Comparison of transcutaneous electrical stimulation and suprascapular nerve blockage for the treatment of hemiplegic shoulder pain.

BACKGROUND: Hemiplegic shoulder pain (HSP) is a common morbidity of stroke. Different treatment modalities can be used for optimizing the results and limiting the possible side effects. This research compares the effects of two therapies used to reduce the pain and improve the quality of life of the patients with HSP. OBJECTIVE: This study aimed to compare the effects of transcutaneous electrical nerve stimulation (TENS) and suprascapular nerve blockage (SSNB) in patients with HSP. METHODS: In this clinical research, 24 patients with HSP who participated in a conventional rehabilitation program were randomized into TENS or SSNB treatment groups. A 100 mm visual analogue scale was used to assess the severity of pain. Passive range of motion (ROM) of the shoulder was measured. The Modified Ashworth Scale (MAS) was used to evaluate spasticity of the upper extremities, and the Modified Barthel Scale was used to assess activities of daily living (ADL). Quality of life was measured using the Stroke-specific Quality of Life (SS-QoL) questionnaire. RESULTS: The pain scores of the SSNB group decreased more significantly (p< 0.05) than in the TENS group. SS-QoL scores at the 3rd week in both groups were significantly higher than before treatment (p< 0.05). MAS scores and Barthel scores after treatment did not differ significantly between the groups. CONCLUSION: TENS and SSNB were beneficial in relieving pain and increasing passive shoulder ROM and ADL in all patients. The alleviating of pain was faster in patients who underwent SSNB.

Rotator Cuff-Related Shoulder Pain: Is It Time to Reframe the Advice, "You Need to Strengthen Your Shoulder"?

SYNOPSIS: Progressive resistance exercise, in isolation or in combination with other noninvasive therapies such as therapeutic touch, is the first-line approach to managing nontraumatic rotator cuff-related shoulder pain (RCRSP). Resistance exercise may be effective for people with RCRSP secondary to improving mechanical features of the shoulder, including strength, kinematics, and muscle timing and activation. However, strength gains are often small and clinically unimportant when measured during clinical trials. In this Viewpoint, we argue that clinicians should (1) continue to prescribe resistance exercise when managing RCRSP, and (2) embrace the broad biological mechanisms underpinning the efficacy of resistance exercise. Any benefit is governed by more than simple mechanical changes. The clinical message must go beyond the idea that the patient's weak, deconditioned, or frail shoulder is the basis of his or her pain, and all the patient needs to do is to get strong. J Orthop Sports Phys Ther 2021;51(4):156-158. doi:10.2519/jospt.2021.10199.

Effects of electromyographic biofeedback interventions for shoulder pain and function: Systematic review and meta-analysis.

OBJECTIVE: To systematically review the effectiveness of electromyographic biofeedback interventions to improve pain and function of patients with shoulder pain. DESIGN: Systematic review of controlled clinical trials. LITERATURE SEARCH: Databases (Medline, EMBASE, CINAHL, PEDro, CENTRAL, Web of Science, and SCOPUS) were searched in December 2020. STUDY SELECTION CRITERIA: Randomized clinical trials that investigated the effects of electromyographic biofeedback for individuals with shoulder pain. Patient-reported pain and functional outcomes were collected and synthesized. DATA SYNTHESIS: The level of evidence was synthesized using GRADE and Standardized Mean Differences and 95% confidence interval were calculated using a random-effects inverse variance model for meta-analysis. RESULTS: Five studies were included with a total sample of 272 individuals with shoulder pain. Very-low quality of evidence indicated that electromyographic biofeedback was not superior to control for reducing shoulder pain (standardized mean differences = -0.21, 95% confidence interval: -0.67 to 0.24, P = 0.36). Very-low quality of evidence indicated that electromyographic biofeedback interventions were not superior to control for improving shoulder function (standardized mean differences = -0.11, 95% confidence interval: -0.41 to 0.19, P = 0.48). CONCLUSION: Electromyographic biofeedback may be not effective for improving shoulder pain and function. However, the limited number of included studies and very low quality of evidence does not support a definitive recommendation about the effectiveness of electromyographic biofeedback to treat individuals with shoulder pain.

The Effectiveness of Ischemic Compression Technique on Pain and Function in Individuals With Shoulder Pain: A Systematic Review.

OBJECTIVE: To systematically review current literature to determine the effectiveness of the ischemic compression (IC) technique on pain and function in individuals with shoulder pain. METHODS: This review was conducted according to recommendations of Preferred Reporting Items for Systematic Reviews and Meta-Analyses and the Cochrane Collaboration for Systematic Reviews; a search was performed in the electronic databases PubMed, Cumulative Index to Nursing and Allied Health Literature, SPORTDiscus, Physiotherapy Evidence Database, and Web of Science. Randomized clinical trials and quasi-randomized clinical trials were included, and the methodological quality was evaluated through the Physiotherapy Evidence Database scale. RESULTS: The search found 572 studies; of these, 71 were selected by title and, subsequently, 29 were selected through abstract analyses. After critical analyses, 5 studies were included. The methodological quality ranged from 4 (reasonable) to 9 (excellent) points. Pain was assessed by all studies using the visual analog scale, Global Perceived Effect scale, Numerical Rating Scale, pressure pain threshold, or Perceived Amelioration Numerical Scale. Function was evaluated by 3 studies through the Shoulder Pain and Disability Index; Neck Disability Index; American Shoulder and Elbow Surgeons Standardized Shoulder Assessment; and Disabilities of the Arm, Shoulder, and Hand questionnaires. The studies showed that the IC technique produces immediate and short-term positive effects for pain, and positive short-term effects for shoulder function in individuals with shoulder pain. CONCLUSION: The IC technique seems to be beneficial for pain and shoulder function. However, caution is needed when considering this evidence owing to the limited quality of some studies, the few articles found, and the lack of standardization of the application parameters of the technique to facilitate its reproducibility.

Effects of a Single Myofascial Induction Session on Neural Mechanosensitivity in Breast Cancer Survivors: A Secondary Analysis of a Crossover Study.

OBJECTIVES: The purpose of this study was to investigate the short-term effects of myofascial induction on mechanosensitivity of upper limb nerves. METHODS: In this secondary analysis of a randomized, single-blind, placebo-controlled crossover study, 21 breast cancer survivors with stage I-IIIA cancer were randomly allocated to an experimental group (30 minutes of myofascial induction session) or placebo control group (unplugged pulsed 30 minutes of shortwave therapy), with a 4-week washout period between sessions that occurred in a physical therapy laboratory in the Health Science Faculty (University of Granada, Spain). Range of motion (universal goniometry), structural differentiation, symptoms (yes/no), and pressure pain thresholds (electronic algometry) were assessed during neurodynamic tests and attitude toward massage scale as covariate. RESULTS: An analysis of covariance revealed significant time × group interactions for range of motion in affected upper limb nerves (median, P < .001; radial, P = .036; ulnar, P = .002), but not for nonaffected upper limb nerves (median, P = .083; radial, P = .072; ulnar, P = .796). A χ2 or Fisher exact test, as appropriate, also revealed a significant difference (P = .044) in sensitivity for the affected upper limb ulnar nerve in the experimental group, whereas the rest of the assessed nerves (affected and nonaffected upper limb nerves) showed no significant changes in either the experimental or control groups (P > .05). An analysis of covariance revealed no significant interactions on pressure pain thresholds over the nerves for affected (all P > .05) and nonaffected (all P > .05) upper limb nerves. CONCLUSION: A single myofascial induction session may partially improve mechanosensitivity of median, radial, and ulnar nerves and yield positive effects on symptom mechanosensitivity, especially regarding the ulnar nerve in breast cancer survivors.

Treatment of individuals with chronic bicipital tendinopathy using dry needling, eccentric-concentric exercise and stretching; a case series.

Objectives: To describe the outcomes of 10 patients with chronic biceps tendinopathy treated by physical therapy with the novel approach of dry needling (DN), eccentric-concentric exercise (ECE), and stretching of the long head of the biceps tendon (LHBT). Methods: Ten individuals reporting chronic anterior shoulder symptoms (> 3 months), pain with palpation of the LHBT, and positive results on a combination of tests including active shoulder flexion, Speed's, Hawkins Kennedy, Neer, and Yergason's tests participated in this case series. Validated self-reported outcome measures including the mean numeric pain rating scale (NPRS) and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) were taken at baseline. Participants were treated with two to eight sessions of DN to the LHBT and an ECE program and stretching of the biceps muscle. At discharge, patients completed the global rating of change (GROC), QuickDASH and NPRS. Results: Patients had an improved mean NPRS of 3.9 (SD, 1.3; p < 0.001), QuickDASH of 19.01% (SD, 10.8; p < 0.02) and GROC +5.4 (SD, 1.3). Conclusion: Findings from this case series suggest that DN and ECE may be beneficial for the management of patients with chronic LHBT tendinopathy. Further research on the efficacy of this novel treatment approach is warranted.

Effect of Psychomotricity in Combination With 3 Months of Active Shoulder Exercises in Individuals With Chronic Shoulder Pain: Primary Results From an Investigator-Blinded, Randomized, Controlled Trial.

OBJECTIVE: To evaluate whether psychomotor therapy (PMT) in combination with usual care active exercise (AE) rehabilitation for the shoulder is superior to merely AE. DESIGN: The trial was a single-center, stratified (by corticosteroid injection [yes or no]), randomized, and controlled superiority trial. SETTING: Shoulder unit of the orthopedic department at Hospital Lillebaelt, Vejle Hospital. PARTICIPANTS: Eligible participants (N=87) were adults aged 18-75 years with shoulder complaints lasting for at least 3 months, in addition to a score equal to or below 3 on the Multidimensional Assessment of Interoceptive Awareness score. Furthermore, patients had at least a visual analog scale pain score of 2 at rest, 3 at night, and 5 in activity (range: 0-10). INTERVENTIONS: Patients were randomized to 12 weeks of AE (control group) or in combination with 5 PMT sessions (intervention group). MAIN OUTCOME MEASURE: The primary outcome was the patient-reported outcome score Disability of the Arm, Shoulder and Hand questionnaire. The primary endpoint was 12 weeks after baseline. RESULTS: There was no between-group difference in function between the intervention group and control group. CONCLUSIONS: Our results showed no additional benefit on patient-reported function and pain from PMT over usual care in patients with long-lasting shoulder pain and low body awareness. This finding suggests that PMT adds no additional benefit to patients' recovery in relation to pain and active function in comparison to standard care.

Rotator CUFF disorders: A survey of current physiotherapy practice in Belgium and the Netherlands.

BACKGROUND: Disorders of the rotator cuff are a common musculoskeletal pain presentation in the general population, and treatment by a physiotherapist is often prescribed. In 2011, 2016, surveys of physiotherapy practice in the United Kingdom (UK) were performed, which reported that advice and exercise were the most common treatment strategies used. The aim of this current survey was to examine current physiotherapy practice in Belgium and The Netherlands, with consideration of differences between physiotherapists who were members of a shoulder network and physiotherapists who were not. METHODS: During February/March 2018, a cross-sectional online survey was conducted in Belgium and The Netherlands. RESULTS: 505 physiotherapists completed the survey. Advice (n = 362/505), isotonic exercises (n = 302/505) and scapular stabilisation exercises (n = 359/505) were the most common treatment modalities for patients with rotator cuff disorders. Physiotherapists not part of a shoulder network group more commonly integrated mobilization (n = 66/254 SN, n = 125/251 N-SN), electrotherapy (n = 1/254 SN, n = 19/251 N-SN) and massage (n = 48/254 SN, n = 89/251 N-SN) compared to those who were member of the group. CONCLUSION: Advice and exercise were the most common treatment prescriptions, which aligns with recommendations from current research evidence. Practice differs between physiotherapists involved with a shoulder network group compared to those who are not.

Effect of Kinesiology Taping on Upper Torso Mobility and Shoulder Pain and Disability in US Masters National Championship Swimmers: An Exploratory Study.

OBJECTIVE: The purpose of this study was to observe changes in shoulder pain and upper-extremity functional movement after kinesiology taping (KT) in competitive swimmers. METHODS: Seventy-six healthy participants competing in the US Masters Swimming 2017 National Championship participated in the study. Participants performed functional movement of shoulder flexion along with Disabilities of the Arm, Shoulder, and Hand index assessments for the shoulder before and 30 minutes after application of KT. RESULTS: A change in the functional movement assessment was observed after KT application when compared to the pre-KT application (33.56 ± 1.39 cm vs 35.35 ± 1.52 cm, P < .001). A statistical significant change for pain and disability scores of 2.17 was observed (12.29 ± 1.22 vs 10.12 ± 1.16, P < .01). CONCLUSION: For the participants in this study, KT changed shoulder pain and active functional movement scores significantly in swimmers.

Electrical Stimulation in the Treatment of Hemiplegic Shoulder Pain: A Meta-Analysis of Randomized Controlled Trials.

OBJECTIVE: The aim of the study was to determine the effect of electrical stimulation in the treatment of hemiplegic shoulder pain. DESIGN: Eight databases were systematically searched for randomized controlled trials with a treatment duration of at least 2 wks comparing electrical stimulation with sham stimulation or no stimulation for patients with hemiplegic shoulder pain. Shoulder pain on the hemiplegic side after stroke at baseline was required at study selection. The overall effects of electrical stimulation were calculated using a meta-analytic method. RESULTS: Six studies were included. The pooled data indicated that electrical stimulation may have a positive effect for patients with hemiplegic shoulder pain on pain reduction (n = 193, standardized mean difference = -1.89, 95% confidence interval = -3.05 to -0.74) and pain-free external rotation (n = 164, weighted mean difference = 18.92, 95% confidence interval = 7.00 to 30.84). Meta-analysis also showed better recovery of activities of daily living independence in patient groups receiving electrical stimulation (n = 167, weighted mean difference = 8.96, 95% confidence interval = 5.26 to 12.66). CONCLUSIONS: Electrical stimulation may be an effective pain management methodology for hemiplegic shoulders and may contribute to pain-free range of external rotation as well as activities of daily living recovery. However, these results should be interpreted with caution, given the low number of selected studies and risk of potential bias.

The effect of upper trapezius muscle dry needling treatment on sleep quality: A case report.

Myofascial pain syndrome is characterized by trigger points in muscles, resulting in pain, limitation of motion, muscle weakness and also referral pain. Upper part of trapezius muscle is one the most common sites in upper quadrant affected by this condition. Among various manual and non-manual techniques, dry needling is one of the most effective treatment methods, and is widely used recently by physiotherapists. A 34 year old, female hairstylist with chronic shoulder pain was admitted to a physiotherapy clinic and was treated with dry needling approach, after which she found improvement of shoulder symptoms and sleep quality. Results from this case report can create an interesting and clear precedent for considering dry needling treatment in future clinical trials.

Effects of high-frequency repetitive transcranial magnetic stimulation on reducing hemiplegic shoulder pain in patients with chronic stoke: a randomized controlled trial.

OBJECTIVE: To examine whether high-frequency (10 Hz) repetitive transcranial magnetic stimulation (rTMS), applied over the primary motor cortex of the affected hemisphere, could be used to manage hemiplegic shoulder pain (HSP). METHODS: Twenty-four chronic stroke patients with chronic HSP, randomly assigned into the rTMS group (10 sessions of high-frequency stimulation) or the sham group (sham stimulation), were performed. The Numeric Rating Scale (NRS) was used to evaluate the intensity of pain at pretreatment, and at 1 day, and 1, 2 and 4 weeks after treatment. Changes in upper-limb motor function were evaluated using the Motricity Index (MI-UL) and modified Brunnstrom Classification (MBC). RESULTS: When compared to pretreatment, the rTMS group showed a significant decrease in the NRS score at 1 day, and 1, 2 and 4 weeks after finishing rTMS sessions, with no significant change in the sham group. The NRS score after the rTMS sessions reduced by 30.1% at 1 day, 29.3% at 1 week, 28.0% at 2 weeks and 25.3% at 4 weeks. Passive shoulder range of motion, MI-UL, and MBC, however, did not significantly change in either group. CONCLUSIONS: High-frequency rTMS could be used as a safe, beneficial therapeutic tool to manage HSP. We think it can be used as an adjuvant therapeutic modality to enhance the therapeutic outcome of HSP.

The effect of shoulder position on inferior glenohumeral mobilization.

STUDY DESIGN: Cross-sectional clinical measurement study. INTRODUCTION: Inferior mobilizations are used to treat patients with shoulder dysfunctions. Common positions recommended for promoting an inferior glide include: (1) an open-packed position (OPP) in which the shoulder is in 55° of abduction, 30° of horizontal adduction, and no rotation; (2) neutral position (NP) of the shoulder; and (3) position of 90° of shoulder abduction (ABDP). Studies comparing the impact of position on inferior mobilization are lacking. PURPOSE OF THE STUDY: To determine the effect of shoulder position on humeral movement and mobilization force during inferior mobilizations. METHODS: Twenty-three subjects were tested bilaterally. Subjects were placed in the OPP, and an ultrasound transducer placed over the superior glenohumeral joint. As inferior mobilization forces were applied through a dynamometer, ultrasound images were taken at rest and during 3 grades of inferior mobilization. This process was repeated in the NP and the ABDP. RESULTS: In the NP, movements during grade 1, 2, and 3 mobilizations were 1.8, 3.8, and 4.5 mm, respectively. Movements measured in the OPP (1.0, 2.4, and 3.6 mm, respectively) and in the ABDP (1.0, 2.2, and 2.3 mm, respectively) were less. Forces were higher in the NP during grade 1, 2, and 3 mobilizations (51.8, 138.7, and 202.1 N, respectively) than in the OPP (37.2, 91.2, and 139.9 N, respectively) and the ABPD (42.5, 115.3, and 165.5 N, respectively). DISCUSSION: Mobilization position altered the movement and force during inferior mobilizations. CONCLUSIONS: Shoulder position should be considered when utilizing inferior mobilizations. LEVEL OF EVIDENCE: NA.

Treatment of axillary web syndrome using instrument assisted soft tissue mobilization and thoracic manipulation for associated thoracic rotation dysfunction.

PURPOSE: There is a paucity of research that investigates physical therapy management for patients with axillary web syndrome (AWS) and thoracic rotation dysfunction. The purpose of this case report is to describe the management of a patient with AWS and thoracic rotation dysfunction using an impairment-based approach that includes instrument assisted soft tissue mobilization (IASTM), thoracic manipulation, and stretching. CASE DESCRIPTION: The patient was a 48-year-old female with a past medical history of bilateral breast cancer with a bilateral latissimus dorsi flap reconstruction. The patient was referred to physical therapy with chief complaints of right shoulder pain with reaching and an inability to resume running due to right shoulder and scapula pain. The patient was seen in outpatient physical therapy for four visits over four weeks. Treatment consisted of IASTM, thoracic manipulation, stretching exercises, and home exercise program instruction. OUTCOMES: Upon discharge, the patient had improved right shoulder and thoracic range of motion, decreased pain, and improved function on the patient specific functional scale (PSFS). CONCLUSION: Utilization of an impairment-based physical therapy approach to treat a patient with AWS and thoracic dysfunction yielded positive outcomes. Further research on the efficacy of IASTM and physical therapy management of AWS is warranted.

Physiotherapy for patients with shoulder pain in primary care: a descriptive study of diagnostic- and therapeutic management.

BACKGROUND: Shoulder pain is one of the three main musculoskeletal complaints and more than 50% of the patients have symptoms longer than 6 months. Until now, limited data exist about the content of physiotherapy for patients with shoulder pain in primary care. OBJECTIVE: Describe current physiotherapeutic diagnostic- and therapeutic management, including the use of diagnostic ultrasound, in patients with shoulder pain in primary care. DESIGN AND SETTING: A prospective cohort study in primary care physiotherapy with a 12 week follow-up. METHODS: Descriptive data from physiotherapists was collected, such as: the diagnostic hypotheses after patient history and physical examination, the use of specific tests and diagnostic ultrasound, the interventions used and possible changes in treatment plan. RESULTS: Subacromial impingement syndrome was the most common hypothesis after patient history (48%) as well as physical examination (39%). Diagnostic ultrasound was used in 31% and of these patients the clinical diagnosis changed in 29%. Various interventions were used in all clinical diagnoses. After 12 weeks 41% of patients still received physiotherapy treatment. CONCLUSIONS: Patients with shoulder pain in physiotherapy practice frequently show signs of subacromial impingement syndrome. The interventions used by the physiotherapists were generally in line with the guideline for subacromial impingement syndrome however a small proportion of physiotherapists used massage and tape/bracing techniques. A large proportion of patients were still receiving treatment after 12 weeks when no improvement was observed. If treatment for patients with subacromial impingement shows no benefit patients should be referred back to the general practitioner or orthopedic surgeon. Conclusions from this study might be slightly biased because of the selection of physiotherapists.

Immediate Effects of Mirror Therapy in Patients With Shoulder Pain and Decreased Range of Motion.

OBJECTIVE: To determine the effects of a brief single component of the graded motor imagery (GMI) sequence (mirror therapy) on active range of motion (AROM), pain, fear avoidance, and pain catastrophization in patients with shoulder pain. DESIGN: Single-blind case series. SETTING: Three outpatient physical therapy clinics. PARTICIPANTS: Patients with shoulder pain and limited AROM (N=69). INTERVENTION: Patients moved their unaffected shoulder through comfortable AROM in front of a mirror so that it appeared that they were moving their affected shoulder. MAIN OUTCOME MEASURES: We measured pain, pain catastrophization, fear avoidance, and AROM in 69 consecutive patients with shoulder pain and limited AROM before and immediately after mirror therapy. RESULTS: There were significant differences in self-reported pain (P=.014), pain catastrophization (P<.001), and the Tampa Scale of Kinesiophobia (P=.012) immediately after mirror therapy; however, the means did not meet or exceed the minimal detectable change (MDC) for each outcome measure. There was a significant increase (mean, 14.5°) in affected shoulder flexion AROM immediately postmirror therapy (P<.001), which exceeded the MDC of 8°. CONCLUSIONS: A brief mirror therapy intervention can result in statistically significant improvements in pain, pain catastrophization, fear avoidance, and shoulder flexion AROM in patients presenting with shoulder pain with limited AROM. The immediate changes may allow a quicker transition to multimodal treatment, including manual therapy and exercise in these patients. Further studies, including randomized controlled trials, are needed to investigate these findings and determine longer-term effects.

Comparative Effectiveness of Nonoperative Treatments for Chronic Calcific Tendinitis of the Shoulder: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials.

OBJECTIVE: To investigate the effectiveness of various nonoperative treatments for chronic calcific tendinitis of the shoulder, a systematic review and network meta-analysis of randomized trials was performed to evaluate changes in pain reduction, functional improvements in patients with calcific tendinitis, and the ratio of complete resolution of calcific deposition. DATA SOURCES: Studies were comprehensively searched, without language restrictions, on PubMed, Embase, Cochrane Controlled Trials Register, the Cochrane, and other databases. The reference lists of articles and reviews were cross-checked for possible studies. STUDY SELECTION: Randomized controlled trials from before August 2016 were included. Study selection was conducted by 2 reviewers independently. DATA EXTRACTION: The quality of studies was assessed and data extracted by 2 independent reviewers. Disagreements were settled by consulting a third reviewer to reach a consensus. DATA SYNTHESIS: Fourteen studies with 1105 participants were included in the network meta-analysis that used a random-effect model to investigate the mean difference of pooled effect sizes of the visual analog scale, Constant-Murley score, and the ratio of complete resolution of calcific deposition on native radiographs. CONCLUSIONS: The present network meta-analysis demonstrates that ultrasound-guided needling (UGN), radial extracorporeal shockwave therapy (RSW), and high-energy focused extracorporeal shockwave therapy (H-FSW) alleviate pain and achieve complete resolution of calcium deposition. Compared with low-energy focused extracorporeal shockwave therapy, transcutaneous electrical nerve stimulation, and ultrasound therapy, H-FSW is the best therapy for providing functional recovery. Physicians should consider UGN, RSW, and H-FSW as alternative effective therapies for chronic calcific tendinitis of the shoulder when initial conservative treatment fails.

Acute Radial Neuropathy at the Spiral Groove Following Massage: A Case Presentation.

Massage-related nerve injury is an uncommon, rarely reported complication. We report an unusual case of radial nerve neuropathy at the spiral groove in a 58-year-old woman that resulted from a single episode of deep tissue massage. Although the spiral groove is known as the most common site implicated in radial nerve neuropathy, to our knowledge, there have not previously been any reports of massage-related spiral groove radial nerve neuropathy. Electrodiagnostic and ultrasound examinations were used to localize the nerve lesion at the spiral groove and also to provide prognostic evaluation. Serial follow-ups demonstrated concomitant improvement in clinical symptoms and electrodiagnostic parameters. A near-total recovery was achieved after 6 months. This case presentation aims to increase awareness and early recognition of massage-related nerve injuries. LEVEL OF EVIDENCE: V.

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.

The Effect of Peripheral Nerve Stimulation on Shoulder Biomechanics: A Randomized Controlled Trial in Comparison to Physical Therapy.

OBJECTIVE: To establish the effects on shoulder biomechanics from a peripheral nerve stimulation (PNS) treatment compared to physical therapy (PT) in stroke survivors with chronic hemiplegic shoulder pain. DESIGN: Single-site, pilot, randomized controlled trial for adults with chronic shoulder pain after stroke. Participants were randomized to receive a 3-week treatment of single-lead PNS or physical therapy (PT). The outcomes included isometric shoulder abduction strength, pain-free shoulder external rotation range of motion (ROM), delay in initiation and termination of shoulder abduction electromyogram (EMG) activity, and the Fugl-Meyer Motor Assessment (upper extremity section). Outcomes were measured at baseline, and at weeks 1, 4, 12, and 16. RESULTS: Twenty-five participants were recruited, 13 to PNS and 12 to PT. There were significant improvements for both PNS and PT in maximum isometric shoulder abduction strength, pain-free external rotation ROM, and Fugl-Meyer Motor Assessment. There were no significant changes in delay of initiation or termination of deltoid EMG with either treatment. CONCLUSIONS: Both PNS and PT are capable of improving shoulder biomechanics in those with HSP, though changes in biomechanics alone do not account for the greater pain relief associated with PNS than PT.