Research Review By Dr. Ceara Higgins©


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Date Posted:

September 2017

Study Title:

A Preliminary Randomized Clinical Trial on the Effect of Cervicothoracic Manipulation Plus Supervised Exercises vs a Home Exercise Program for the Treatment of Shoulder Impingement


Vinuesa-Montoya S, Aguilar-Ferrandiz ME, Mataran-Penarrocha GA, et al.

Author's Affiliations:

Andalusian Health Service, Almeria, Andalucia, Spain; Department of Physical Therapy, University of Granada, Andalucia, Spain; Department of Nursing, Physical Therapy and Medicine, University of Almeria, Andalucia, Spain; Hospital de Poniente, Almeria, Andalucia, Spain.

Publication Information:

Journal of Chiropractic Medicine 2017; 16(2): 85–93.

Background Information:

Shoulder impingement syndrome (SIS) has been related to rotator cuff weakness, posterior glenohumeral capsular tightness, poor scapulohumeral rhythm and scapular muscle imbalances (1). Shoulder pain is reported in 20-50% of the population (3), with rotator cuff tendinopathy with impingement identified as the most prevalent diagnosis (2). Previous research has shown that SIS responds better to treatments composed of exercises combined with other therapies compared to single-intervention approaches (4).

It has been reported that manual therapy applied to the thoracic spine alone, or combined with exercise, improves pain and disability in individuals with SIS (6). However, the mechanisms for this benefit have not yet been established. Relevant theories include the idea that the neurophysiological effect of joint manipulation might alter the inflow of sensory information into the central nervous system (7). It is also possible that the concept of regional interdependence as described by Wainner and colleagues (8) may come into play. This concept suggests that impairments in remote anatomic regions that seem unrelated may be associated with the primary symptoms in shoulder pain (or some other affliction).

This study aimed to investigate changes in pain, disability, and range of motion in individuals with unilateral shoulder impingement, treated with either 10 sessions of cervicothoracic manipulative treatment plus exercise therapy or a home exercise program alone.

Pertinent Results:

One participant in the home exercise group was lost to follow-up. 65% of study participants reported anterior or posterior shoulder pain, 27.5% reported upper or lateral shoulder pain, and 7.5% reported dorsolateral forearm pain. No side effects were reported in either group.

At the end of 5 weeks of treatment, significant differences were found between groups in the DASH but no differences were seen in overall shoulder disability or pain intensity. Within-group differences were seen in both groups in DASH and SDQ, but only the manipulation plus exercise group showed significant improvements in pain intensity.

There were no significant differences in the Neer test or Hawkins-Kennedy test between groups, but significant differences were found within the home exercise group in the Hawkins-Kennedy test. In the home exercise group, 100% of patients had a positive Hawkins-Kennedy test at baseline, while only 52.6% were positive after 5 weeks of treatment.

There were no significant between group differences in active shoulder flexion, external rotation, internal rotation or abduction. Within-group comparisons showed significant differences in all ranges of motion in the manipulation plus exercise group from baseline to five weeks post-treatment. The home exercise group only showed significant differences in flexion, extension, adduction, and abduction.

These results agree with previous studies by Delgado-Gil and colleagues (5) and Teys and colleagues (12), who showed that individuals receiving 4 sessions of Mulligan mobilization with movement (MWM) showed better outcomes in pain-free range of shoulder flexion and maximal external rotation.

The neurophysiologic mechanisms underlying spinal manipulation are not fully understood. It is theorized that the mechanical force from manual therapy initiates a cascade of neurophysiologic responses in the peripheral and central nervous systems leading to hypoalgesia (13). This may be why previous clinical trials incorporating thoracic spinal manipulation showed improved patient-reported outcomes when compared to treatments without spinal manipulation (14).

Clinical Application & Conclusions:

This study indicates that while both treatment options reduced disability, positive results on clinical tests for subacromial impingement syndrome, and active flexion, extension, adduction, and abduction, individuals receiving cervicothoracic manipulative treatment plus exercise also showed improvement in pain intensity and range of motion in all directions, including shoulder internal and external rotation.

Both types of treatment lead to improvements and represent useful methods of treating shoulder impingement syndrome. However, it appears the combination of spinal manipulation and exercise may result in superior outcomes for patients with shoulder impingement – something we commonly see in our offices!

Study Methods:

12 men and 29 women were recruited based on the following inclusion criteria:
  • Unilateral shoulder pain compatible with a medical diagnosis of SIS in the dominant arm
  • Pain or dysfunction with overhead activities
  • Pain during active shoulder movements
  • Positive Neer/Hawkins-Kennedy test
  • Onset of pain within the last 12 months
  • Non-traumatic onset of pain
  • Baseline pain levels of 2 out of 10 on the visual analogue scale (VAS)
Exclusion Criteria:
  • Presence of red flags
  • History of frozen shoulder
  • Disorders of the acromioclavicular joint
  • Degenerative arthritis of the glenohumeral joint
  • Calcifying tendonitis identified on radiograph
  • Post-traumatic disorders
  • Shoulder, elbow, hand, or wrist surgery
  • Blatantly misdiagnosed cervical spine disorders
Outcome measures included the visual analog scale (VAS - 10-cm line anchored with 0, indicating no pain and 10, representing the worst pain imaginable, at the other end) (9). Disability was assessed using the Disabilities of the Arm, Shoulder, and Hand (DASH), a 30-item self-reported questionnaire. This scale includes items of physical function, symptoms, and social/role (10) providing a final score from 0 (no disability) to 100 (most severe disability). The Shoulder Disability Questionnaire (SDQ) was also used. This self-reported questionnaire contains 16 descriptions of common situations that can induce symptoms in individuals with shoulder disorders. Patients are asked to answer yes or no to symptom induction based on the preceding 24 hours. Situations which did not occur during this time are identified as not applicable. A final score is calculated based on all applicable situations and ranges from 0 (no disability) to 100 (all applicable items positive) (11). The Neer and Hawkins-Kennedy tests for subacromial impingement were performed by a physical therapist with 15 years of experience and identified as positive or negative. Finally, active range of motion of the shoulder in flexion, extension, internal rotation, external rotation, adduction, and abduction were measured using a digital goniometer.

Participants underwent a baseline evaluation consisting of the above measures and were then randomly assigned to either the cervicothoracic manipulative therapy plus exercise group or the home exercise group. A computer-generated randomized table of numbers was utilized for concealed allocation to the groups.

Individuals in the cervicothoracic manipulative therapy plus exercise group received a set sequence of mobilization/manipulation. First, repetitive lateral translation was applied to the cervical spine from both sides. Next, they received axial distraction with a fulcrum to the thoracic area (2), ‘dog technique’ manipulation in flexion to the upper thoracic spine (T1-T4), mid-thoracic spine (T5-T8), and low thoracic spine (T9-T12) (NOTE: The dog technique was not described, although based on the pictures included in the paper, the technique appeared to be similar to a thoracic anterior adjustment) (3), and manipulation to the mid-thoracic area with the therapist contacting the transverse processes to either side of the spine with one thumb facing superior and the other facing inferior and then compressing with the pisiforms (patient prone). Exercises were demonstrated in the clinic at the beginning of the study and participants took home a handout for the exercises. The exercise program consisted of shoulder flexion and extension exercises, counter-resistance exercises using an elastic band with the elbow at 90 degrees, shoulder flexion with elbow extension using a 1-4kg bar, shoulder flexion at 90 degrees with the elbow extended using a 1-4kg bar, a body lift from a seated position with the elbows extended, exercises for flexion, extension, rotation, and head tilt, and exercises with shoulder circles. Participants received SMT twice per week for 5 weeks in the clinic and performed the exercise program for 30 minutes, twice a day.

Participants in the home exercise group performed the same exercise program described above for 30 minutes twice a day for 5 weeks.

Study Strengths / Weaknesses:

  • By including a commonly utilized method of treatment for shoulder impingement syndromes (exercise) in both groups the authors were able to more clearly show the additional benefits of the manipulation intervention.
  • The exercise program was poorly described and no pictures were provided in the paper.
  • Only one therapist provided both treatments. This slightly limits the generalizability of the results.
  • No long-term follow-up was undertaken.
  • It would have been beneficial to have a control group receiving no intervention and/or a control group receiving thoracic, but not cervical mobilization to clarify the results.

Additional References:

  1. Pribicevic M, Pollard H, Bonello R, de Luca K. A systematic review of manipulative therapy for the treatment of shoulder pain. J Manipulative Physiol Ther 2010; 33: 679-689.
  2. Pribicevic M, Pollard H, Bonello R. An epidemiologic survey of shoulder pain in chiropractic practice in Australia. J Manipulative Physiol Ther 2009; 32: 107-117.
  3. Luime JJ, Koes BW, Hendriksen IJ, et al. Prevalence and incidence of shoulder pain in the general population; a systematic review; Scand J Rheumatol 2004; 33: 73-81.
  4. Dong W, Goost H, Lin XB, et al. Treatments for shoulder impingement syndrome: a PRISMA systematic review and network meta-analysis. Medicine (Baltimore) 2015; 94: e510.
  5. Delgado-Gil JA, Prado-Robles E, Rodrigues-de-Souza DP, et al. Effects of mobilization with movement on pain and range of motion in patients with unilateral shoulder impingement syndrome: a randomized controlled trial. J Manipulative Physiol Ther 2015; 38: 245-252.
  6. Boyles RE, Ritland BM, Miracle BM, et al. The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Man Ther 2009; 14: 375-380.
  7. Pickar JG. Neurophysiological effects of spinal manipulation. Spine J 2002; 2: 357-371.
  8. Wainner RS, Whitman JM, Cleland JA, Flynn TW. Regional interdependence: a musculoskeletal examination model whose time has come. J Orthop Sports Phys Ther 2007; 37(11): 658-660.
  9. Jensen MP, Turner JA, Romano JM, Fisher LD. Comparative reliability and validity of chronic pain intensity measures. Pain 1999; 83(2): 157-162.
  10. Kitis A, Celik E, Aslan UB, Zeneir M. DASH questionnaire for the analysis of musculoskeletal symptoms in industry workers: a validity and reliability study. Appl Ergon 2009; 40(2): 251-255.
  11. Alvarez-Nemegyei J, Puerto-Ceballos I, Guzman-Hau W, et al. Development of a Spanish-language version of the Shoulder Disability Questionnaire. J Clin Rheumatol 2005; 11(4): 185-187.
  12. Teys P, Bisset L, Vicenzino B. The initial effects of a Mulligan’s mobilization with movement technique on range of movement and pressure pain threshold in pain-limited shoulders. Man Ther 2008; 13(1): 37-42.
  13. Bialosky JE, Bishop MD, Price DD, et al. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Man Ther 2009; 14(5): 531-538.
  14. Bergman GL, Winters JC, Groenier KH, et al. Manipulative therapy in addition to usual care for patients with shoulder complaints: results of physical examination outcomes in a randomized controlled trial. J Manipulative Physiol Ther 2010; 33: 96-101.