Investigating the effects of mobilization with movement and exercise on pain modulation processes in shoulder pain - a single cohort pilot study with short-term follow up.

OBJECTIVE: To explore the association between manual therapy and exercise and pain modulation and clinical characteristics in people with musculoskeletal shoulder pain. METHODS: This is a prospective, longitudinal, single cohort pilot study. People with shoulder pain for longer than 6 weeks underwent 4 weeks of glenohumeral mobilization with movement and shoulder exercises. Measures of pain modulation, shoulder pain, disability, range of motion and psychosocial factors were assessed at baseline and immediately after the 4-week period of treatment. Treatment effectiveness was assessed through parametric, non-parametric and multilevel modeling statistics. RESULTS: Twenty-three individuals participatedwith no loss to follow-up. Significant and meaningful improvements in shoulder pain (NRS mean change 1.6/10, 95% CI 0.4 to 2.7), disability (SPADI mean change 20.5/100, 95% CI 13.1 to 27.9) and range of motion (mean change 33°, 95% CI 23 to 43°) were observed following treatment. Statistical but non-clinically meaningful changes were observed in temporal summation of pain (mean change 0.3/10, 95% CI 0.1 to 0.4) and anxiety (mean change 0.86/21, 95% CI 0.18 to 1.55). Significant reductions were observed in temporal summation of pain (mean change 0.3/10, 95% CI 0.1 to 0.4) and anxiety (mean change 0.86/21, 95% CI 0.18 to 1.55), however these were not considered clinically important. No association was found between clinical characteristics and sensory measures. No association was found between clinical characteristics and sensory measures. CONCLUSION: Glenohumeral mobilization with movement and exercise did not improve pain modulation, despite improvements in pain, function and range of motion, in people with shoulder pain.

Short-Term Effects of Thoracic Spine Manipulation on Shoulder Impingement Syndrome: A Randomized Controlled Trial.

OBJECTIVE: To investigate the short-term effects of thoracic spine manipulation (TSM) on pain, function, scapular kinematics, and scapular muscle activity in individuals with shoulder impingement syndrome. DESIGN: Randomized controlled trial with blinded assessor and patient. SETTING: Laboratory. PARTICIPANTS: Patients with shoulder impingement syndrome (N=61). INTERVENTIONS: Participants were randomly allocated to TSM group (n=30) or sham-TSM group (n=31) and attended 2 intervention sessions over a 1-week period. MAIN OUTCOME MEASURES: Scapular kinematics and muscle activity were measured at day 1 (baseline, before the first intervention), day 2 preintervention (before second intervention), day 2 postintervention (after the second intervention), and day 3 (follow-up). Shoulder pain and function were assessed by the Disability of the Arm, Shoulder and Hand questionnaire and Western Ontario Rotator Cuff Index at baseline, day 2 preintervention, and follow-up. An assessor blinded to group assignment measured all outcomes. RESULTS: Pain decreased by 0.7 points (95% confidence interval, 1.3-0.1 points) at day 2 preintervention and 0.9 points (95% confidence interval, 1.5-0.3 points) at day 2 postintervention in the TSM group. The Disability of the Arm, Shoulder and Hand questionnaire (P=.01) and Western Ontario Rotator Cuff Index (P=.02) scores improved in both groups. Scapular upward rotation increased during arm lowering (P<.01) at day 2 postintervention (5.3°) and follow-up (3.5°) in the TSM group. Upper trapezius activity increased (P<.05) in the sham-TSM group. Middle trapezius, lower trapezius, and serratus anterior decreased activities in both groups during elevation and lowering of the arm. CONCLUSIONS: TSM may increase scapular upward rotation during arm lowering. TSM does not seem to influence activity of the scapular muscles. The results concerning shoulder pain, function, scapular tilt, and internal rotation are not conclusive.

Effects of Stretching and Strengthening Exercises, With and Without Manual Therapy, on Scapular Kinematics, Function, and Pain in Individuals With Shoulder Impingement: A Randomized Controlled Trial.

STUDY DESIGN: Randomized controlled trial. OBJECTIVE: To evaluate the effects of an exercise protocol, with and without manual therapy, on scapular kinematics, function, pain, and mechanical sensitivity in individuals with shoulder impingement syndrome. BACKGROUND: Stretching and strengthening exercises have been shown to effectively decrease pain and disability in individuals with shoulder impingement syndrome. There is still conflicting evidence regarding the efficacy of adding manual therapy to an exercise therapy regimen. METHODS: Forty-six patients were assigned to 1 of 2 groups, one of which received a 4-week intervention of stretching and strengthening exercises (exercise alone) and the other the same intervention, supplemented by manual therapy targeting the shoulder and cervical spine (exercise plus manual therapy). All outcomes were measured preintervention and postintervention at 4 weeks. Outcome measures were scapular kinematics in the scapular and sagittal planes during arm elevation, function as determined through the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, pain as assessed with a visual analog scale, and mechanical sensitivity as assessed with pressure pain threshold. RESULTS: Independent of the intervention group, small, clinically irrelevant changes in scapular kinematics were observed postintervention. A significant group-by-time interaction effect (P = .001) was found for scapular anterior tilt during elevation in the sagittal plane, with a 3.0° increase (95% confidence interval [CI]: -1.5°, 7.5°) relative to baseline in the exercise-plus-manual therapy group compared to a decrease of 0.3° (95% CI: -4.2°, 4.8°) in the exercise-alone group. Pain, mechanical sensitivity, and the DASH score improved similarly for both groups by the end of the intervention period. CONCLUSION: Adding manual therapy to an exercise protocol did not enhance improvements in scapular kinematics, function, and pain in individuals with shoulder impingement syndrome. The noted improvements in pain and function are not likely explained by changes in scapular kinematics.