Depending on the severity of the problem heart disease can be a relative or an absolute contra-indication to Rolfing. Suspected heart disease is however always an absolute reason for referral before starting our work.

Symptoms
(what the client may tell you, if you ask)

The symptoms of cardiac disease are weakness, fatigue, palpitations, light headedness, syncope, dyspnea, pain.

Weakness and Fatigability: Many people do not complain of weakness and fatigability, these symptoms may develop so gradually that they are not recognized as such and you will only get a sense for it if you know the person, or if you have a good sense of what is normal for a person of that age and size.

A diseased heart will not be able to do its normal work, the muscles, when in use, need the heart more than any other system. Initially people will only notice that they have diminishing strength with strong exertion, but they will become progressively weaker and eventually feel fatigued just from sitting around and do not feel better from resting or sleeping.

Palpitations, the perception of the heart beat by the client. The heartbeats, controlled by the autonomic nervous system, are not normally felt unless people exercise or really focus on them, but they are felt by people who are anxious and by people who have abnormal rhythms (arrhythmia)… and since people with abnormal rhythms are often also anxious and vice versa this is also one of those heart symptoms that has to be seen in conjunction with other symptoms.

A definitely more worrisome piece of information would be dyspnea, the perception of increased work of breathing. This may start very gradually too. The elderly people often consider it normal, not because it is normal but because people gradually do less because they get weaker. What you could notice is that they sigh a lot without any apparent reason. You might only notice this in the background of your awareness. If this symptom becomes bad enough it becomes also a sign (something everybody can see). In the beginning the person only feels out of breath with exertion. You can see how that relates to weakness: First there is trouble breathing with exertion, getting better with rest, then gradually it gets worse until people can barely walk a few steps without having trouble breathing. As the situation gets worse people are out of breath while lying down, and get better by sitting up or standing and eventually they cannot sleep unless they are propped up with several pillows.

As these symptoms worsen, people feel also light headed and eventually faint. This is called Svncope. This does not necessarily mean that a person, particularly an elderly person, has a severe heart problem, if she gets up fast from the Rolfing table, feels light headed and almost faints. In the absence of anything mentioned above or below, this would probably just be postural hypotension, a benign transitory state. Remain watchful if it occurs often, start asking questions, if you have doubts or observe any more worrisome signs described below.

The most ominous symptom of heart disease is pain. I will elaborate somewhat about this to show you how hard it is to be certain about pain, but I would refer with the slightest suspicion of heart pain.

The pain mostly associated with the heart is called “central chest pain” because it is typically situated in the center of the chest, right behind the sternum. People describe this pain as heavy, tight, pressing, squeezing, crushing and hold a fist to their sternum to describe it. Early in the course of heart disease pain like that can last 3-5 minutes, it starts with exertion and stops with rest. Exertion does not mean just exercise, it means anything that can get the heart working harder like strong emotions (good or bad ones), the team losing on TV., indulging in controlled substances, making love, eating a large meal, drinking and carrying on with friends, being Rolfed etc. This type of pain is attributed to angina, a temporary insufficiency of the cardiac arteries.

If the pain is lasting longer it indicates probably ischemia (lack of oxygen) to the heart. This pain is similar in quality but can also come on suddenly at rest or wake people up from sleep. People often start by having angina which may result in myocardial infarction, a prettier way to say: a heart attack. The problem may slowly degenerate into heart failure, a very slow death with many accompanying aspects. Heart failure can be preceded by a heart attack that was silent, meaning pain free. It could have occurred at night and could have been mistaken for a horrible nightmare. Evidence of this is often found when people have an EKG (electrocardiogram) for symptoms of early heart failure or atrial fibrillation or other cardiac problems. If you take the time to read up on cardiovascular disease, you can see that there is a large amount of varying pathologies of the heart.

Another type of dangerous chest pain is pericardial pain. This is the same pain but getting worse with coughing, swallowing, deep breathing and lying down, better by leaning forward. This pain is more understandable from a Rolfer’s point of view, it involves the fascial wrapping of the heart around the heart.

An important fact of cardiac pain is it’s radiation. The heart in the embryo starts its life in the neck and then migrates down into the chest. When it is installed in it’s appropriate position it still is surrounded by the same fascial wrapping, together with all the structures that have developed from the same primordial tissue.

Cardiac pain is transmitted up to the cerebral cortex along the autonomic nerve fibers and has a variable referral area that can extend from the ear to the umbilicus.

Myocardial ischemic pain (the pain of the heart muscle due to lack of oxygen, which announces or indicates a heart attack) radiates in the distribution of the lower cervical nerves and may therefore be felt in the neck, the lower jaw and teeth, either shoulder or either arm (most often down the inside of the left arm), or the back. It can happen that the central pain is not there, it may just be a “sense of fullness”, sometimes mistaken for indigestion. If the situation is critical there can be radiating pain down both arms when taking a breath.

When asking about chest pain we should see if we can relate it to specific muscular motion or joint position. Cardiac pain, as you can see does not fit with that. It does happen though that people have chest pain described exactly as I did above with all detail and the M.D.s will not find anything in the heart. They may find pathology in any of the thoracic and many of the extra-thoracic structures including muscles, joints and bones, pleura, lungs, diaphragm, esophagus, great vessels, stomach and gall bladder.

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Signs

The signs of heart disease that are perceptible without instrumentation are a little easier for us visually oriented people. Unfortunately they only are obvious with advanced disease. Important ones are: increased and shallow respiratory rate, edema, central cyanosis.

Increased and shallow breathing: If there is visible respiratory effort without preceding exertion, you should always refer people first. It indicates a number of problems and all are serious: It could be lung disease, heart disease, diabetes, kidney disease and others. You could help with some of these diseases like scleroderma or ankylosing spondylitis, if you are an experienced manipulator, but you need to know why people have trouble breathing. If the client in question is merely obese, you should still remain reluctant to start Rolfing. Obesity is a predisposing factor to heart disease.

Generalized Peripheral, Edema: Accumulation of fluid in the interstitial space can be caused by serious diseases like congestive cardiac failure, acute kidney disease, severe gastro-intestinal problems like malnutrition and mal absorption, cirrhosis. People in such state often look fat. The question is how does this look and feel different from adipose tissue? Edema starts around the ankles, both ankles. It will progress upwards and it can engulf the entire person, in an extreme case it can make the scapulae look pushed away from the thorax, in this case the person will really be out of breath. If the edema is slight it does not feel very different from adipose tissue but very edematic tissue feels hard, tight, tightness starting right under the skin. It is almost impossible to palpate any discrete structure underneath or inside the edema because there is so much fluid filling the inter stitium. This is very different from obesity. Adipose tissue follows structures, muscles and organs, you can feel where the septa are, the tissue has some resilience. You can feel, even though it may be difficult, where things stop and where they start. With edema you cannot.

Know that the heart is too weak to do it’s job, there is not much happening in peripheral edematic tissue. It may also feel cold, because there is not much circulation. Should the person have a small injury that breaks the skin, the blood would flow slowly, it would be watery and there would be clear fluid at the edge of the wound. Edema fills interstitial spaces that normally are just somewhat loose (which would only be invested by adipose tissue if the person was very obese), like the back of the knees, around the sacrum, below the armpits, the top of the feet, the back of the hands, the face and inside the abdominal cavity.

The other distinct aspect is that if you push the tip of your finger on this swelling, there will be a little indentation, a pit. This is called “pit-ting edema”, the pit will stay there for a while, the worse the problem, the longer the pit will stay. If you massaged the legs of a person with pitting edema who is reclining, you could slowly push the edema away from the legs and within a few minutes it would be back.

Central Cyanosis,a bluish discoloration of the lips, tongue and conjunctivae, is due to the lack of sufficient oxygen. This may progress to a similar bluish coloring of the hand and feet and of the nail beds, even when hands or feet are warm. This is also a no fail indication of heart or lung disease. It may be transitory if people are very cold or in shock. It can also indicate anemia, or inability to adapt to high altitude. I will never forget the haughty bag lady on Union Square who was holding a burning cigarette in her cigarette holder and stared me down because I arrested my gaze on her bluish face, dark blue lips and blue finger nails.

Risk factors to Heart Disease

Many obese people are easily out of breath, because their heart obviously has to work much harder. Some obese people also have heart disease. Obesity is one important predisposing factor of heart disease, so is smoking, alcoholism (a beer belly may really be edema), atherosclerosis, high blood pressure, diabetes, cocaine, heroin and any drug abuse, type A behavior and mental stress.

All the aspects of heart disease will most probably not show up at the same time in your practice. If they do, you will have an easy time knowing what to do. Some aspects may be there and may really be striking, and no disease may be found by the MD.. but as I said in a former article: So what if you refer somebody to a doctor just because you got spooked and overreacted? Better to look silly than fail a client who trusted you.

You also may be completely unable to recognize the signs of heart disease, because very often they are severe and not obvious at all and clients often ignore symptoms of disease out of fear of disease. It also happens, as you probably know, that some people are so anxious about heart disease that they think they can feel symptoms and drive their doctors crazy. It is also possible that the examining doctor is having a bad day, does not do all the tests and fails to recognize signs of pathology.

Rolfers are not trained to recognize pathology and not legally responsible for recognizing pathology. It would be great though, if, in most circumstances, you were able to keep your heart open and cover your… back.

References:

The Merck Manual, 16th Edition 1992: Cardiovascular Diseases

Eric R. Beck, John L. Francis, Robert L. Souhami, Tutorials in Differential Diagnosis, 3rd Edition, Churchill / Livingstone 1992.

Yale University School of Medicine Heart Books, 1st Edition, 1992