Specific Thoracic Pain: Red flag screening pathway for Physiotherapists. A Systematic Review

Abstract

Background: The lifetime prevalence of isolated pain in the thoracic spine is relatively low, approximately 13-17%, compared to neck and low back pain, 40% and 57% respectively. However a patient with thoracic or chest pain is more likely to mask a serious pathology, such as spinal fracture, spinal tumor or metastasis, myocardial ischemia, pneumonia, etc.. A physical therapist is a primary healthcare professional and it is his responsibility to screen and identify serious pathologies outside the scope of practice. That is, differential diagnosis may help in excluding medical pain sources and, most importantly, recognize emergencys scenarios. An in-depth subjective and objective examination are the two pillars for the clinical evaluation that may help clinicians to determine if the pain is of musculoskeletal origin or not. In the literature, there is a lack of knowledge about the red flags (i.e. warning symptoms and signs) that can be useful for the screening for referral, not medical diagnosis, in the thoracic and chest wall pain. The aim of our systematic review is to investigate which findings form the subjective (symptoms and red flags) and objective examination (signs and tests) are valid tools for the differential diagnosis for thoracic pain or chest pain suspected to be caused by a serious pathology. METHODS This systematic review will be conduct in accordance with the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) statement. The following databases will be searched: Medline (PubMed), Embase, Cochrane Library, DITA, Google Scholar, CINAHL. The search will be limited to English language publications only. No study design or language limits will be imposed on the search. In addition, a manual search will be performed on the reference lists of included articles and other grey literature sources (eg. Google Scholar). References list of identified articles and reviews will be also checked for any relevancy. We will include all the findings used by all kind of Healthcare Professional, different healthcare setting that were compared compared to the gold standard, (i.e. diagnostic imaging, laboratory testing and biopsy examination) possessing information of their diagnostic accuracy and their psychometric properties. Partecipants will be adults, suffering of thoracic pain and/or chest pain. We will include only primary studies: diagnostic accuracy studies and longitudinal observational studies, e.g. cohort and case-control studies. We will include different type of effect measure: Odds Ratio, Sensitivity, Specificity, positive likelihood ratio (LR+), negative likelihood ratio (LR-), positive and negative predictive value (PPV and NPV) in detecting serious pathology by screening or diagnostic tool used by healthcare professional.