Musculoskeletal Science and Practice 39 (2019) 58–66

Contents lists available at ScienceDirect

Musculoskeletal Science and Practice

journal homepage: www.elsevier.com/locate/msksp

Original article

Management of thoracic spine pain and dysfunction: A survey of clinical T

practice in the UK
Nicola R. Heneghana,∗, S. Gormleyb, C. Hallamc, Alison Rushtona
a
Centre of Precision Rehabilitation for Spinal Pain, School of Sport, Exercise & Rehabilitation Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
b
Shropshire Physiotherapy, Newport, Shropshire, TF10 7AB, UK
c
Reading Football Club, Reading, Berkshire, RG2 0FL, UK

A R T I C LE I N FO A B S T R A C T

Keywords: Background: The thoracic spine (TS) is relatively under-researched compared to the neck and low back. As the
Thoracic spine challenge of managing spinal pain persists, understanding current physiotherapy clinical practice for TS pain and
Examination dysfunction is necessary to inform future research in this area.
Management Objective: To investigate physiotherapy practice for managing thoracic spine pain and dysfunction (TSPD) in the
Clinical practice survey
UK, with a secondary focus on examining differences across settings and expertise.
Design and method: A cross sectional e-survey informed by existing evidence was designed. Comprising closed
and open questions, the survey is reported in line with Checklist for Reporting Results of Internet E-Surveys.
Eligible participants were UK-trained physiotherapists managing patients with TSPD, recruited for 9 weeks up to
8/2/16. Data analysis included descriptive analyses (closed questions) and thematic analysis (open questions).
Results: From the 485 respondents, fulfilling the required sample size, key findings included. Examination:
Active motion testing, palpation and postural assessment was ‘always’ undertaken by > 89% of respondents.
Management: Active (exercises) and passive (e.g. mobilisations) techniques were used by > 85% of respondents,
with ∼50% using manipulation, taping and acupuncture. Practice settings: Although broadly similar passive
techniques were used more in private practice and sport. Expertise: Broadly similar patterns were seen for use of
exercise across levels of expertise, although differences observed for electrotherapy and manipulation.
Conclusion: Despite limited research exercise is widely used in all areas of practice and across all level of ex-
pertise. Further research is required to investigate exercise prescription for TSPD and implementation of evi-
dence-based practice.

1. Introduction 2009); however, there is now compelling evidence of a complex re-

lationship between the TS and other regions. Literature has demon-
The escalating prevalence and societal costs (e.g. decreased pro- strated co-existing thoracic pain in musculoskeletal complaints in other
ductivity, disability claim, days lost from work etc.) associated with regions e.g. neck and elbow (Heneghan et al., 2018a; Roquelaure et al.,
managing chronic spinal pain continues unabated, with neck and low 2014; Berglund et al., 2008), motion analysis studies where full func-
back pain leading causes of disability globally (Global Burden of tional arm elevation is affirmed as a composite of shoulder flexion and
Disease Study, 2016; Foster et al., ). Management of neck and low back thoracic extension (Theisen et al., 2010; Theodoridis and Ruston, 2002)
pain is informed by evidence-based clinical practice guidelines; how- and, TS intervention studies reporting improvements for complaints in
ever, no comparable guidelines exist for the thoracic spine (TS); despite the neck (Salom-Moreno et al., 2014; Gonzalez-Iglesias et al., 2009;
a growing body of evidence reporting thoracic spine pain and dys- Cleland et al., 2007a, 2007b; Suvarnnato et al., 2013; Young et al.,
function (TSPD) (Briggs et al., 2009; Heneghan et al., 2015, 2016, 2004; Cross et al., 2011; Lau et al., 2011), shoulder (Peek et al., 2015;
2018a; Roquelaure et al., 2014; Berglund et al., 2008). Strunce et al., 2009; Walser et al., 2009; Muth et al., 2012), and low
The lifetime prevalence of isolated pain in the TS is relatively low, back (Sung et al., 2014). More specifically, passive TS interventions,
13–17% (Briggs et al., 2009; Leboeuf-Yde et al., 2009), compared to including joint mobilisation, manipulation, have shown promising im-
neck and low back pain, 40% and 57% respectively (Leboeuf-Yde et al., provements in neck (Salom-Moreno et al., 2014; Cleland et al., 2005,

∗
Corresponding author.
E-mail addresses: n.heneghan@bham.ac.uk (N.R. Heneghan), scott.physiotherapy@hotmail.co.uk (S. Gormley), chrishallam94@gmail.com (C. Hallam),
a.b.rushton@bham.ac.uk (A. Rushton).

https://doi.org/10.1016/j.msksp.2018.11.006
Received 11 April 2018; Received in revised form 3 November 2018; Accepted 12 November 2018
2468-7812/ Crown Copyright © 2018 Published by Elsevier Ltd. All rights reserved.
N.R. Heneghan et al. Musculoskeletal Science and Practice 39 (2019) 58–66

2007b; Suvarnnato et al., 2013; Puntumetakul et al., 2015; Casanova- qualifications, clinical presentations of TSPD (Questions 1–10), 2) ap-
Méndez et al., 2014) and shoulder complaints (Peek et al., 2015; proaches to examination (Questions 11–13, 3) approaches to manage-
Strunce et al., 2009; Sanzo et al., 2016). Adopting the term ‘dysfunc- ment (Questions 14–19) and 4) to explore differences across practice
tion’ recognises impairment in the musculoskeletal system of TS which settings and levels of expertise. A final open-ended question (Question
may affect its integrity during functional movement; a synergy of mo- 20) invited free text responses for other comments.
tion occurring across different joints (Heneghan and Rushton, 2016). Content validity was enhanced through the inclusion of evidence-
Within a biopsychosocial model of practice, where a multimodal based clinical examination and management approaches (Suvarnnato
approach to the management of spinal complaints is recommended et al., 2013; Peek et al., 2015; Walser et al., 2009; Heneghan and
(National Institute for Health and Care Excellence (NICE) guidelines, Rushton, 2016; Carlesso et al., 2014; Fernández-de-las-Penas, 2007;
2015; National Institute for Health and Care Excellence (NICE) guide- Petty and Moore, 2002) and clinical expert opinion (NRH, AR).
lines, 2016) the therapeutic value of passive interventions (e.g. mobi- The survey was piloted by 5 musculoskeletal UK-trained phy-
lisation and manipulation) is recognised, hence their inclusion in some siotherapists. Based on their feedback revisions were made regarding
clinical practice guidelines. In contrast, active interventions, such as wording, clarification of response choices, and expected duration of
exercise, which are unequivocally recommended in clinical practice completion. Participants and pilot study data were not included in the
guidelines (Foster et al., ; National Institute for Health and Care main study.
Excellence (NICE) guidelines, 2015; National Institute for Health and
Care Excellence (NICE) guidelines, 2016; Blanpied et al., 2017; 2.2. Sample and recruitment
Buchbinder et al.,) have received relatively little attention in TSPD.
Exercise interventions including ‘stretching’, ‘endurance’, ‘postural Inclusion criteria: UK-trained physiotherapists who manage patients
control’, ‘motor control’ and ‘stabilisation’, are utilised widely in the with TSPD as part of their clinical practice. Participants were invited,
management of neck pain (Carlesso et al., 2014) and offer considerable based on stated eligibility criteria (UK physiotherapist working pri-
potential for TSPD. With recent research providing preliminary evi- marily in musculoskeletal physiotherapy) included within the in-
dence to support TS stabilisation exercises for postural back pain formation sheet to participate online via professional networks, e-mail
(Çelenay Ş, 2017) and the development of inexpensive valid and reli- [interactive Chartered Society of Physiotherapy (iCSP), Musculoskeletal
able measurement approaches the foundation is growing to support Association of Chartered Physiotherapists (MACP)] and social media
further research in this spinal region (Bucke et al., 2017; Johnson et al., (Twitter, LinkedIn, and Facebook). Promoting participation in the
2012). survey was continuous throughout the period the survey was live with
Whilst there is clearly a considerable way to go in conquering the specific prompts and updates on participation provided at 3 and 6
challenge of musculoskeletal-related dysfunction (Foster et al., ; weeks using the same sources. The required sample size to ensure
Buchbinder et al.,), knowledge of the current landscape of managing precision for the UK physiotherapy population was determined based
patients with TSPD will assist prioritising research efforts in this rela- on:
tively under-researched spinal region (Heneghan and Rushton, 2016).
(Np)·(p)·(1−p)
As evidenced by earlier surveys of physiotherapy management for neck Sample size =
(Np−1)·(B/C)2 + (p)·(1−p)
and low back pain (Carlesso et al., 2014; Foster et al., 1999) the tra-
jectory of subsequent research has largely been focused, rationalised Where Np = size of target population, p = proportion of population
and evidence informed; a critical consideration given the finite re- predicted to choose one of two response categories, B = sampling error
sources available. Furthermore, knowledge of practice across settings (0.05 = ± 5% of the true population value), C = Z statistic associated
and levels of expertise are required to inform professional practice with the confidence level (Dillman, 2007).The total UK physiotherapy
priorities linked to implementation of evidence based practice. population (Np) is ∼53,000. The proportion of the population (p) ex-
pected to choose one of the two response categories (to participate or
1.1. Aim of the study not) was set as 0.50. The acceptable sampling error (B) was set as 0.05,
and the confidence level (C) at 95%, giving a corresponding Z statistic
To investigate clinical physiotherapy practice for managing TSPD in of 1.645. The required sample size was therefore n = 270 based on the
the UK, with a secondary focus on examining differences across practice calculation of 269.25.
settings and levels of physiotherapist expertise.
2.3. Data analysis
2. Design and methods
Data summaries were produced via LimeSurvey with data imported
An online 20-question survey was created using LimeSurvey soft- into Microsoft Office Excel and SPSS [IBM SPSS Statistics for Windows,
ware package [https://www.limesurvey.org/about-us/imprint], see Version 21.0. Armonk, NY] to facilitate reporting of data and devel-
Appendix A. The survey was designed, and results were analysed and opment of graphs and tables. Participant characteristics (sex, age,
reported in accordance with the Checklist for Reporting Results of In- practice location, physiotherapy grade, years qualified, years practising
ternet E-Surveys (CHERRIES) (Eysenbach, 2004), see Appendix B. The in musculoskeletal physiotherapy, and qualification), approaches to
survey could be completed on any electronic device with internet access examination and management of TSPD were analysed from categorical
and was available for completion from 24/12/15 to 08/02/16. variables and presented as frequencies and percentages. Pie charts and
bar graphs are used to visually display results. Posteriori content ana-
2.1. Survey development lysis (themes and frequencies) for free text data was used for data
generated from open questions (Questions 1,3, 7, 8, 10, 11, 13–20)
Survey structure and content were informed by a review of current involving 3 researchers (SG, NRH, CH). This resulted in additional
evidence, including comparable surveys of management of neck and themes/categories which were quantified with calculation of fre-
low back pain (Carlesso et al., 2014; Foster et al., 1999), reviews (Peek quencies (Vaismoradi and Bondas, 2013). Further descriptive analyses
et al., 2015; Heneghan and Rushton, 2016) and author expertise (NRH, were used to enable comparison across practice setting and levels of
AR, SG). The survey comprised primarily closed questions with open experience. For each we only included data from participants who de-
questions for additional information e.g. types of training courses or clared their graded level of practice or practice setting [National Health
details of additional approaches to examination and management. The Service (NHS), private practice or sport setting] as their primary work
survey was developed to capture 1) demographic data, training and setting; to avoid contamination where some respondents do not align to

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a specific grade or regularly work in different practice settings. Table 1

Characteristics of respondents.
2.4. Ethics Physiotherapists n
(%)
This study was approval by the School of Sport, Exercise and
Sex Female 268 (55.2)
Rehabilitation Sciences Ethics Committee, University of Birmingham.
Male 200 (41.2)
Participation in the survey was voluntary, with informed consent as- N/A 18 (3.7)
sumed through completion of the survey. Participants were informed Age < 25 years 49 (9.3)
regarding the survey content and duration prior to commencing the 26–35 years 215 (44.3)
survey, with clear details informing options to withdraw and assurance 36–55 years 210 (43.3)
> 56 years 15 (3.1)
of participant anonymity through the process of analysis and reporting.
Physiotherapy Gradinga Band 5 (Junior) 42 (8.7)
Band 6 (Senior) 155 (32.0)
3. Results Band 7 (Senior) 128 (26.4)
Band 8 (Advanced 42 (8.7)
Practitioner)
A total of 627 surveys (unique IP addresses) were returned of the
Extended Scope 76 (15.7)
681 viewed, resulting in a view rate of 99%. With 485 surveys complete Practitioner/Consultant
in full, this accounts for a participation rate of 72% (485/672). A fur- (Advanced Practitioner)
ther 187 incomplete surveys were not included in the final analysis as Lecturer/Researcher 6 (1.2)
inclusion of returns with missing data would introduce bias and affect Other – Sport 36 (7.4)
Years Qualified 0–2 years 43 (8.9)
overall findings.
3–5 years 60 (12.4)
6–10 years 141 (29.1)
3.1. Demographics and characteristics 11–15 years 90 (18.6)
16–20 years 57 (11.8)
Respondents worked primarily in one of the following practice 21–25 years 34 (7.0)
> 25 years 61 (12.6)
settings, NHS (32%, n = 153), private (28%, n = 137) or mixed (e.g. Years in Musculoskeletal 0–2 years 62 (12.8)
NHS and private) (32%, n = 156). Other settings included sport (5%), Practice 3–5 years 94 (19.4)
military (2%), and academia (1%). Other respondent characteristics are 6–10 years 142 (45.6)
detailed in Table 1. 11–15 years 78 (16.1)
16–20 years 47 (9.7)
21–24 years 36 (7.42)
3.2. Professional development > 25 years 29 (5.8)
Physiotherapy Postgraduate Diploma 8 (1.6)
The majority of respondents indicated they had completed con- Qualifications Graduate Diploma 29 (6.0)
tinuing professional development courses focussing on the lumbar Bachelors 275 (56.7)
Masters 93 (19.2)
(81%, n = 391), cervical (74%, n = 357) and thoracic (60%, n = 289) Musculoskeletal 71 (14.6)
spine regions. Of the 198 respondents that provided detail of TSPD Association of Chartered
specific training, this included specialist postgraduate training (e.g. Physiotherapists
Masters or Postgraduate Diploma Advanced Musculoskeletal Other 9 (1.9)
Physiotherapy) (29%, n = 57), manipulation/osteopathic techniques a
Grading is based on level of experience and expertise within musculoske-
(16%, n = 32), Society of Orthopaedic Medicine/Cyriax (12%, n = 23),
letal physiotherapy professional practice.
in-service training (9%, n = 18), Mulligan concept (9%, n = 18),
McKenzie (9%, n = 17), ‘Linda Joy Lee course/Thoracic ring’ (7%,
n = 13), muscle energy techniques (5%, n = 10) and a range of 'Other'
courses making up the rest (22%, n = 44) e.g. soft tissue massage,
acupuncture, radiology/imaging, and Pilates.

3.3. Clinical presentation of TSPD

Compared to a mean of 12 lumbar and 8 cervical spine patients per

week, respondents reported seeing just 4 patients per week with TSPD.
Thoracic presentations were wide ranging with muscular (89%,
n = 430), postural (86%, n = 419), facet joint (76%, n = 371), non-
specific pain (72%, n = 348) the most common presentations (Fig. 1).
Using thematic analysis presentations reported in ‘Other’ included
scoliosis (n = 3), movement imbalances/overuse (n = 3), pregnancy
related pain (n = 2), post hepatic neuralgia (n = 2), costochrondritis
(n = 1), tumour (n = 1) and centrally maintained pain (n = 1).
Fig. 1. TS clinical presentations.
3.4. Examination of TSPD

3.4.1. History taking and special questions possible special questions were provided by 17% (n = 84) of re-
The majority of respondents included the following special ques- spondents. These included neural involvement, weight loss, and ma-
tions: painful deep breath (96%, n = 465), history of cancer (94%, laise/night sweat/fever, history of tuberculosis, previous fracture/os-
n = 454), pain coughing/sneezing (89%, n = 429), pain lying down teoporosis, infection/visceral involvement, red flags, pain pattern,
(75%, n = 362), shortness of breath (73%, n = 354), pain on exertion trauma, steroid use and rheumatological screening.
(62%, n = 299), and a relatively small percentage asking about
symptom behaviour with eating/drinking (29%, n = 139). ‘Other’

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Fig. 2. TS physical examination techniques.

3.4.2. Physical Examination Techniques

The majority of respondents reported ‘always’ including active
range of movement testing (98%, n = 476), palpation (90%, n = 435),
postural assessment (89%, n = 432), functional movement (72%,
n = 349) and passive accessory intervertebral movements (PAIVMs)
(57%, n = 274). The majority of respondents indicated routinely ex-
amining the TS in patients with issues in the cervical (94%, n = 458),
lumbar (76%, n = 367) spine, and shoulder regions (81%, n = 395). TS
physical examination was routinely used less frequently by respondents
for issues involving the elbow (14%, n = 68), hip (8%, n = 40), rib
dysfunction (n = 5), lumbar/sacral/pelvic (n = 4), lower limb issues
(n = 4), other upper limb issues not involving the shoulder or elbow
(e.g. wrist, forearm) (n = 4), and neural presentations (n = 3). See
Fig. 2.
Fig. 3. Active and Passive Interventions used to Manage TSPD.

3.5. Management of TSPD

3.5.1. Use of interventions targeted at the TS to manage other Clinical
Complaints
The majority of respondents used both active and passive techni-
Treatment techniques targeting the TS were used to assist in the
ques, with exercise, passive mobilisation and soft tissue massage being
management of issues in the cervical spine (89%, n = 429), shoulder
utilised most. See Fig. 3. From our thematic analysis ‘Other’ interven-
(82%, n = 398), lumbar spine (63%, n = 306), and elbow (17%,
tions included other exercises (n = 15) (e.g. motor control, cardiovas-
n = 82). From our thematic analysis ‘Other’ regions (6%, n = 31)
cular, foam roller, breathing), education (n = 12), muscle energy
mentioned by respondents included lower limb (n = 7), pelvis/sacroi-
techniques (n = 6), Mulligan techniques (n = 6), relaxation (n = 3),
liac joint/groin (n = 6), rib (n = 3), hand and wrist (n = 4), neurody-
needling (e.g. electro acupuncture or dry needling) (n = 2), neural
namic symptoms (n = 4), autonomic presentations (n = 3), and head-
mobilisation (n = 3), hydrotherapy (n = 3), McKenzie mobilisations
ache (n = 1). See Fig. 4 for details of the specific TS treatment
(n = 1), and TENS (n = 1). See Fig. 3.

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using active range of motion, palpation, functional movement, and

postural assessment routinely to examine TSPD. See Fig. 6 for details.

3.8. Examination of TS for other complaints

The majority of respondents across all practice settings indicated

they examine the TS in patients experiencing cervical spine and
shoulder issues. See Fig. 7 for details. More variability exists for the
lumbar spine with those working in private (79%) or sports setting
(89%) examining the TS compared to 69% in NHS. Examination of the
TS with elbow and hip complaints was notably higher for those working
in private (n = 19, n = 8 respectively) or sports setting (n = 15, n = 23
respectively) compared to less than 5 respondents in NHS. With respect
to the high percentage of those working in sport reporting using tech-
niques for ‘Other’ complaints these included complaints related to the
Fig. 4. Management of Clinical Complaints using TS Targeted Interventions. arm (n = 4), ribs/chest (n = 4), knee (n = 4), sacroiliac/pelvis (n = 4),
foot and ankle (n = 2). See Fig. 7.
techniques used to aid in management of issues in the cervical lumbar,
shoulder, and elbow regions: grouped to differentiate, active, passive 3.9. Management of TSPD
and miscellaneous treatments.
Exercise interventions, including stretching, and postural and
3.6. Comparison of clinical presentations across clinical practice settings strengthening exercises were used to manage TSPD across all settings
(private vs NHS vs sport) with little variability. Overall, passive interventions were used more
frequently in private and sport settings with the exception of acu-
Across different settings the prevalence of clinical presentations was puncture, which was used by approximately a third of those working in
similar with respect to muscle, posture, thoracic outlet syndrome and NHS (36%) and sport settings (35%) and two-thirds of those working in
neural presentations. Notwithstanding the smaller sample of re- private practice (58%). Of the all the passive interventions available,
spondents working primarily in a sports setting (n = 26) reported use of manipulation varied most, with 85% of those respondents
seeing some clinical conditions less than those ion NHS and private working in sport using this technique, compared to 61% and 47% in
setting, most notably autonomic disorders, T4 syndrome, Ankylosing private practice and NHS respectively. See Fig. 8.
spondylitis, disc, Scheuermann's disease, osteoporosis, and RTA/trauma
compared to the NHS and private practice. Specific diseases/conditions 3.10. Clinical Experience and the influence of management approaches
were more prevalent within the NHS, e.g. T4 syndrome, whereas non-
specific complaints relating to muscle and facet joint, were more pre- From those respondents who declared their level of experience/
valent in private practice and sports setting. See Fig. 5. expertise some variability was observed between levels of experience
and the management strategies used for TSPD. The majority of re-
3.7. Physical examination of TSPD spondents across all experience levels indicated they use active ex-
ercises in patients presenting with TSPD. More variability exists in the
Across all practice settings, the majority of respondents indicated use of proprioceptive exercises across grades, ranging from 13 to 48%.

Fig. 5. Clinical presentations across practice settings.

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Fig. 6. Physical Examination Techniques for TSPD across Practice Settings in a. NHS b. Private Practice and c. Sport Practice Setting.

Fig. 7. Examination of the TS in cervical and lumbar spine, shoulder, elbow, hip, and other complaints across practice settings.

Fig. 8. Management of TSPD.

For passive interventions, patterns were similar for mobilisation, soft

tissue massage and acupuncture, although manipulation techniques
were used by just half the junior respondents compared to more than
Fig. 9. Influence of clinical experience on management approach for TSPD.
67% in other groups, with the highest percentage being advanced
practitioners (> 80%). Electrotherapy was used by all junior band re-
spondents compared to less than 7% in any other categories. See Fig. 9. themes including, importance of the TS as part of kinetic chain and
linked to regional interdependence (n = 20), different presentations
3.11. Additional comments seen or approaches used including, respiratory dysfunction, ribs, re-
laxation, pain sciences (n = 17), population specific factors e.g. func-
Additional comments were provided by 76 respondents with 7 key tion and movement patterns in swimmers, women's health, trauma

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(n = 14), decisions would be based on clinical reasoning (n = 9), poor Whilst both exercise and manual therapy have good support for man-
teaching on undergraduate programmes and often over-looked (n = 8), agement of patients with neck and low back pain (National Institute for
association with more serious presentations/red flag/metastases Health and Care Excellence (NICE) guidelines, 2016; Gross et al., 2016),
(n = 6), bias of passive treatments (n = 3), and ‘Others’ (n = 12) (e.g. there is little empirical evidence investigating TS exercise (Andersson
more research required, experiences of manipulation, lacking innova- et al., 2017). In recent years the emergence of research supporting the
tion in rehabilitation, acupuncture, or reporting nil else to add etc.) use of ‘passive’ thoracic mobilisation and manipulation (Suvarnnato
et al., 2013; Young et al., 2004; Cross et al., 2011; Peek et al., 2015;
4. Discussion Walser et al., 2009; Huisman et al., 2013) has exposed a relative gap in
the literature regarding exercise prescription for the TS. A recent ran-
This is the first survey investigating clinical practice for TSPD in the domised controlled trial of thoracic spine stabilisation exercises found
UK and incorporating differences in practice across settings and levels improvements in postural back pain and core endurance in young
of expertise. Results indicate that active interventions, including adults which highlights the need for further research on TSPD (Çelenay
stretching, postural, and strengthening exercises, and passive inter- Ş, 2017).
ventions, including mobilisation and soft tissue massage are preferred Management approaches often associated with specialist skills or
management strategies by the majority of respondents irrespective of further post qualifying training, e.g. manipulation, taping and acu-
practice setting and level of expertise; approaches which reflect current puncture, were used by around half the respondents. Exploration of
practice for managing neck and low back pain. respondents' clinical reasoning would be useful, given empirical evi-
dence is only currently available to support the use of manipulation
4.1. Clinical presentation (Cleland et al., 2005, 2007b; Walser et al., 2009). Notwithstanding the
influence and importance of patient preference in management plan-
The reported ratio of complaints seen in practice across spinal re- ning, our findings suggest that management decisions are not always
gion (12, 8, and 4, lumbar, cervical and thoracic cases per week) closely underpinned by empirical evidence and highlight a need to further
reflects the ratio of reported lifetime prevalence of spinal pain (lumbar investigate exercise prescription for TSPD. Given the ever shrinking
57%, cervical 40%, TS 17%) (Leboeuf-Yde et al., 2009). Respondents healthcare budget, increase in sedentary occupations and behaviours
reported seeing an array of presentations of TSPD including, specific (Heneghan et al., 2018b), continued growth in spine related disability
conditions e.g. osteoporosis, pathologies affecting musculoskeletal tis- (Global Burden of Disease Study, 2016; Foster et al., ) there has never
sues e.g. muscle, facet joint, or complaints relating to a broader de- been a more urgent need to have evidence-based exercise guidelines for
scription of a presentation e.g. posture. This range of presentations is management of TSPD.
reflected in the epidemiology literature where pain prevalence varies
widely (Briggs et al., 2009), is associated with a known condition or 4.4. Comparison of Clinical Presentations and practises across practice
disease, or where thoracic pain co-exists with pain in other regions, settings
albeit less severe or secondary to the primary complaint (Briggs et al.,
2009; Heneghan et al., 2016, 2018a; Berglund et al., 2008). Patterns of practice, including use of special questions and techni-
ques for physical examination across settings showed little variability,
4.2. Physical examination of the TS for TSPD and other complaints despite medical conditions or diseases being likely managed in the NHS.
The observed differences in use of passive physiological intervertebral
Results illustrate consistency in the use of some clinical indicators movements and PAIVMs, TS examination and management approaches
although some variability was found for others, (e.g. Pain on eating or across UK practice settings may be attributed to factors such as spe-
drinking) and many clinical indicators were reported in the ‘Other’ cialisation, confidence in using clinical practical skills, level of experi-
category. This may reflect the diversity of clinical presentations seen ence, patient contact time and managing different caseload types (acute
and encompassed within the broad clinical diagnosis of TSPD. vs sub-acute vs chronic); all of which were not captured in this survey.
Moreover where many clinical indicators were not exclusive to the TS Notwithstanding the value of having further data to support a more in-
this reflects the broader scope of spinal ‘red flag’ questions (Greenhalgh depth analysis, groups were comparable with respect to years qualified
and Selfe, 2006) e.g. history of cancer. although less than half (48%) of NHS respondents had more than 10
The variability among examination approaches used by respondents years' experience working specifically in musculoskeletal physiotherapy
for TSPD may be attributable to the range of presentations being compared to a third in private practice (33%) and sport (31%); years in
managed, with some focused on pain and others dysfunction. Other practice and expertise are not necessarily proportional.
plausible explanations include a lack of assessment techniques with
known diagnostic utility, and convention driving clinical practice with 4.5. Comparison of Clinical Presentations and practises across levels of
those approaches used ‘always’ reflecting core teaching from standard Clinical Experience
textbooks (Petty and Moore, 2002). Although half the respondents had
completed some form of higher degree e.g. Masters, it is unclear whe- Whilst similar patterns of practice were seen for many management
ther these were entry level or specialist programmes; a useful point for approaches, some differences were seen, with all junior respondents
clarification to inform curriculum development. using electrotherapy; a noteworthy finding given that electrotherapy is
Consistent with research supporting the use of thoracic techniques largely unsupported nor recommended in the management of spinal
for managing complaints in other regions, respondents indicated ex- complaints (National Institute for Health and Care Excellence (NICE)
amining the TS in patients with cervical, lumbar, and shoulder issues guidelines, 2015; Blanpied et al., 2017; Gross et al., 2016). Although
(Salom-Moreno et al., 2014; Gonzalez-Iglesias et al., 2009; Cleland not considered entry level skills for UK physiotherapist acupuncture
et al., 2005, 2007a, 2007b; Suvarnnato et al., 2013; Peek et al., 2015; and taping were used by almost half of all respondents within each
Walser et al., 2009). grade for the management of TSPD, suggesting these are perceived
beneficial adjunctive skills to manage patients' complaints. For ma-
4.3. Management of TSPD nipulation, where evidence and guidelines supports their use (Young
et al., 2004; Blanpied et al., 2017; Gross et al., 2015) there was a trend
In line with the survey investigating clinical practice for manage- for greater use with higher levels of experience, perhaps related to
ment of neck pain, active management approaches were used more different caseloads, knowledge of evidence and/or confidence/skills in
consistently compared to passive approaches (Carlesso et al., 2014). performing manipulation.

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4.6. Strengths and limitations Conflicts of interest

Survey development was informed based on current evidence None declared

(Heneghan et al., 2018a; Walser et al., 2009; Muth et al., 2012;
Heneghan and Rushton, 2016; Sueki et al., 2013), expertise (NRH, AR) Ethical approval
and comparable surveys (Carlesso et al., 2014; Foster et al., 1999). View
and participation rates for the survey were excellent compared to other Granted by the School of Sport, Exercise and Rehabilitation Sciences
e-surveys (Nulty, 2008). With a third of respondents working primarily 16/12/15 (Ref RR_24/11/15).
in a single practice setting, establishing levels of respondent expertise
allowed for a more detailed analysis of data to inform further research Funding
or make recommendations for the UK physiotherapy profession. Lim-
itations include the closed nature of this type of survey that precludes None
an understanding of respondent's clinical reasoning in decisions. Many
respondents were working in a mixed practice setting and were there- Funding statement
fore excluded from the analysis of practice across settings. Findings are
only representative of a self-selected population, so caution should be This research did not receive any specific grant from funding
taken in generalising these findings. Finally the survey was focused to agencies in the public, commercial, or not-for-profit sectors.
exploring examination and management from a biophysiological per-
spective, mirroring existing surveys in the cervical and lumbar spine Acknowledgements
(Carlesso et al., 2014; Foster et al., 1999). Whilst this enables some
comparisons to be made across spinal regions data relating to man- The authors gratefully acknowledge the assistance of all the phy-
agement within a biopsychosocial framework was not captured. siotherapists who took part in this study and those that assisted pro-
motion including the Musculoskeletal Association of Chartered
Physiotherapists.
4.7. Clinical and research implications
Appendix A. Supplementary data
Findings from this survey identified priorities for practice and fur-
ther research in TSPD; a requirement for evidence-based practice and Supplementary data to this article can be found online at https://
research led teaching, and in lieu of limited resources e.g. time, and doi.org/10.1016/j.msksp.2018.11.006.
funding. Given the widespread use of active management approaches
with little supporting empirical evidence a key priority is a review of References
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