Chest pain and chiropractic

The common question posed during the patient encounter: "can chiropractic help pain in XYZ area?" can be applied to many many places but today I want to explore the chest. Pain in the chest obviously raises a lot of alarms about the potential of life-threatening cardiothoracic causes, and those obviously always need to be ruled out before I will look at a patient with acute chest and chest wall pain. But in many cases, I see patient come in who have had a battery of tests and being told with glee that the do not have a heart or lung problem, but not given a lot of options to resolve their pain.

Chest and chest wall pain can come from many know musculoskeletal structures that are treated by chiropractic. Below are my most common culprits.

– Mid cervical disc herniation, spinal nerve compression. The C5 and C6 nerve roots will radiate to the upper shoulder and clavicle. Submit cervical disc herniations for example, or chronic degenerative bony spurs, can trigger a sensation of vague pain in the upper chest. In most instances, patients will have noticed a correlation to neck movement and position.

– Brachial plexus above the clavicle in the scalene muscles. A remarkably common area of problem that's escaping detection. I sometimes joke that I could pay my mortgage alone by working on the anterior cervical spine muscular injuries. The brachial plexus exits between 2 branches of the scalenes, and is remarkably susceptible to irritation or compression between the exit from the spine and the entrance into the axilla. Another 1 of my overused jokes is that there is as much cervical spine in the front as there is in the back. Carefully palpating the neurological structures as they exit the anterior cervical spine can be a bull's-eye for mysterious pain in the shoulder chest and arm. Of all the conditions affecting the chest, this particular 1 is more immediately gratifying since you can often get release of symptoms within 1 or 2 treatments and sometimes right away on the spot.

– Anterior shoulder, especially deep intrinsic protractor muscles like the pectoralis minor and the pectoralis major. The pectoralis minor in particular is known to have trigger points referring to the area underneath the breast. It's a muscle that's often shortened due to postural anterior strain. It's also a muscle that can be pretty easily injured with pushing activities, and certain athletic activities like planks when people decide to become weekend warriors or for the 1st 2 weeks of their New Year's resolution after prolonged couch potato status.

– The costochondral junction: slightly lateral to the breastbone/sternum, the junction of the anterior ribs to the central sternum is through a complex cartilage called the costochondral cartilage. It can get inflamed from systemic inflammatory conditions, and be remarkably painful, even during normal breathing. It's also subject to trauma, especially with compressive rotational forces to the chest. It does respond pretty well to modified adjustments.

– 1 of my all-time favorite, the sternal clavicular joint. I never cease to be surprised how many times it's an issue and how much it's below everyone's radar. The junction of the distal clavicule to the breastbone is actually a fairly complicated join with the meniscal cartilage similar to your knee. The sternal clavicular joint is the last joint in the kinetic chain from the arm to the neck and is often involved in incidents of force transmitted from the arm to the body, such as catching yourself falling on your arm. I also had seen it a fair amount after motor vehicle accidents when people slam into both hands on the steering wheel. Almost as gratifying as the brachial plexus at the scalenes, attempts to respond pretty fast to manual adjustments.

The moral of the story: if you chest pain has been ruled out as not being cardiac or pulmonary in nature, it's worth a chiropractic evaluation.

Topical treatment for pain and inflammation

It's a question that comes up frequently and I realized recently that I don't have a good written resource material to direct patients to and I find myself repeating the same thing over and over in the middle of a busy day. Unlike some of my colleagues, who tend to downplay their value in an overall treatment plan, I feel that topical's can have huge benefits to direct therapeutic activity to a local local area, and can overall minimize the patient's need for more toxic oral medications.

Understand that this is a generic list, and that you will probably need to figure out with your own individual healthcare provider which 1 of these may be the best, and understand that you may need different topical treatments at different times. Also understand that while mostly safe, a few of them do have some potential contraindication related to other medications and comorbidities that you should be aware of.

Topical treatments full in different broad categories matching their mode of action: counter irritant, vasodilators, anti-inflammatory, analgesics, and some of them crossover into more than one category.

COUNTER IRRITANTS: those agents tend to create a local receptor response that competes with pain receptors, thus tricking the body in perceiving sensation rather than pain. Menthol is probably the most common one. It's found as a base in the majority of topical treatments. It's usually quite safe, short acting and reversible. There's a huge variety of products available, and ultimately it boils down to preferring water-based versus oil-based, and how much of an overlying sent or not you want to have.

VASODILATORS: those agents tend to increase local blood flow by increasing vasodilation of smaller blood vessels. The main benefit is to improve circulation to a particular area, especially in the periphery of the body. The main ingredient is capsaicin, derived from hot peppers. On the tail end of the activity, they tend to have a mild analgesic effects. The benefits are to improve blood flow to deliver soft tissue repair nutrients, especially oxygen, in areas that are having a hard time healing or are somewhat avascular because of previous trauma or general health issue with blood circulation. You have to be quite careful with them, since they can create great irritation to the skin, and they are more medical contraindications to using them, especially with peripheral vascular disease and diabetes. It comes in different potencies, and you also have to be extremely careful not to rub your eyes after applying them.

ANTI-INFLAMMATORIES: it's a relatively broad category, with many agents having a secondary anti-inflammatory effect in addition to another primary effect. The effect pathways of information in peripheral tissue. This includes both pharmacological over-the-counter substances as well as naturally occurring substances.

- salicylate and dicofenac are topical versions of pharmacological oral equivalents, which are available over-the-counter. (Aspercream or generic equivalent is the most common version). They are quite effective, have a moderate acting range, but have to be used very carefully especially if it's used consistently in the long term because it does eventually reach your bloodstream. I think there is definitely a time and a place for short-term use during acute trauma recovery, to minimize the need for oral pain medication. There are some definite contraindications, so best to check with your provider before using.

-Essential oils like frankincense: should be used in small amounts in a carrier oil because of their potency, but can be a very nice long-term alternative because in smaller doses they really quite safe.

- Arnica: increasing in popularity in the US, I grew up with Arnica as a mainstay in our pharmacy box. It's a little bit of an atypical anti-inflammatory, which is used mostly for acute trauma and contusions. It has virtually no side effects so that one is safe for just about everyone to try.

- CBD: an oil-based extract from the hemp plant, CBD alone has no psychotropic effect and is relatively easy to use in the long term quite safely. I find that CBD takes a little bit to kick in, and I think it's best used for long-term management of chronic joint or soft tissue inflammation rather than as an acute aid.

- MSM: a sulfur based compound, it has a great safety profile when used topically. It has a mild anti-inflammatory effect, but is primarily used to support chronically injured collagen, such as osteoarthritis of joints, and chronic ligamentous or tendon injuries.

ANALGESICS: it's a little bit of a difficult category to pain, since analgesics means pain reducer. The mechanism of pain can vary in different patients, so all of the above can act as analgesics in a particular patient. However technically only very few compounds are considered true analgesics and they are relatively uncommon. The most commonly available over-the-counter is a pharmacological compound called lidocaine usually applied in transdermal patches. Lidocaine is powerful, short to moderate acting, but it has a fair amount of side effects and many medications adverse interactions for a lot of people so I would use that one was a lot of caution and with the green light of your provider. There are very few nonpharmacological true analgesics, such as California Poppy.

This is not an exhaustive list, with several other less commonly used compounds such as homeopathic's, and many bundled products. But this should at least be enough of a background for patients to start asking the right questions to select the right topical for their personal use.

PSOAS 101: what is it, what does it do, when does it hurt ???

Many people are getting familiar with the name of this sometimes hidden and obscure muscle, because of its importance and clinical relevance.

The psoas muscle, or more accurately the iliopsoas muscle group, is part of a broader group of muscle known as the hip flexors. As their name would indicate, their function is to flex the hip. But in reality the iliopsoas muscle group is involved in many more functions and clinical conditions that I would like to briefly highlight below.

– The iliopsoas is a very deep muscle group that is in the anterior part of the lumbar spine. As such it's difficult to palpate part of it. It's also a surprisingly large muscle group. For those among our readers who may be hunters, or butchered their own meat, it's the tenderloin muscle. The circumference of the muscle is larger than that of the spine itself which highlights its importance in the stabilization of the lumbar spine.

– In addition to being a hip flexor, the iliopsoas is a very strong lateral stabilizer of the lumbar spine. Which is why it's important to have a strong healthy and fully lengthened psoas in any persistent lumbar pain.

– The iliopsoas is important for a variety of clinical presentations. We always need to check it in persistent lumbar pain.

– Due to the modern lifestyle associated with frequent and prolonged sitting, the iliopsoas muscle will spend a large amount of daytime in the shortened position. This will create a lot of issues, most notoriously some anterior pelvic tilt of the lumbar spine and compression of the lumbar spine and lumbar discs. It's important if you have a sedentary job to offset this issue with frequent anterior hip extension stretches and gluteal activation.

– The iliopsoas has fascial connections into the thoracic diaphragm, as well as into the quads, and this latter connection can easily influence the function of the quads and normal alignment and tracking of the patella. When people have persistent patella pain, it's worth making sure that the psoas is firing and lengthening normally.

– The psoas influences pelvic tilt, and is an important muscle group to assess when patients have lumbar postural distortion such as a very anterior pelvic tilt.

– Several important peripheral nerves have to make their path through the psoas when exiting the lumbar spine and entering the leg. This would include the main femoral nerve, as well as some continuous nerves which only provides sensory input to the upper thigh such as the lateral femoral cutaneous nerve. Assessing the iliopsoas is absolutely crucial for any anterior leg pain and tingling presentations.

– Manually treating the iliopsoas requires a fair amount of training and experience on behalf of the practitioner due to the location of the muscle group within the abdomen, and close correlation to internal organs as well as traversing nerves.

CHIROPRACTIC ADJUSTMENT AND ANTIOXIDANT MARKERS

I recently had a little more time traveling, which has given me the opportunity to catch up on some of my chiropractic research podcasts.

One of the remarkable development of chiropractic research over the last 25 years has been in the basic science department among other places. In particular, while empirically chiropractors and their patients have known for a long time that the manual adjustment is associated with many changes in body chemistry well beyond neuromusculoskeletal markers such as pain reduction and range of motion, trying to document and quantify that has been comparatively lagging behind.

Some of the non-neuromusculoskeletal changes reported by patients often include feeling more energy, sleeping better, feeling less inflamed overall, improved mood and digestion and cognition. While some of those changes are thought to be associated with changes in neurological feedback loops between the brain and the body, this most recent piece of research seems to suggest that there is potentially an additional core biochemical change associated with the chiropractic adjustment, namely the modulation of local free radicals as well as the up regulation of the body's own antioxidant pathways. The research project was unfortunately interrupted by the arrival of the covid pandemic, which did reduce the total sample size of patients, making some of the statistical data a little tough to analyze, however this paper is still a very exciting first step in further investigating how chiropractic care can improve the overall long-term well-being of our patients.

https://pubmed.ncbi.nlm.nih.gov/39966844/

https://pubmed.ncbi.nlm.nih.gov/35760595/

Specific chiropractic adjustments versus random manual mobilization: why it really matters

https://www.researchgate.net/publication/377361433_A_randomized_controlled_trial_comparing_different_sites_of_high-velocity_low_amplitude_thrust_on_sensorimotor_integration_parameters

Over the last 30 years of practice I have often found myself answering the same question many times over. 1 of those questions is why I seem to only be adjusting only one side and only one very specific spot, when patients may have had previous experiences with chiropractors or other manual therapist that showed a much broader contact, and adjusting multiple areas of the spine on both sides. With the addition of Dr. Steve as my esteemed colleague and associate, I realize I'm not the only one answering that question. Dr. Steve and I have very similar approaches and background in manual adjusting, (more specifically we both had most of our training in the Gonstead technique and system), which means that on occasion we will both bemoan the drift of our profession away from specific and systematic manual adjustments based on a system of analysis that aims at isolating the main segment(s) of spinal dysfunction that should be adjusted, while leaving the rest alone.

There are good scientific rationales behind that approach: the spine is a very dynamic system of action and reaction based in gravity. What happens in one area of the spine will often lead to broad compensations in a different area, and it takes some clinical investigation to make sure you address the root cause rather than waste your time (and your body's limited healing energy) on areas of compensation.

There is also good and pretty solid research to validate the specific approach. I was thrilled to come across this wonderful paper by our colleagues from down under in New Zealand (especially Dr. Heidi Haavik who has been a workhorse of basic science chiropractic research for well over a decade). The nuts and bolts of the study was to measure the brain-based motor response of an adjustment in a randomly selected area of the spine across the test subjects, versus a specific spinal segment determined by chiropractic analysis including static palpation, palpatory tenderness, abnormal motion segment etc.). The results were statistically incredibly different between the 2 interventions.

The moral of the story is that chiropractic care is most likely to give you longer-lasting neurologically integrated results if your provider spends time to specifically isolating the main problem area and adjusting it according to best biomechanical correction principles.