2nd rib interspace bilaterally • With anterior MI you will expect to find viscero‐somatic changes in T1‐4 paraspinal muscles on the left
Serratus Posterior Superior Trigger Points can mimic cardiac chest pain
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Pectoralis Major
Musculoskeletal: Costochondritis/Tietze’s syndrome Rib dysfunction • The same 62 yo female patient presents to your office for her scheduled post hospitalization follow‐up but with a complaint of chest pain that is different from what she went to the ED with. She went home after her hospitalization and started smoking again and developed bronchitis with a frequent hacking cough • She describes the pain as dull and burning in the back. She also notes that she is having increased dyspnea. Patient rates her pain as 4/10. The pain sometimes worsens with positioning or deep breathing. She denies associated diaphoresis or nausea. She reports that the pain improves with Tylenol.
Musculoskeletal: Costochondritis/Tietze’s syndrome Rib dysfunction • On physical exam, the patient was noted to have left ribs 1‐4 exhaled and right ribs 2‐3 inhaled. She was also found to have T3, T5, and T7 ERSL. She also had somatic dysfunction at C3, C4, and C7. • OMT was performed using muscle energy technique at the affected segments. After the treatment, the patient reported that her chest pain was completely resolved and she felt she could breath “easier.”
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Musculoskeletal: Costochondritis/Tietze’s syndrome Rib dysfunction
• Key features • Dull, burning type chest pain (atypical) • No associated nausea/diaphoresis • Improved with tylenol • History of trauma or coughing • “Idiopathic” • Physical exam findings • Tenderness to palpation along chondrosternal junctions • Rib somatic dysfunction
Respiratory: Asthma/Pneumonia • An intern is precepting a case with you and you hear audible wheezing when she is talking and she seems to be having a little difficulty getting through her presentation • On questioning, she tells you she has had asthma since childhood with flares often precipitated by respiratory infections. She has recently been feeling a little feverish and fatigued and has had to increase her rescue inhaler use to every few hours
Respiratory: Asthma/Pneumonia • You offer to evaluate her before you send her home and find diffuse expiratory wheezes, the diaphragm restricted, preferring inhalation and multiple inhaled ribs, C 3‐4 ERSR. She is afebrile, O2 sat 98%, peak flows were mildly diminished • You do some muscle energy for the ribs and myofascial release of the diaphragm with good response and offer her a course of prednisone which she declines.
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Respiratory: Asthma/Pneumonia • Despite feeling less dyspnic after the OMT, she goes on to develop left upper lobe pneumonia and pleuritic chest pain
Respiratory: Asthma/Pneumonia • Key features of pleuritic pain • Sudden, intense located over the area of inflammation • Worse with breathing • Can be relieved with pressure over the area (somato‐somatic reflex)
• Treatment • Treat the source • OMT for both the mechanical dysfunctions and effects as well as improving better movement of air and fluids
Respiratory/Circulatory Model • The diaphragm acts as the piston in the thoraco‐ abdomino‐pelvic cylinder. • Descent of the diaphragm creates a relative negative intra‐thoracic pressure, causing the inflow of air as well as fluids in the low pressure circulatory system, bringing venous and lymphatic fluid back to central circulation.
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• Lymphatic drainage of the thorax
Gastrointestinal: GERD • 50 yo obese Caucasian female presents for routine exam, states she has been well but getting some substernal chest pain which is burning, non radiating, is sudden onset, lasts a few minutes, resolves spontaneously • Denies any dyspnea on exertion, diaphoresis, nausea although she does occasionally cough when she has the pain • ROS reveals an acid taste in her mouth in the morning
Gastrointestinal: GERD • Physical exam is benign other than epigastric tenderness to palpation. • Structural exam showed mild tissue texture changes in the upper to mid thorax on the left, poor diaphragmatic excursion
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Gastrointestinal: GERD • Key features • Sudden onset with quick resolution • Does not occur with activity • Wakes up with it in the a.m. when reflux may have been worse from being recumbent • Acid taste in mouth with waking • Physical exam findings • Tenderness to palpation of the epigastric area • Abdominal exam otherwise benign • May find facilitation at : T2‐8 (esophagus) and T5‐9 (stomach/duodenum)
Neuropsych: Anxiety • 46 yo woman presents to your office with chest pain, palpitations and dyspnea accompanied by perioral and peripheral numbness and tingling. The symptoms are episodic with no clear aggravating factors but have been gradually worsening over the year • PMHx: multiple office and ED visits for various musculoskeletal injuries, mostly minor contusions but last year she had 3 fractured ribs after a fall down the stairs • Soc Hx: Married for 5 years, 2 young children, homemaker and doesn’t drive
Neuropsych: Anxiety • Physical exam: Flat affect, soft spoken, NAD • Skin shows multiple ecchymoses in various stages of healing • All other physical exam findings are benign with no evidence for any systemic illness • Structural screen shows somatic dysfunction in most regions, with chronic tissue texture changes in the paraspinal musculature and tenderness in the musculature across her neck, shoulders and upper back
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Neuropsych: Anxiety • You offer to do some OMT • While you are performing some gentle MFR to the neck and scapular regions, she breaks out in tears • On further questioning, she admits that she has been in multiple physical altercations with her husband that have been escalating in frequency and severity over the last year or so, resulting in her fractured ribs and other injuries
Neuropsych: Anxiety • Key features of anxiety disorders • Excessive worrying • Muscle tension • Fatigue • Headaches • Sleep disturbance • Palpitations • Substance abuse • Many other symptoms that overlap with depression
Neuropsych: Anxiety • Key features of Intimate Partner Violence • Psychological/emotional • Physical • Sexual • ~1 in 4 women have experienced this and 44 % of women who die as a result have visited an ED within 2 years and 93% saw a physician for their injuries • Shares many of the same symptoms as anxiety, depression, substance abuse and PTSD
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Neuro: Intercostal Neuralgia • A 45 yo African American female co/of right sided chest pain that radiates around to the back. Gradual onset over the last several weeks Aggravated by deep inspiration and coughing. She also can not lay on her left side. The pain improves with Tylenol. • Structural exam reveals a hard end feel over the 5th right rib at the angle and poor movement with respiration. The pain is reproducible with palpation. • OMT using gentle balanced ligamentous tension technique improves the pain but does not resolve it. • She returns the following week for follow up. The pain is better but she can still elicit some pain with palpation of the 5th rib in the mid‐axillary line.
Neuro: Intercostal Neuralgia • You order a rib series x‐ray and the radiologist calls you to tell you that there is a deformity of the 5th right rib anteriorly that interpreted as concerning for neoplasm. • Further review of past medical, surgical and family history reveals a strong family history of breast cancer. The patient admits non‐compliance with mammography because she was afraid of what they might find. • Mammogram shows a mass and biopsy is positive for breast cancer. Bony metastasis in the area of the patient’s tenderness is found on bone scan • The chest pain she was experiencing was likely costal nerve impingement from the boney lesion.
Neuro: Intercostal Neuralgia • Key features • Pain follows distribution of nerve • If pain does not resolve or improve with treatment further evaluation is warranted • Strong family history of breast cancer • Can also be caused by bone spurs or herniated discs, herpes zoster • Physical exam findings • Tenderness to palpation over the affected rib head and often along the pathway of the nerve
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Rheumatologic: Pericarditis • 35 year old white female presents to with chest pain. • Pain is sharp, has been present for 3 hours and is worse with inspiration. She also notes some dull pain in the shoulders. • The patient is leaning forward during the interview because that improves the pain. • You also notice that her cheeks are very pink. You ask about this as well and she states that she has SLE. • She was on prednisone recently and has been attempting to wean off this medication. • While waiting for an EKG, you examine your patient and notice a “squeak” when you auscultate heart sounds. • You review the EKG, which is now available, and note diffuse ST segment elevation..
Rheumatologic: Pericarditis • Key features • History of SLE with what appears to be a flare of the disease • Patient meets 3 of 4 criteria even before echo
Other Diagnoses to Consider • • • • • • • •
Shingles Aortic aneurysm or dissection Pancreatitis Pulmonary embolism Fibromyalgia Pneumothorax Postural decompensation Poor fitting bras
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Posture
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Treatment •
Cervical:
•
Thorax:
• •
Lumbar: Ribs:
• •
Diaphragm: Other:
Facilitated positional release OA Release Cervical soft tissue HVLA Muscle energy Inhibition Soft tissue Rib raising Balanced ligamentous tension Upper bucket handle dysfunction Myofascial release Pectoral traction Serratus anterior release
OA Release 1. 2. 3. 4.
Stabilize C1 posteriorly with 1st and 3rd fingers Cup occiput with palm of other hand Disengage slightly with cephalad traction Balance occiput relative to C1 until release is palpated
Cervical Facilitated Positional Release • Dx FRSL 1. Patient supine 2. C‐spine placed in neutral in the sagittal plane 3. Then placed in position of ease at the segment (FRSL) 4. Compress from the head to the dysfunctional segment 5. Wait 3‐5 seconds or until resolves and return to neutral
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FPR/Still Modification 1. 2.
3.
Place dysfunctional segment in position of ease Add gentle compression down to level of dysfunction until release is palpated Using finger as fulcrum, reverse position to engage the barrier
Cervical Soft Tissue 1. Stand at the patient's side. 2. Place one hand lightly on the forehead. 3. Put the pads of the fingers of the other hand on the posterolateral part of the neck. 4. Stretch the soft tissues of the neck in a perpendicular direction while GENTLY sidebending and extending the cervical area. The hand on the forehead offers gentle resistance to these motions. Treat both sides.
Thoracic HVLA Type II Vertebral Somatic Dysfunction (ERS, FRS) These are segmental dysfunctions. In using this technique, a flexed dysfunction will be corrected with localized extension, and an extended dysfunction will be corrected by bringing the head up to localize in flexion. 1.
The patient is supine. Stand opposite the side of the vertebral rotation.
2.
Cross the patient's arms so that the opposite arm is superior.
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Thoracic HVLA Type II Vertebral Somatic Dysfunction 3.
Reaching across and under the patient, place your thenar eminence under the posterior transverse process and sidebend the patient's trunk towards you until you feel sidebending motion at the segment. Flexion/extension motion is localized by raising or lowering the head.
Lowering the head will extend down to the level of the flexion lesion.
Thoracic HVLA Type II Vertebral Somatic Dysfunction 4. While adding the necessary weight through the patient's shoulders (via elbows) to maintain the fulcrum's position (thenar eminence), the correction may be made by raising or lowering the patient's head. 5. If necessary, while maintaining flexion or extension, a high velocity, short amplitude thrust may be added through the shoulders (via elbows) during exhalation. This position should induce rotation and sidebending in the same direction and, with the correct addition of flexion or extension, should reestablish normal motion at that segment.
Raising the head will flex down to the level of the extension lesion.
1.
The patient is seated
2.
The physician stands behind and to the right of the patient.
3.
The physician's right arm is placed over the patient's right shoulder, and the operator grasps the patient's left shoulder with his/her right hand.
4.
The operator palpates the transverse processes of T7 with the fingers of the left hand.
5.
The operator introduces extension, left rotation and left sidebending in order to engage the restrictive barriers.
6.
The patient is instructed to sidebend to the right (i.e., push the left shoulder toward the ceiling) while the operator offers isometric resistance.
7.
After 3 seconds the patient is instructed to relax.
8.
The operator then introduces more extension, left sidebending and left rotation in order to engage a new restrictive barrier.
9.
Repeat steps 6, 7 and 8 two more times.
Muscle Energy: T7FRSR
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Rib Raising (Just One of Many methods) 1.
2.
3.
With the patient in the supine position, the physician sits or stands at the side of the patient with his hands under the rib cage and his fingers contacting the angles of the ribs. By flexing the fingers in a rhythmic manner, the patient's rib cage is pulled laterally and raised, then released. Two physicians can work together, one on each side of the patient.
This is an excellent hospital technique to aid respiration and circulation of the patient with congestion, such as those with pneumonia and cardiovascular problems. It is also indicated during pre‐ and/or post‐ operative care.
Balanced Ligamentous Tension for the Ribs Supine 1. 2.
Patient supine The same rib is palpated from both anterior and posterior and put in position of ease in all planes until release is palpated and motion is restored
Balanced Ligamentous Tension for the Ribs Seated 1. 2.
3.
Patient supine, physician seated at the affected side The angle of the rib is contacted with one hand while the other hand stabilizes the 2 attached vertebra at the transverse or spinous process The ribs are balanced relative to the vertebrae until release is palpated and motion is restored
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Paraspinal Inhibition for Sympathetic Dysfunction • inhibitory pressure technique, the application of steady pressure to soft tissues to reduce reflex activity and produce relaxation. • (Chila 1098)
Lumbar Spine Soft Tissue Source: Outline of Osteopathic Manipulative Procedures
Diagnosis: paraspinal muscle dysfunction 1.
Patient is lateral recumbent and the physician stands at the side of the table.
2.
Physician hooks the fingers of both hands over the medial aspect of the erector spinae muscles. His/her cephalad forearm is in the patient’s axilla and the other forearm is braced against the anterior superior margin of the iliac crest.
3.
Physician’s fingers are drawn anteriorly and laterally to scoop the muscle laterally creating kneading. At the same time, he/she carries the shoulder and innominate posteriorly and widens the distance between them, creating stretching.
4.
Sufficient force is applied to feel the muscles relax but not enough to cause discomfort or to cause the muscles to tighten further.
5.
The force is slowly relaxed.
6.
Kneading and stretching are repeated rhythmically until maximal response is obtained. This technique can be applied to the muscles on the other side.
Lumbar Spine Soft Tissue You can rotate the shoulder back further and use muscle energy to get further stretch of the lumbar and lower thoracic paraspinals.
Source: Outline of Osteopathic Manipulative Procedures
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Lower Thoracic Lymphatic Pump: Diaphragm Doming 1. The physician stands at the side of the supine patient, facing the patient. 2. The physician's hands contact the patient's lower lateral rib cage. 3. As the patient exhales, the physician's hands augment the medial motion of the lower ribs. 4. The patient is instructed to inhale. As the patient inhales, the physician resists the lateral movement of the lower rib cage. 5. As the patient reaches the height of inhalation, the physician's hands are suddenly removed from the rib cage, causing an in rush of air. 6. The technique may be repeated 2‐3 times.
Lower Thoracic Lymphatic Pump: Diaphragm Doming
There are some situations which may preclude the use of vigorous thoracic pump techniques, e.g., advanced osteoporosis, presence of external ventilatory devices, recent chest surgery or trauma, etc.
Pectoral Traction 1.
The patient is supine, knees raised, fingers laced and feet flat on the table.
2.
The physician is seated at the head of the table, grasps the patient's anterior axillary folds, initially with gentle pressure on the pec major and then ultimately with deeper pressure to reach the pectoralis minor. Start with fingers flatter and curl around the pec major as the tissue releases so that you can reach the pec minor.
3.
Traction is applied superiorly to stretch the muscles and the deep underlying fascia in the axillary spaces.
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Serratus Anterior 1.
2.
Diagnosis is made by assessment of muscle tone and inability to retract scapula or move fingers into superficial aspect of scapulothoracic joint Treatment is done as any myofascial release
Upper Rib “Bucket Handle” Dysfunction 1.
2.
Diagnosis is made by palpating ribs in mid‐axillary line, applying a gentle inferior springing motion Caudad traction is applied with postural augmentation and respiration until movement is improved
Sources •
•
Diagnosing the cause of chest pain. William E Cayley, Jr, MD. American Family Physician. Vol 72 No 10. November 15, 2005. Chila, Anthony. Foundations of Osteopathic Medicine, 3rd Edition. Lippincott Williams & Wilkins, 102010. VitalBook file. Osteopathic considerations in somatic dysfunction. Kuchera and Kuchera
•
Comlex OMM review 2nd edition. William Thomas Crow, DO, FAAO
• • •
Up TO Date Diagnosing the Cause of Chest Pain WILLIAM E. CAYLEY, JR., M.D., Eau Claire Family Medicine Residency, Eau Claire, Wisconsin
• • • •
Chest pain in general practice: incidence, comorbidity and mortality Ana Ruigo´meza, Luis Alberto Garcı´a Rodrı´gueza, Mari‐Ann Wallanderb, Saga Johanssonb and Roger Jones Family Practice Advance Access published on 3 February 2006
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