Fascia in primary care: When chest pain is not in your chest

“Imagination is more important than knowledge. For knowledge is limited to all we now know and understand, while imagination embraces the entire world, and all there ever will be to know and understand.”
– Albert Einstein

“Mr. Thomas, are you OK? Sir, are you OK?”  It was a full clinic day, and I had just improvised a treatment on him.

I had met this patient, “Mr. Thomas,” only once before.  After meeting me in urgent care, he had switched to me as his primary care physician. A few months earlier, Mr. Thomas had been a full-time consultant for industrial companies, a job that required extensive walking.  Mr. Thomas enjoyed his work and responsibility as the primary breadwinner of his household. Ever since his heart attack, however, Mr. Thomas suffered from constant chest pressure and pain, and he was unable to work.

Unlike the “typical” heart disease patient, Mr. Thomas had a slight build, like what you would expect of a former high school basketball player.  His face, weathered by acne, sun, tobacco, and other trials of aging, was incongruous with his haircut, parted on the side, and barely gray.

Mr. Thomas’s speaking style was soft and halting, the kind with pauses to search for the most accurate words to express himself.  It made him appear both credible and earnest. His deliberate energy was out of sync with the pressured pace of today’s modern medicine visit.  His speech added drama and suspense for me.

He had already been evaluated for his chest pain —  his heart and lungs were functioning well, and a chest CT had detected nothing abnormal. On the job, he had walked 1 to 2 miles per day, but after several months of recovery, he could barely walk around the block in his neighborhood.

My empathy with him was very personal.  Recently, I suffered from severe nerve pain and numbness while continuing to work full-time.  I sought out the unfamiliar in acupuncture, myofascial work, and anti-inflammatory diet.  I marveled at the lasting and progressive pain relief achieved with a facilitated change in body mechanics. In the pressured agenda of primary care, I had forgotten about the physics of the body. I began experimenting on myself to accelerate my healing.

I had begun applying my new skills to my patients, but up to this point, I had mostly helped back, knee, hip … common muscular pains, but chest pain?  In medicine, complaints such as chest pain or shortness of breath command gravitas — like a request from the IRS, not taken lightly.  With his “negative workup” thus far, I wondered, could his problem be in his fascia?

Originally dismissed as static connective tissue covering our muscles, fascia is slowly being recognized as an organ with its own blood supply.  It is responsible for thirty percent of muscle strength, and represents a system that is contiguous from the cellular nucleus all the way to the visible macrostructures. Like a Mobius strip, fascia is continuous with an inside and outside simultaneously.

The part of fascia that encases our muscles and organs is supposed to “glide” on itself, but with injury, inflammation, and/or disuse, fascia can become adherent and restrict movement.  Dense with pain receptors, fascial strain is increasingly recognized as the source of musculoskeletal pain.

After a heart attack, patients are encouraged to sit in a chair as soon as they are able, and progress to walking before discharge. Once at home, however, patients are often afraid to resume exercise or even walking.

I learned that Mr. Thomas was spending much of his day in a recliner at home, a body shape that was very similar to his standing posture before me.  Could his chest pain originate from contracted fascia and muscles?

In medicine, empiric therapy is treatment that is administered based on the probability of success because we don’t have all of the information.  We make our “best guess.”  Actually, empiric decision-making exists in our everyday lives — running the garbage disposal when the sink is clogged, jiggling the key in the lock when it doesn’t turn. Mr. Thomas was in stable condition, and I estimated that his chances of finding an answer to his chest pain with another specialist, was very low.  It was time to make my best guess.

I explained my theory to Mr. Thomas and suggested we try some myofascial bodywork.  In the best case, he would feel a difference; and in the worst case, he would feel a little sore and looser in his body, but without pain relief.  Mr. Thomas was definitely interested.

With hope and caution, we proceeded.  I started with the sides of his chest … zig … then his abdominals … zag … then low back … zig … I checked with him frequently as he groaned with each maneuver, but he always nodded to continue.  When the trial was over, I helped him sit up on the exam table.

“Mr. Thomas, are you OK?”  I repeated. Early in my career, a patient had fainted after a procedure and fallen on top of me.  One must be vigilant. I braced myself. After several gasping breaths, Mr. Thomas finally lifted his head and said, “These are tears of joy.”

No, I hadn’t cured his pain, but it was noticeably reduced.  I repeated the whole sequence, less gingerly, and achieved more reduction in pain.  I had no idea how long the improvement would last, but I offered to see him twice a week.  He would decrease his time in the recliner and do stretches to preserve the work we had done.

When he returned four days later, I almost didn’t recognize him.  I hadn’t realized how tall he was. He had told his wife all about the visit and worked on the stretches.  He was able to walk farther with minimal discomfort. We repeated the treatment. Three days later, he returned only to thank me and to inform me that he was returning to his old job.  His pain never recurred.

Cathy Kim is a family physician and can be reached at Dr. Cathy.

Image credit: Shutterstock.com

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