Objective: To investigate the most common physical examination tests (PET) for the screening for referral of patients with back or chest pain caused by serious pathology. Methods: A systematic review was conducted. Searches were performed on seven electronic databases between June 2020 and December 2021. Only studies evaluating patients with back and/or chest pain with clear reporting of PETs and prompt patient referrals were included. Results: 316 full texts were included, and these studies had a total of 474/492 patients affected by a serious disease. Only 26 studies of them described suspicion of serious disease due to at least one positive PET. Cardiac/pulmonary auscultation and heartbeats/blood pressure measurements were the most frequently reported tests. None of the reported studies included physiotherapists and chiropractors who reported the use of various tests, such as: cardiac and pulmonary auscultation, lung percussion, costovertebral angle tenderness, and lymph node palpation, highlighting a lack of attention in measuring vital parameters. On the contrary, doctors and nurses reported the assessment of the range of motion of the thoracolumbar spine and hip less frequently. Conclusions: Appropriate reporting of PETs is sparse, and their utilization is heterogeneous among different healthcare professionals. Further primary studies are needed to describe PETs results in patients suffering from back and/or chest pain.

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.