Open Access

Ana Izabela Sobral de Oliveira Souza, Maximilian Baumgärtner, Philipeh Brecht, Jordana Barbosa da Silva, Nikolaus Ballenberger, Susan Armijo-Olivo

• Background: Pain in the thoracic spine is considered a debilitating pain in other parts of the spine and the consequences are similar to those of neck pain. Thoracic Spine Pain (TSP) is defined as pain experienced in the region between the first and 12th thoracic vertebrae on the posterior trunk, with possible radiation ventrally to the ribcage. The prevalence can be up to 30% depending on the population. Despite this, there is significantly less research in this area and therefore a lack of guidelines to enable clinicians to provide optimal care for this patient group. Thus, this systematic review aimed to find out the comparative effectiveness of manual therapy (MT), exercise therapy (ET), pharmacological intervention, or educational therapy on pain in adults with TSP. In addition, to verify the effect of the above therapies on physical functioning and emotional functioning. Methods: A systematic review (SR) with meta-analysis was conducted. For this, a literature search of five electronic databases (Ovid Medline All, Embase, Cinahl, Scopus, and Cochrane Library Trials) was performed in October 2021 and updated in September 2023 by a professional librarian without restriction in terms of year of publication and language. It included randomized controlled trials (RCTs) with adults (>18 years old) suffering from TSP. The interventions investigated had to include at least one of these approaches: MT, ET, pharmacological intervention (PI), or education therapy. First (abstract and title) and second (full text) screening, data extraction, and risk of bias (Cochrane RoB-2 tool) assessments were performed by two independent reviewers and then checked by a third reviewer. The results were presented qualitatively and quantitatively. When possible, the data from the included studies were pooled in a meta-analysis. The certainty of evidence was assessed using the GRADE approach. Results: Ten RCTs were included. MT was investigated in 7 studies,[1-7] ET in 3 studies,[1,5,8] and PI in 3 studies.[1,9,10] Four studies [2-4,6] compared MT vs placebo, but no statistically significant (NSS) difference at any time point was found (e.g., 3 months (SMD [95%CI] -0.01 [-0.36, 0.35]) follow-up). The comparison between two PI (local anesthetic vs local anesthetic plus steroids),[9,10] demonstrated NSS in pain intensity at any follow-up. One study [5] compared MT (spinal manipulation, manual pressure release) plus ET (stretching and strengthening) vs just ET, and found SS difference favoring the combined therapy (SMD [95%] 0.59 [0.07, 1.10]) after 3 weeks. No study compared the four treatments of interest against each other. One study was classified as low RoB, 3 studies as some concerns, and 6 studies as high RoB. All results presented a very low certainty of evidence according to the GRADE. Conclusion: Although thoracic pain is considered a disabling pain, the best conservative treatment option to relieve pain has not been substantially explored to provide high evidence-level information. Based on the restricted data included in this review, just manual therapy was compared with placebo therapy, and the results demonstrated that this technique is not superior to a placebo treatment to relieve thoracic pain. The other modalities explored in this review (exercise, pharmacological, and education therapy) were just compared between the same classes of treatment. And no difference between them was found. Just when manual therapy was combined with exercise therapy and compared with exercise alone, the results showed a medium effect favoring the combined therapy. Thus, the combination of manual therapy and exercise could be a promising treatment to relieve thoracic pain. However, more studies with better quality and more homogeneity in treatments are needed for further conclusions.