Intended for healthcare professionals

Clinical Review

Assessment and management of medically unexplained symptoms

BMJ 2008; 336 doi: (Published 15 May 2008) Cite this as: BMJ 2008;336:1124

Re: Assessment and management of medically unexplained symptoms

In recent BMJ discussions I described how, between 1975 and 1980, I came to the conclusion that poor posture, due to abnormal forward curvature of the upper spine, was the cause of many previously unexplainable symptoms.

One of them was lower left sided chest pains which I experienced once every few months, for no apparent reason, when I was a teenager.

It felt as if a sharp sewing needle had stabbed into my chest to a depth of about five centimetres and out again in a fraction of a second.

When I was reading the medical literature to find evidence relating to my conclusions I found a 1956 book by Paul Wood which contained a photo of a full sized portrait of a patient with a thin and stooped physique which was described as “typical”.

It was almost exactly the same as mine.

He also suggested that possible causes might be “faulty posture”, and lifting heavy items, and he gave an example of cranking a car engine, which puts strain on the muscular attachments of the chest wall.

He also noted that it could sometimes be aggravated by laying on the left side.

He further suggested that constant anxiety may be a cause due to it’s affect on breathing and strain on the respiratory muscles, and then presented examples of patients whose kindly mothers and doctors had protected them from the dangers of football, swimming, and gymnastics when they were children, so he concluded that they grew up with a fear of football and swimming, and related fears of failure and responsibility etc.

However that was the exact opposite of my experience because I learned to swim at local beaches, played sport at school, and was involved in gymnastics for more than a decade.

Therefore, the evidence indicated that my symptoms were primarily related to my physique.

In that regard, I have observed people sitting side by side where one with an upright posture breathed effortlessly, and the one with a stooped posture had their head and shoulders rising each time they inhaled, and dropping each time they exhaled, which would put a lot of repetitive strain on the respiratory muscles and the chest wall, as would any activity which involved repetitive bending, which would all contribute to the symptoms.

Paul Wood also noted that some patients had brief twinges, or stitch like pains which persisted for a few minutes, or an ache which lasted for hours, and he tried to treat it by injecting the area of tenderness with a pain killing drug called novocaine just below the surface of the skin, but it had no effect.

However, when he injected it deeper into the muscle of the chest wall the pain was abolished.which indicates that it has a very precise location.

He also suggested that patients may become anxious about that chest pain because they think that it is due to their hearts, and that they need reassurance.

Nevertheless, while reassurance is useful in alleviating any concerns that patients may have it doesn’t remove the actual cause of the pain, and leaves an element of doubt.

I therefore recommended that physicians could explain the difference between the location of the pain and it’s distance from the heart.

They could also, in some cases, use injections to diagnose the problem, by inserting them into the appropriate area and determining if the pain is abolished, in which case it would verify the location, and distinguish it from heart disease.

I also recommended that an improvement in physique and posture could reduce or eliminate the incidence of that symptom, particularly in children where their spinal bones are still pliable, and may actually begin to grow straighter rather than continue to curve, and the improvement may ultimately remove the excess postural pressure on the chest wall.


Banfield M.A. 1980 (June), The Matter of Framework, Australasian Nurses Journal, p.27-28.

Paul Wood, 1956, Diseases of the heart and circulation, 2nd, revised edition, Eyre and Spottiswoode, London, p.937-947.

Banfield M.A. 2014 (March 30th), The Posture Theory as an explanation for many previously unexplainable symptoms, BMJ 2008:336:1124.

Competing interests: No competing interests

27 April 2014
Max Allan Banfield
Unit 6, No.6 Hartman Ave., Modbury, South Australia 5092