Marge T, aged 52, presented with an extraordinary story of modern medical mismanagement. While carrying heavy suitcases in Hong Kong she developed anterior chest pain. She was taken to an emergency department where, despite a normal ECG, she was told she had heart trouble and had to be careful.
Upon returning to Melbourne and while under the care of her son-in-law, who was a specialist, she developed episodes of central chest pain with, at times, mid-thoracic back pain. She felt tired and languid. A stress ECG was normal. She was admitted to a teaching hospital for further investigation. Unfortunately, an ultrasound examination was reported to be abnormal (? chronic relapsing pancreatitis). The incompatible clinical history was ignored as she went from investigation to investigation over a period of nine months. The eventual diagnosis was chest pain of unknown cause with anxiety.
The anxious and devastated Marge, as a result, first consulted me with classic depression. The history was interesting—the pain invariably followed a lifting or laborious activity such as vacuuming and bed-making. The associated back pain tended to get ignored as the focus was on the retrosternal pain. Examination revealed tenderness at the T5 and T6 levels of her thoracic spine while a plain X-ray showed mild degenerative changes.
She had dysfunction of her mid-thoracic spine with referred pain. After three treatments by spinal mobilisation and manipulation, her pain completely subsided as did her ‘stress-related problem’, anxiety and depression (although it took some months).
Elana W, aged 32, presented as a new patient with epigastric pain brought on by physical activity including lifting her children. A careful history determined associated back pain ‘just around my bra strap’. The problematic T7 area of her thoracic spine was appropriately treated.
Elana came in with one of her children some weeks later and said, ‘You know, Doctor, that stomach pain I’ve had for three years has gone. To think that it was thought to be an ulcer and then a hiatus hernia. I’ve had two barium meals and a tube passed down but they found nothing.’
Joan G, aged 41, requested a second opinion about recurrent pains under her right costal margin for 12 months or so. Cholecystectomy did not help at all, but correction of her thoracic spinal problem at T7–T8 completely alleviated the pain.
The writer has a personal testimony worth recording. Poliomyelitis affected the back at 8 years of age and then from age 12 to 24 with persistent thoracic back pain that would radiate antero-laterally just below the nipple line, either right or left side. ‘You have to learn to live with it John—it will probably get worse as you get older’, came the reassuring prognostication from my attending neurologist.
Other more adventurous doctors proffered diagnoses such as post-polio neuralgia, da Costa’s syndrome and Tietze’s syndrome. I noted during medical school that if patients were unfortunate enough to get the pain on the left side of the chest it was called ‘cardiac neurosis’.
However, while attending a football club physiotherapist for an ankle injury, he noted my thoracic deformity and asked if it gave me pain. ‘I can fix that.’ ‘No, you can’t.’ ‘Yes, I can—let me try.’ Thumbs and hands deftly worked on the T4–T6 levels—impressive sound effects with cracking and clicking. To the profound relief and gratitude of this impressionable patient, the 13 years of pain was relieved. Yes, it returns occasionally but is likewise fixed with physical therapy.
DISCUSSION AND LESSONS LEARNED
The medical profession tends to have a blind spot with various pain syndromes in the chest, especially the anterior chest and upper abdomen, caused by the common problem of dysfunction of the thoracic spine.
Doctors who gain this insight are amazed at how often they diagnose the cause that previously did not enter their ‘programmed’ medical minds.
Physical therapy to the spine can be dramatically effective when used appropriately. Unfortunately, many of us associate it with quackery. It was an interesting experience presenting Marge T’s case to a grand round at one of the hospitals who mismanaged her. The consultants were divided in their responses. Many accepted the insight with knowing gratitude while others became very upset and threatened.
It is devastating for patients to create doubts in their minds about having a ‘heart problem’ or an ‘anxiety neurosis’. Substituting vague or even dogmatic incorrect labels for ignorance is a dishonest strategy.