Management

• Treatment should take into account individual patient needs, preferences, expectations and functional status.
• Clinical reasoning should inform treatment based on subjective and objective findings.
• Good communication between therapist and patient is essential if a successful outcome is to be achieved.
• Treatment options should be clearly explained so that patients can make informed decisions with regard to their care and management.

• Reduce pain and/or symptoms
• Maximise postural awareness and control
• Maintain/improve normal movement
• Functional restoration
• Prophylaxis
• Long term management of their structural deformity including:
  • To maximise aerobic and respiratory function
  • To improve aesthetics through postural control

The main treatment objectives in the management of thoracic problems are to:

• Improve patient’s confidence in their own ability to manage and cope with their condition (including structural deformity)
• Advise on strategies that provide pain relief
• Initiate appropriate physiotherapy intervention
• Provide advice and information that facilitate self-management strategies and encourage the individual to remain physically active (within the limitations of any structural deformity and include contraindications to exercise with confirmed osteoporosis)
• Work with the individual to facilitate a return to their desired level of activity and function
• Prevent reoccurrence and/or improve the management of any reoccurrence
• Reduce the potential for chronicity and associated disability developing
• Informed consent should be sought before beginning treatment

Any advice given should be appropriate to the patient’s needs, consistent and evidence-based. It should also involve reassurance, encouragement and positive feedback. The physiotherapist should endeavour to:

• Provide a clear explanation of the patient’s presenting complaint tailored to the individual’s needs and understanding.
• Explain that radiological investigations are not indicated in the first instance as they provide no clinical benefit (unless red flags are suspected or in the presence of a structural deformity).
• Advise that simple painkillers can help alleviate symptoms and that cold and heat packs can afford some pain relief. Regular paracetamol is considered the first medication option. Where this proves ineffective, non-steroidal anti-inflammatory drugs (NSAIDs) may be prescribed by a medical practitioner/pharmacist. Some patients with radicular symptoms may benefit from neuropathic pain medications which are prescribed by a medical practitioner.
• Provide advice and information to promote the self-management of thoracic pain. This should be supported by evidence-based written documentation and should be accessible to individuals with additional needs.
• Encourage patients to remain physically active despite experiencing discomfort. Explain that pain associated with movement is generally not harmful or damaging.
• Advise and encourage individuals to engage in exercise as part of a healthy lifestyle e.g. highlight the benefits of walking
• Encourage the individual to remain at work or return to work as soon as possible. Explain that this will promote recovery and decrease the probability of further problems occurring. Where necessary provide guidance on the return to work process e.g. light duties, flexible working hours and a gradual return to tasks. Highlight the importance of workstation assessments and manual handling training when appropriate.
• Advise on the importance of pacing of activities and exercise where necessary
• Provide information on voluntary organisations or community fitness and exercise groups, which encourage a return to normal functional activities e.g. Live Active scheme, Vitality classes and physiotherapy-led osteoporosis 12 week classes
• When required, provide information about other health improvement agencies as appropriate.

There is very little evidence to support any specific physiotherapeutic management for patients with musculoskeletal thoracic pain. Utilising the guidelines for cervical and lumbar patients, there is consensus and supporting evidence for the use of manipulations/ mobilisation and supervised exercise (NICE, 2015, Tsakitzidis et al, 2013).

However there is also consensus that an increased kyphosis associated with poor posture is related to the onset of thoracic pain (O'Connel et al, 2002, McKenzie and May, 2006). Therefore postural correction and control along with the maintenance of thoracic extension movements is important within physiotherapy treatment (SIGN, 2015).

There is strong evidence from systematic reviews that exercise and advice to remain active helps restore function and reduce pain. There is some evidence that exercise helps improve psychological wellbeing (Hayden et al. 2004 and Van Tulder et al. 2001).

A range of exercises may be used to promote self-management strategies. These may include:

• (Structured) aerobic exercise – aims to increase general cardiovascular fitness
• Mobilising exercises – aim to increase the ability to move
• Strengthening exercises – aim to increase muscle strength
• General exercise – a combination of the above
• McKenzie exercises – direction-specific repeated exercises

Posture and balance exercises aim to improve postural control and reduce the risk of falls.

A stand-alone education programme without exercise therapy is not advised (NICE, 2009).

There does not appear to be any significant difference between the strength and endurance training with regards to pain or disability (Ylinen et al, 2006).

It is recognised that the therapist’s special interest or training may affect the choice of exercise prescribed e.g. McKenzie MDT.

In both lumbar and cervical spine guidelines there is strong evidence to support the use of manual therapy in conjunction with exercise. If used, it should be part of a package of interventions aimed at promoting and directing patient self-management. This should be made clear to the patient.

The therapist should ensure that knowledge and skills are updated and recorded through their CPD as confidence and expertise in performing manual techniques can greatly affect the outcome.

Valid consent should be sought and documented when manipulation is used. A risk of possible adverse events should be understood by the therapist and clearly explained to the patient to allow for an informed decision to be made.

TENS

There is both limited and contradictory evidence to support the use of TENS. This information is gained primarily from the literature regarding both lumbar and cervical spine(Albright et al, 2001; Kroeling et al, 2005) , If no contra-indications, TENS may be employed. When offered it should only be considered as a subordinate component to exercise based on sound clinical reasoning, or where other treatments are contra-indicated supporting an active self-management approach.

Supported Self-Management

Supported self-management for individual patients should be considered throughout their physiotherapy journey.

Consideration should be given to:

• Diagnosis and natural history
• Pain control
• Communication
• Education
• Patient empowerment and reassurance
• Appropriateness of treatment approach used
• Long-term management of structural deformity
• Health improvement services (e.g. info dir)

Albright, J., Allman, R., Bonfiglio, R., Conill, A., Dobkin, B., Guccione, A., Hasson, S., Russo, R., Shekelle, P., Susman, J., 2001. Philadelphia Panel Evidence-Based clinical practice guidelines on selected rehabilitation interventions for neck pain. Physical Therapy, Vol. 81, (10), 1701-1717.

Gross, A., Goldsmith, C., Hoving, J., Haines, T., Peloso, P., Aker, P., Santaguida, P. and Myers, C. 2007. Conservative management of mechanical neck disorders: A systematic review. Journal of Rheumatology, 34: 1083 – 1100 Link Here (link correct as of 13/12/19). NHS Scotland Athens username and password may be required.

Gross, K., Goldsmith, C., Santaguida, P., Hoving, J. and Bronfort, G., Cervical overview group. 2005. Exercises for mechanical neck disorders. Cochrane database of systematic reviews. Issue 3. Art. No.: CD004250. DOI: 10.1002/14651858.CD004250.pub3 Link Here (link correct as of 13/12/19). NHS Scotland Athens username and password may be required.

Hayden, J., van Tulder, M.W., Malmivaara, A. and Koes, B.W. 2004. Exercise therapy for the treatment of non-specific low back pain. Cochrane Database of systematic reviews 2004. Issue 4 Link Here (link correct as of 13/12/19). NHS Scotland Athens username and password may be required.

Kroeling, P., Gross, A., Goldsmith, C., 2005. A Cochrane review of electrotherapy for mechanical neck disorders. Spine, Vol. 30, (23), pp. E641-E648.

Nice – Non Specific Neck Pain: https://cks.nice.org.uk/neck-pain-non-specific

Tsakitzidis, G., Remmen, R., Dankaerts, W. and Van Royen, P. 2013. Non-specific neck pain and evidence-based practice. European Scientific Journal, 9 (3): 1-19 Link Here (link correct as of 13/12/19). NHS Scotland Athens username and password may be required.

Van Tulder, MW, Malmivaara, A, Esmail, R and Koes, BW (2000a). Exercise Therapy for Low Back Pain (Cochrane Review), The Cochrane Library, no3, Update Software, Oxford

TMD Information for patients