Southerst D, Marchand AA, Côté P, et al. The effectiveness of noninvasive interventions for musculoskeletal thoracic spine and chest wall pain: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration. J Manipulative Physiol Ther. 2015;38(7):521-531. doi:10.1016/j.jmpt.2015.06.001. 

Few randomized clinical trials (RCTs) provide guidance on the most effective management for musculoskeletal thoracic spine or chest wall pain. Canadian researchers performed a rigorous systematic review of RCTs, cohort studies, and case-control studies that examined nonpharmacologic treatments for managing acute mechanical thoracic spine and chest wall pain. Contrary to previous recommendations,^1,2 the study determined that manual therapy provided clinically irrelevant pain reduction in patients with thoracic pain. 

Inclusion criteria were studies published in English, between 1990 and 2015, with a subsample of at least 30 participants per treatment arm for RCTs or 100 for cohort or case-controlled studies. Authors excluded visceral or systemic disease–related pain studies. Independent reviewers used the Scottish Intercollegiate Guidelines Network criteria to assess the risk of bias, calculated relative risk, strength of association between interventions and outcomes, and intervention effectiveness by measuring mean changes between groups. 

Researchers assessed more than 8000 potentially relevant articles and found 2 appraisable studies. One of the studies found a small statistically significant—but not clinically important—impact of manual physiotherapy on reducing acute thoracic spinal pain when comparing the effectiveness of thoracic spinal manipulation, needle acupuncture, and placebo electrotherapy in the management of thoracic spine pain. The other study, which compared a multimodal program of care with a single education session in the management of musculoskeletal chest wall pain, suggested that chiropractic spinal manipulation and soft tissue therapy have the same effect in reducing acute chest wall pain as an education session. 

The researchers concluded that manual therapies are not effective for acute musculoskeletal thoracic spine or chest wall pain management. A high-quality RCT subsequently substantiated the findings of this systematic review.³ 

The osteopathic medical profession needs rigorously designed, low bias, large cohort studies, similar to those that support the American Osteopathic Association’s recently updated osteopathic manipulative treatment guidelines for low back pain,⁴ to validate reimbursement claims for treating patients with acute thoracic spine and chest wall pain conditions with osteopathic manipulative treatment.