Man Ther. 2009 (Dec); 14 (6): 702–705 ~ FULL TEXT
Steven R. Passmore, Andrew S. Dunn
Veterans Affairs of Western New York Health Care System,
Buffalo, New York, USA.
When angina pectoris is suspected but adequately ruled out,
upper anterior chest pain and related symptoms may be attributed
to cervical angina, particularly in the presence of radiculopathy and
myelopathy (Nakajima et al., 2006). Cervical angina is theorized to
involve the C6, C7, or T1 nerve roots, and possibly the medial and
lateral pectoral nerves (Jacobs, 1990; Freccero and Donovan, 2005).
While the prevalence of cervical angina is not completely clear, it is
described as a virtually unknown and neglected clinical syndrome
that may not be uncommon but is under diagnosed (Nakajima et al.,
2006; Christensen et al., 2005). Aside from cardiac enzyme and
exercise tolerance testing, Christensen et al. (2005) suggest cervical
angina is potentially recognized from true angina through manual
palpation of the spine and thorax.
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Manual palpation for locating
vertebral joint dysfunction is most reliably indicated through eliciting
tenderness (Jull et al., 1988; Hubka and Phelan, 1994; Haavik-
Taylor and Murphy, 2007). Further diagnostic tactics that may
discern cervical from true angina may include improvement after
corticotrophin therapy but not glyceryl trinitrate, normal temperature,
and lack of vasomotor changes (Grieve,1988). However, upon
recognition of the presentation, what is an appropriate course of
care for cervical angina? Nakajima et al. (2006) suggest that anterior
cervical surgical procedures that alleviate compression on
nerve roots or the spinal cord and may be palliative. The same
authors also mention surgery should be avoided until conservative
measures have been exhausted, but caution the use of ‘‘aimless
conservative therapy’’ (Nakajima et al., 2006). So the question
remains what is an appropriate, focused approach to the conservative
treatment of cervical angina? Furthermore, what type of
intervention and treatment frequency should be recommended
and what is the sustainability of such an intervention?
This paper follows the case of a patient with cervical angina in
whom radiographic findings can be correlated to patient presentation.
The symptoms of cervical angina responded to a brief course
of spinal manipulative therapy (SMT) targeted at the cervicothoracic
junction, a novel finding previously absent in the
A 42–year-old woman was referred for evaluation and management
of neck pain with cervical radiculopathy and comorbid
cervical spondylosis. Upon subjective evaluation, symptoms
reportedly developed over the previous five years, for which the
patient had not actively pursued management options. During her
history, the patient described her neck pain as ‘‘numb, dull, and
sometimes accompanied by sharpness across the chest’’. The
patient was naive to SMT, and was referred to the clinic by her
primary care physician.
A cervical spine radiographic study performed the week prior to
consultation was compared to a study performed 3 years earlier
that revealed minor anterior wedging of the C3 vertebral body
without instability. The remaining cervical vertebral heights and
alignment were otherwise maintained. The prevertebral soft
tissues were intact. Subtle narrowing of the C4–5 disc space was
observed and minimal uncovertebral spurringwas noted on the left
at the C3–4 and C5–6 levels (Fig. 1). The right intervertebral
foramina were patent.
During the objective examination a Neck Disability Index (Cleland
et al., 2006) (NDI) score of 58 was recorded as a baseline
outcome measure. Valsalva’s manoeuvre/test (Rubinstein et al.,
2007), the Cervical compression test (Rubinstein et al., 2007), and
Cervical traction/neck distraction test (Rubinstein et al., 2007) were
positive. Muscular reflexes were 1–2+ and bilaterally symmetric at
levels C5–7. Upper extremity clonus was absent. Motor strength
was 4–5+ throughout. Sensory examination was hypoesthetic over
the C7 dermatome. Passive cervical range of motion as observed
was pain producing into extension, lateral flexion and rotation
toward end range. Hypokyphosis was noted in the thoracic spine.
Segmental palpation (Jull et al., 1988) was painful at C3–4 bilaterally,
and T4–5 on the left. Manual palpation revealed hypertonicity
with tenderness in the suboccipital and levator scapulae musculature
bilaterally. Due to the pre-existing diagnoses of cervical
radiculopathy and spondylosis, with no additional upper extremity
complaint peripheral joint examination was deferred at this time.
Interventions and outcomes
Treatment was initiated and the patient received high-velocity,
low-amplitude (HVLA) SMT to the regions indicated by segmental
palpation (C3–4 bilaterally, and T4–5 on the left) in conjunction
with passive stretches for the suboccipital and levator scapulae
bilaterally. Stretches were held once muscle tension was attained
for 10 s. In the cervical spine a supine digit pillar pull (Peterson and
Bergmann, 2002)was employed for SMT while in the thoracic spine
a bilateral hypothenar transverse push (Peterson and Bergmann,
2002) was utilized. Immediately following treatment the patient
verbally self-reported localized ‘‘decreased stiffness and pain’’ in
the cervical region. These procedures and outcome occurred on two
instances (treatment visits 1 and 2).
The present body of literature on spinal manipulation has not
specifically identified an optimal dosage of care in regard to the
number and frequency of visits (Jull and Moore, 2002; Haas et al.,
2004). While laboratory studies have examined changes immediately
following a single instance of spinal manipulation (Martinez-
Segure et al., 2006; Tseng et al., 2006; Haavik-Taylor and Murphy,
2007), this immediate re-evaluation with completed outcome
measures and full physical assessment has not yet translated into
standard clinical practice. Clinical papers cite delay of thorough reevaluation
for periods up to 9 or 12 visits, to follow a course of care
as opposed to a single instance of intervention (Haas et al., 2004). In
the present case the plan included a treatment frequency of two
visits per week with re-evaluation after the forth visit in an attempt
to minimize the number of patient visits needed to bring about
clinical change or lack thereof, and indentify an appropriate end
point early on in care to minimize potential over treatment (Dunn
and Passmore, 2008).
Upon presentation for her third scheduled appointment, she
reported that the prior treatment had minimally sustained palliative
effects, and that sleep the night before was interrupted by
sensations of a self perceivedmyocardial infarction, including chest
pain with dizziness, and pain in the lateral aspect of the left upper
extremity with paresthesia distribution into the first through third
digits (Fig. 2), in addition to her previous neck pain. Manual therapy
was deferred and the patient, who had a previous borderline
exercise tolerance test (ETT) to investigate a prior apparent cardiac
episode, was sent to the emergency department (ED) for evaluation.
Immediately prior to referral for manual therapy the referring
physician performed cardiac auscultation and described the presence
of regular rate and rhythm of all heart sounds with the
absence of murmur.
The attending ED physician requested an electrocardiogram,
and chest radiographs, but found no significant findings. Serial
cardiac enzyme laboratory analysis was also negative. Upper
extremity pain radiation was provoked positionally by cervical
spine left lateral flexion (Lindgren et al., 1992) and the diagnosis of
cervical angina was communicated. Having ruled out cardiac
etiology, a return to manual therapy was determined. The patient’s
course of care for neck pain with cervical spine radiculopathy was
resumed at levels indicated by palpation in the cervical and
thoracic spine (C3–4 bilaterally, and T4–5 on the left) with the
addition of HVLA techniques directed specifically to hypomobile
and tender segments (C5–6 on the left, C6–7 on the right and the T2
costotransverse joint on the left) at the cervicothoracic junction as
cervical angina is theorized to involve the C6, C7, or T1 nerve roots
(Jacobs, 1990; Freccero and Donovan, 2005).
Manipulation directed at the cervicothoracic junction was
delivered utilizing the thumb spinous push technique (Peterson
and Bergmann, 2002). The patient lay prone and the clinician made
a first distal phalange to spinous process contact while inducing
lateral flexion targeted at facet joint manipulation. Also, the prone
hypothenar costal push, (Peterson and Bergmann, 2002) was
utilized in which the clinician’s hypothenar region contacted the
patient’s upper costal angles, and HVLA SMT was delivered to
manipulate the costovertebral articulations. These techniques were
integrated into the existing treatment plan with delivery at an
intended frequency of twice per week at dysfunctional motion
segments (Dunn and Passmore, 2008). This was performed on two
occasions before re-evaluation (treatment visits 3 and 4).
After her fifth scheduled appointment (treatment visit 4), a reevaluation
was performed. Segmental palpation was no longer
painful in the cervical or thoracic spine regions. Valsalva’s
manoeuvre/test, Cervical Compression Test, and Cervical traction/neck distraction test were painless and a re-evaluation NDI score of
48 was recorded. Immediately following treatment she noted
a sustained decrease in cervical spine pain and chest pain, and
following the second treatment directed to the cervicothoracic
region her pain had resolved. While spontaneous recovery can
never be completely dismissed, based on the temporal correlation
of the decrease in symptom presentation, clinical findings, and
outcome measure scores while undergoing a course of SMT it is
theoretically feasible to attribute this patient’s improvement to the
intervention. She followed up with her primary care physician for
her biannual physical examination 11 weeks later without report of
chest pain at that time.
Atypical chest pain presentations related to cervical radiculopathy
entered the literature over 70 years ago when Nachlas (1934)
identified what he described as ‘‘pseudo angina pectoris’’. Later,
Hanflig (1936) suggested pain in the shoulder girdle, arm and precordium
can be attributed to cervical arthritis. The term ‘‘cervical
angina’’ came into favour following a publication by Jacobs (1990).
Recent cases in the literature reported chest pain with associated
nerve root impingement ranging from C6–T2 (Freccero and
Donovan, 2005; Ozgur and Marshall, 2003; Yeung and Hagen,1993).
A retrospective chart review of 241 cases of C6–7 anterior cervical
discectomy with unilateral nerve root impingement revealed that
15% presented with breast/chest pain (Ozgur and Marshall, 2003).
Ozgur and Marshall (2003) proceed to state that of those 15% of
individuals, 90% experienced long-term relief following anterior
cervical discectomy and fusion, which they feel, is a clear indication
of nerve root involvement.
However, Grant and Keegan (1968) and more recently Erwin
et al. (2000) suggest that costovertebral joints might be an under
recognized site of pain generation in atypical chest, upper back and
arm pain. Grant and Keegan (1968) found that pressure applied
over the ribs that reproduced chest pain could be used to identify
‘‘costal syndrome’’, and additional pressure over the dorsal spine
could identify ‘‘vertebro-costal syndrome’’ which occurred most
often at a single vertebral level. Although no treatment options,
descriptions, or protocol were detailed in the primarily diagnostic
clinical paper the authors mentioned pain was often relieved by
spinal traction. They also state that in their 41 clinical patients there
were five consistent symptoms reported that were congruent with
presentation which included accurate localization, accentuation by
thoracic spine movement, exacerbation by breathing/coughing/
straining, association with posture/position, and a history of
mechanical stress (Grant and Keegan, 1968). Erwin et al. (2000)
demonstrate the anatomic possibility of pain production via
evidence for the existence of enervated synovial folds in the costovertebral
joints. It remains unclear if chest pain generation is
occurring at the site of the nerve root, the costotransverse joints, or
potentially the zygapophyseal joints (Erwin et al., 2000).
In this patient when cervicothoracic SMT was delivered, it was
directed at both the upper thoracic costotransverse joints, and
lower cervical zygapophyseal joints. With a theoretical etiology of
cervical radiculopathy, a positive response to manual therapy in
this case of cervical angina was congruent with predictions theorized
in a recent radiculopathy study (Cleland et al., 2007). In
agreement with a cervical radiculopathy and manual therapy
outcome prediction paper this patient’s anticipated response was
favourable as her age is less than 54 years, and radicular symptoms
were in her non-dominant arm (Cleland et al., 2007). Supporting
a recent cervical radiculopathy outcome measure study, this patient
demonstrated an NDI improvement that exceeds a minimally
detected change of 7, and meets a minimally clinically important
difference of 10 points improvement (Cleland et al., 2006).
In a study on the diagnostic accuracy of cervical spine palpation,
while there were no false-positives (medically asymptomatic zygapophysial
joints diagnosed as symptomaticmanually), therewas an
instance of a false-negative (medically symptomatic zygapophysial
joints diagnosed as asymptomatic manually) (Jull et al., 1988). This
false-negative occurred at the level of the C6–7 zygapophysial joint. It
was also the only instance inwhich a joint belowC5–6was indicated
by either medical or manual diagnosis. This finding could be interpreted
as indicative that manual diagnoses of symptomatic lower
cervical, or cervicothoracic joints may be more difficult to discern.
Symptomatic joints in the cervicothoracic region could have falsely
been declared clear until patient symptomatic presentation clearly
warrantedmore thorough assessment of the joints in this region. This
was the case in the present course of management.
This patient presented with unilateral osteophytes of the uncovertebral
joints projecting into the intervertebral foramen potentially
serving as the etiology of her cervical radiculopathy and cervical
angina, but they may also be a benign comorbid condition. Had she
not experienceda sustainedresponse toSMT,other treatmentoptions
include but are not limited to active exercise, cervical spine traction,
grade I–IV mobilisation, pharmacological intervention, or surgery.
Authors of a recent study suggest that there is controversy over the
possibility of relieving radicular symptoms without removal of
offending osteophytes via direct surgical decompression of the
uncovertebral joints.Shenet al. (2004)postulate thatanterior cervical
discectomy and fusion (ACDF) can add the 2–3mm of distraction
prerequisite for a favourable clinical outcome without osteophyte
removal. Finding that it is unnecessary to remove potentially
offending osteophytes to see clinical improvement supports why
radicular symptoms could be alleviated by SMT, which has been
demonstrated to increase zygapophysial joint space on MRI post
manipulation (Cramer et al., 2002). However, should future patients
fail to respondto cervicothoracicSMTorotherconservativemeasures,
and where patients fail to respond to ACDF, uncoforaminotomy to
remove osteophytes is the suggested approach to care (Pechlivanis
et al., 2006).
When assessing a patient presenting with chest pain, a distinction
between cervical angina, and true angina must be made to
diagnose and manage cardiac issues distinct from mechanical neck,
costovertebral and shoulder pain. Patients should be screened to
rule out cardiac etiology first. A study examining co-morbidity for
people in their seventies with mild, moderate and severe neck and
shoulder pain revealed a significant percentage of individuals
reported a history of angina (Vogt et al., 2003). With regard to neck
pain rated mild, moderate, or severe, the associated percentages of
people who reported angina were, respectively, 13.1%, 19.1%, and
16.4%. With regard to shoulder pain rated mild, moderate, or
severe, the associated percentages of people who reported angina
were, respectively 13.3%, 14.5%, and 18.6%.
This case identified an individual with the under diagnosed
phenomena of cervical angina. This patient demonstrated a sustained
improvement up to 11 weeks following a brief trial of SMT
directed to the cervicothoracic region, suggesting a mechanically
based, musculoskeletal etiology to her presentation. Future
prospective studies are needed to assess the viability of a course of
SMT management, and the consideration of related treatments
such as grade I–IV joint mobilisation for patients who have tested
negative for true angina, but continue to present with unrelenting
atypical chest and upper extremity pain prior to directing them for
surgical management. These additional studies also need to
confirm the appropriate dosage of SMT for these patients following
clearance and referral from cardiology through carefully controlled
clinical studies with re-evaluation following each intervention. This
case also raises the issue of the need for careful palpation to
ascertain dysfunction in tissues, and the possibility that such
dysfunction in the cervicothoracic junction may be more difficult to
identify through manual palpation then other regions. Future work
is needed to determine whether it is HVLA manipulation of the
costotransverse, zygapophyseal or the combination of these joints
in conjunction with passive stretches that may have contributed to
the therapeutic benefit of this course of management.
The research endeavours of Steven Passmore are funded in part
by Fellowships from the Foundation for Chiroparactic Education
and Research, New York Chiropratic College and an Ontario Graduate
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