Co-occurrence of outlet impingement syndrome of the shoulder and restricted range of motion in the thoracic spine--a prospective study with ultrasound-based motion analysis

Shoulder mobility and strength impairments in patients with rotator cuff related shoulder pain: a systematic review and meta analysis

Background

The methods previously proposed in the literature to assess patients with rotator cuff related shoulder pain, based on special orthopedic tests to precisely identify the structure causing the shoulder symptoms have been recently challenged. This opens the possibility of a different way of physical examination.

Objective

To analyze the differences in shoulder range of motion, strength and thoracic kyphosis between rotator cuff related shoulder pain patients and an asymptomatic group.

Method

The protocol of the present research was registered in the International Prospective Register of Systematic Review (PROSPERO) (registration number CRD42021258924). Database search of observational studies was conducted in MEDLINE, EMBASE, WOS and CINHAL until July 2023, which assessed shoulder or neck neuro-musculoskeletal non-invasive physical examination compared to an asymptomatic group. Two investigators assessed eligibility and study quality. The Newcastle Ottawa Scale was used to evaluate the methodology quality.

Results

Eight studies (N = 604) were selected for the quantitative analysis. Meta-analysis showed statistical differences with large effect for shoulder flexion (I2 = 91.7%, p < 0.01, HG = -1.30), external rotation (I2 = 83.2%, p < 0.01, HG = -1.16) and internal rotation range of motion (I2 = 0%, p < 0.01, HG = -1.32). Regarding to shoulder strength; only internal rotation strength showed statistical differences with small effect (I2 = 42.8%, p < 0.05, HG = -0.3).

Conclusions

There is moderate to strong evidence that patients with rotator cuff related shoulder pain present less shoulder flexion, internal and external rotation range of motion and less internal rotation strength than asymptomatic individuals.

Relationship between Spinal Range of Motion and Functional Tests in University Students: The Role of Demographic Factors

Spinal disorders are some of the most prevalent health concerns, especially among students. Based on student demographics, this cross-sectional study evaluated the correlation between functional tests (FTs) and spinal range of motion (ROM). This study included 206 students (age = 19.85 ± 1.80 years) from the Vasile Alecsandri University of Bacău. Participants' assessments were conducted using the following tests: (i) Ott, (ii) Schober, (iii) Stibor, (iv) finger-to-floor distance, (v) lateral flexion of the cervical and lumbar spine, and (vi) flexion of the cervical spine. Correlation analyses were evaluated using the Spearman correlation coefficient analysis. The results indicated a very strong relationship between lateral flexion of the lumbar spine on the left (LFLSL) and right (LFLSR) for all departments (r = 0.85 to 0.97, p < 0.05). There was a stronger relationship between FT results and spinal ROM for physical-education-department students compared to students from other departments (n = 17, r = -0.38 to 0.93, p < 0.05). There was no statistically significant correlation between FTs and spinal ROM based on age (p > 0.05). The study results provide evidence of the primary risk factors that predispose students to postural deviations. Practitioners and physiotherapists can utilize these values as a reference for potential therapeutic interventions.

Efficacy of Mulligan thoracic sustained natural apophyseal glides on sub-acromial pain in patients with sub-acromial impingement syndrome: a single-blinded randomized controlled trial

PURPOSE

To investigate the effects of Mulligan thoracic sustained natural apophyseal glides (SNAGS) techniques and traditional exercises on pain, shoulder function, size of sub-acromial space, and shoulder joint range in patients with sub-acromial impingement syndrome.

METHODS

Seventy-four patients with sub-acromial impingement syndrome (25 to 40 years) joined this research and were allocated randomly into two equal groups; experimental group A (Mulligan SNAGS and exercise) and control group B (exercise only). All patients were assessed by visual analogue scale (VAS) for pain intensity, Shoulder Pain and Disability Index (SPADI) for shoulder function, plain x-ray for the size of sub-acromial space, and goniometer for shoulder range of motion (ROM). The measurements were performed at two intervals (baseline and after four weeks of intervention).

RESULTS

After 4 weeks of intervention, there were statistically significant differences between groups, in favor of Mulligan SNAGS, on sub acromial space size, pain intensity, shoulder function, and shoulder joint range of motion (p < 0.05). In within-group analysis, there were also statistically significant differences between pre- and post-treatment in all measured variables (p < 0.05).

CONCLUSION

Mulligan thoracic spine (SNAGS) mobilization into extension and traditional exercises improve sub acromial space size, pain intensity, shoulder function, and shoulder joint range of motion in patients with sub acromial impingement syndrome. It is recommended to mobilize the thoracic spine by mulligan SNAGS in the treatment of sub-acromial impingement syndrome.

A Field-expedient Arm Care Screening Tool Can Identify Musculoskeletal Risk Factors in Baseball Players

BACKGROUND

Preseason movement screening can identify modifiable risk factors, deterioration of function, and potential for injury in baseball players. Limited resources and time prevent high school baseball coaches from performing movement screens on their players.

HYPOTHESIS

The arm care screen (ACS) will be highly sensitive to detecting musculoskeletal risk factors.

STUDY DESIGN

Cross-sectional.

LEVEL OF EVIDENCE

Level 3.

METHODS

A total of 150 baseball players were independently scored on the ACS electronically by reviewing a video recording of each player's screening performance. Discriminability of the ACS was determined with a 2 × 2 contingency table dichotomizing musculoskeletal risk factors as present or absent based on a predetermined cutoff value and those who passed or failed the corresponding ACS subtest.

RESULTS

High sensitivity was observed on the reciprocal shoulder mobility (0.89; 95% CI 0.81-0.94), 90/90 total body rotation (0.86; 95% CI 0.79-0.92), and lower body diagonal reach (0.85; 95% CI 0.78-0.91) tests of the ACS suggesting sufficient ability to identify musculoskeletal impairments and risk factors.

CONCLUSION

The ACS is a simplistic screening tool that the coach can administer to discriminate between youth, high school, and college-level baseball players who possess musculoskeletal risk factors. The ACS subtests demonstrated high sensitivity for correctly identifying musculoskeletal risk factors common in baseball players and can be useful as a screening tool for baseball coaches developing arm care exercise programs.

CLINICAL RELEVANCE

A field-expedient screen could provide coaches the ability to identify musculoskeletal risk factors that need to be addressed to minimize injury risk factors in a time-efficient manner.

Biomechanical and functional analysis of the shoulder complex and thoracic spine in patients with subacromial impingement syndrome: A case control study

The motions of the shoulder are mainly carried out through the glenohumeral joint, but are also assisted by the scapulothoracic joint. Therefore, changes in the biomechanics of the thoracic spine and scapula affect the function of the shoulder. However, there is limited information on the biomechanical and functional characteristics of the shoulder complex and thoracic spine in patients with subacromial impingement syndrome (SIS). In this study, the biomechanical and functional characteristics of the shoulder complex and thoracic spine were analyzed in patients with SIS compared to healthy individuals. A total of 108 participants were included in this study. Participants were classified into 2 groups, the SIS (n = 55) and healthy (n = 53) groups. The shoulder and thoracic range of motion (ROM), scapular position, and isokinetic shoulder strength were measured in all participants. The shoulder ROM was significantly decreased in the SIS group compared to the healthy group (P < .001). The thoracic spine ROM showed significantly limited extension in the SIS group (P < .001). The scapular position showed significantly increased anterior tilting (P = .005), internal rotation (P = .032), protraction (P < .001), and decreased upward rotation (P = .002) in the SIS group. The isokinetic shoulder external rotation (P < .001) and abduction (P < .001) strength were significantly lower in the SIS group. Patients with SIS showed reduced shoulder ROM and end-range extension of the thoracic spine compared to healthy individuals, and the scapula was in a more anterior-tilted, protracted, and downward rotated position. In addition, it showed lower external rotation and abduction strength. These results suggest the need for interventions to improve the limited thoracic extension and altered scapular position, which may affect shoulder ROM and muscle strength in the rehabilitation of patients with SIS.

Analysis of the Active Measurement Systems of the Thoracic Range of Movements of the Spine: A Systematic Review and a Meta-Analysis

(1) Objective: to analyze current active noninvasive measurement systems of the thoracic range of movements of the spine. (2) Methods: A systematic review and meta-analysis were performed that included observational or clinical trial studies published in English or Spanish, whose subjects were healthy human males or females ≥18 years of age with reported measurements of thoracic range of motion measured with an active system in either flexion, extension, lateral bending, or axial rotation. All studies that passed the screening had a low risk of bias and good methodological results, according to the PEDro and MINORS scales. The mean values and 95% confidence interval of the reported measures were calculated for different types of device groups. To calculate the differences between the type of device measures, studies were pooled for different types of device groups using Review Manager software. (3) Results: 48 studies were included in the review; all had scores higher than 7.5 over 10 on the PEDro and MINORs methodological rating scales, collecting a total of 2365 healthy subjects, 1053 males and 1312 females; they were 39.24 ± 20.64 years old and had 24.44 ± 3.81 kg/m² body mass indexes on average. We summarized and analyzed a total of 11,892 measurements: 1298 of flexoextension, 1394 of flexion, 1021 of extension, 491 of side-to-side lateral flexion, 637 of right lateral flexion, 607 of left lateral flexion, 2170 of side-to-side rotation, 2152 of right rotation and 2122 of left rotation. (4) Conclusions: All collected and analyzed measurements of physiological movements of the dorsal spine had very disparate results from each other, the cause of the reason for such analysis is that the measurement protocols of the different types of measurement tools used in these measurements are different and cause measurement biases. To solve this, it is proposed to establish a standardized measurement protocol for all tools.

Thoracic manual therapy improves pain and disability in individuals with shoulder impingement syndrome compared to placebo: a randomised controlled trial with one year follow-up

OBJECTIVE

To investigate if muscle energy technique (MET) to the thoracic spine decreases the pain and disability associated with shoulder impingement syndrome (SIS).

DESIGN

Single centre, three-arm, randomised controlled trial, single-blind, placebo control with concealed allocation and a 12-month follow-up.

SETTING

Private osteopathic practice.

INTERVENTIONS

Participants were randomly allocated to: MET to the thoracic spine (MET-only), MET plus soft tissue massage (MET&STM) or placebo.

PARTICIPANTS

3 groups of 25 (n=75) participants ≥ 40 years with SIS received allocated intervention once a week for 15 minutes, 4 consecutive weeks.

OUTCOME MEASURES

Primary outcome measure: Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.

SECONDARY OUTCOME MEASURES

Shoulder Pain and Disability Index (SPADI) questionnaire, visual analogue scale (VAS-mm/100) -current, 7-day average, 4-week average, patient specific functional scale (PSFS) and global rating of change (GROC). Measures recorded at baseline, discharge, 4-weeks follow-up, 6-months and 12-months. Also baseline and discharge thoracic posture and range of motion (ROM) measured using an inclinometer.

STATISTICAL ANALYSIS

Mixed effects linear regression model for DASH, SPADI, VAS, PSFS, GROC and thoracic posture and ROM.

RESULTS

MET-only group demonstrated significantly greater improvement in pain and disability (DASH, SPADI, VAS 7-day average) compared to placebo at discharge (mean difference DASH=-8.4; 95% CI -14.0,-2.8; SPADI=-14.7;-23.0,-6.3; VAS=-15.5;-24.5,-6.5), 6 -months (-11.1;-18.6,-3.7; -14.9;-26.3,-3.5; -14.1;-26.0,-2.2) and 12 -months (-13.4;-23.9,-2.9; -19.0;-32.4,-5.7; -17.3;-30.9,-3.8). MET&STM group also demonstrated greater improvement in disability, but not pain compared to placebo at discharge (DASH=-8.2;-14.0,-2.3; SPADI= -13.5;-22.3,-4.8) and 6 months (-9.0;-16.9,-1.2; -12.4;-24.3,-0.5). For the PSFS, MET-only improved compared to placebo at discharge (1.3;0.1,2.5) and 12 months (1.8;0.5,3.2); MET&STM at 12 months (1.7;0.3,3.0). GROC: MET-only improved compared to placebo at discharge (1.5;0.9,2.2) and 4 weeks (1.0;0.1,1.9); MET&STM at discharge (1.2;0.5,1.9) and 6 months (1.2;0.1,1.3). There were no differences between MET-only and MET&STM, and no between-group differences in thoracic posture or ROM.

CONCLUSION

MET of the thoracic spine with or without STM improved the pain and disability in individuals over 40 with SIS and may be recommended as a treatment approach for SIS.

Rehabilitation in Overhead Athletes With Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) is a clinical diagnosis resulting from the impingement of neurovascular structures between the clavicle and first rib. Effective prevention and nonoperative treatment in high-performance athletes with TOS are not well documented. The objective of reporting this case was to discuss the symptom progression, relevant clinical findings, and rehabilitation of an overhead athlete with diagnosed neurogenic TOS. Numerous rehabilitative techniques may be used to treat an athlete with TOS, with an emphasis on restoring full shoulder mobility, motor control, and normalized scapular mechanics in a throwing athlete, as well as improving functional thoracic range of motion. Modalities such as neuromuscular electrical stimulation and targeted muscle exercises are incorporated in the process. In the case presented, a collegiate-level throwing athlete returned to full participation at her previous level of play within 18 weeks of rehabilitation initiation. This report details the clinical findings and treatment options available to address pathology in an overhead athlete with a diagnosis of TOS. The clinical case example shows techniques that may help guide the clinician in establishing effective nonoperative or postoperative treatments for TOS.

Level of Evidence

Level V, expert opinion.

Acromiohumeral distance and supraspinatus tendon thickness in people with shoulder impingement syndrome compared to asymptomatic age and gender-matched participants: a case control study

Background

Shoulder impingement syndrome (SIS) is the most common form of shoulder pain. Conservative and surgical treatments for SIS are often not effective. One such surgical intervention is subacromial decompression, aimed at widening the subacromial space (SAS). A better understanding of the changes in the SAS may help explain the relative ineffectiveness of current interventions.

Objective: To measure the acromiohumeral distance (AHD) and supraspinatus tendon thickness (STT) in people with SIS using a case control study.

Methods

The AHD and STT of 39 participants with SIS ≥3 months and 39 age, gender and dominant arm matched controls were measured using ultrasound imaging. Between-group differences for AHD and STT were compared using t-tests. A linear regression was used to determine if there was a relationship between AHD and STT measures, with group as a covariate.

Results

Compared to controls (mean age 55.7 years, SD 10.6), individuals with SIS (mean age 57.1 years, SD 11.1) had a significantly larger AHD (mean difference 2.14 mm, 95% CI 1.21, 3.07, p < 0.001) and STT (mean difference 1.25 mm, 95% CI 0.60, 1.90, p < 0.001). The linear regression model indicated an association between AHD and STT (β = 0.59, 95% CI 0.29, 0.89, p < 0.01, R² = 0.35, n = 78), suggesting that as STT increases in size, so does the AHD.

Conclusion

Individuals with SIS had a larger AHD and greater STT than controls. These results suggest the SAS is already wider in people with SIS and that the symptoms associated with SIS may be more related to an increased STT than a smaller SAS.

Throwing performance after high-velocity low-amplitude thrust manipulation at the cervicothoracic and thoracolumbar junction in elite female water polo players: a randomized blind cross-over study

BACKGROUND

The effect of high-velocity low-amplitude (HVLA) thrust manipulation at the cervicothoracic and thoracolumbar junction in healthy elite female water polo players on throwing performance is unknown.

METHODS

Ten healthy members of the Dutch National female water polo team participated in this randomized blind cross-over study. All received a HVLA manipulation and a sham manipulation at the cervicothoracic and thoracolumbar junction. Hereafter maximum throwing speed, range of motion and isometric strength were measured at 1 hour, 48 hours and 4 weeks follow-up.

RESULTS

No significant differences in maximum throwing speed was found between HVLA and sham manipulation. In the non-dominant shoulder external rotation increased significantly (5.3±6.7°) 48 hours after sham manipulation, this effect was not considered clinically significant and diminished after four weeks.

CONCLUSIONS

Our results suggest that HVLA and sham manipulation had no effect on shot velocity or shoulder mobility and the same effect on shoulder strength in healthy elite female water polo players. The common use of cervicothoracic and thoracolumbar HVLA manipulation for improving performance in this specific group of athletes is therefore questionable.

Are muscle weakness and stiffness risk factors of the development of rotator cuff tendinopathy in overhead athletes: a systematic review

Background:

Underlying muscle weakness and stiffness may increase the risk of developing rotator cuff tendinopathy. This systematic review aims to assess existing prospective studies to summarize whether muscle weakness and stiffness are risk factors for the development of rotator cuff tendinopathy in overhead athletes.

Methods:

A systematic search was performed using PRISMA guidelines. Prospective studies measuring muscle strength or stiffness and the incidence of rotator cuff tendinopathy were included. Quality assessment was performed with the Newcastle-Ottawa quality assessment scale.

Results:

The search yielded six studies, with a total of 523 trained overhead athletes followed up for one season. External rotation (ER) and internal rotation (IR) strength were described as protective factors against the development of rotator cuff tendinopathy. Athletes who did not sustain shoulder injuries had statistically stronger eccentric IR (p < 0.01) and ER (p < 0.05) strength in the pre-season assessment. Muscle stiffness indicated by limited range of motion of <106° for shoulder ER was described as a risk factor with an odds ratio of 1.12 (p < 0.001). Imbalance between ER and IR strength was reported as risk factors for shoulder injuries in two studies, with a relative risk of 2.57 (p < 0.05) reported in one study. Supraspinatus weakness was also reported as a risk factor for shoulder injuries in one study.

Conclusion:

Limited evidence support ER, IR weakness, limited ER range of motion, and very limited evidence support imbalance in ER/IR strength, and supraspinatus weakness as risk factors for rotator cuff tendinopathy in overhead athletes. No existing studies investigated the general population on this topic. Future cohort studies may improve on existing evidence with investigations on the general public, a longer follow-up time, clearly documented injury history, and a stringent diagnosis to rotator cuff tendinopathy.

Physical Therapy Management of Neurogenic Thoracic Outlet Syndrome

Neurogenic thoracic outlet syndrome is a complex and challenging condition to manage. There is a lack of high-quality evidence to guide clinical decision making and therefore a need to individualize treatment. Examination includes identifying postural, anatomic, and biomechanical factors that contribute to compromise of the neurovascular structures. Patients can experience good outcomes with conservative management with pain science-informed physical therapy combined with biomechanical approaches addressing contributing impairments. Retraining movement patterns while maintaining patency allows for a greater tolerance to functional activities and can have a positive impact on quality of life. Close collaboration with the patient's care team is critical.

Relationship Between Shoulder Impingement Syndrome and Thoracic Posture

BACKGROUND

Shoulder impingement syndrome (SIS) is the most common form of shoulder pain and a persistent musculoskeletal problem. Conservative and invasive treatments, aimed at the shoulder joint, have had limited success. Research suggests shoulder function is related to thoracic posture, but it is unknown whether thoracic posture is associated with SIS.

OBJECTIVE

The objective of this study was to investigate whether there is a relationship between SIS and thoracic posture.

DESIGN

This was a case control study.

METHODS

Thoracic posture of 39 participants with SIS and 39 age-, gender-, and dominant arm-matched controls was measured using the modified Cobb angle from a standing lateral radiograph. Thoracic range of motion (ROM) was also measured using an inclinometer. Between-group differences were compared using t tests. The relationship between thoracic posture and thoracic ROM was determined with linear regression.

RESULTS

Twenty women and 19 men with SIS (mean age = 57.1 years, SD = 11.1) and 39 age-matched, gender-matched, and dominant arm-matched controls (mean age = 55.7years, SD = 10.6) participated. Individuals with SIS had greater thoracic kyphosis (mean difference = 6.2o, 95% CI 2.0-10.4) and less active thoracic extension (7.8o, 95% CI = 2.2-13.4). Greater thoracic kyphosis was associated with less extension ROM (ie, more flexion when attempting full extension: β = 0.71, 95% CI = 0.45-0.97).

LIMITATIONS

These cross-sectional data can only demonstrate association and not causation. Both radiographic measurements and inclinometer measurements were not blinded.

CONCLUSION

Individuals with SIS had a greater thoracic kyphosis and less extension ROM than age- and gender-matched healthy controls. These results suggest that clinicians could consider addressing the thoracic spine in patients with SIS.

Overlapping, Masquerading, and Causative Cervical Spine and Shoulder Pathology: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVE

To assess the current literature regarding the relationship between the shoulder and the spine with regard to (1) overlapping pain pathways; (2) differentiating history, exam findings, and diagnostic findings; (3) concomitant pathology and optimal treatments; and (4) cervical spine-based etiology for shoulder problems.

METHODS

A systematic literature search was performed according to the guidelines set forth by the Cochrane Collaboration. Studies were included if they examined the clinical, anatomical, or physiological overlap between the shoulder and cervical spine. Two reviewers screened and selected full texts for inclusion according to the objectives of the study. Quality of evidence was graded using OCEBM (Oxford Center for Evidence Based Medicine) and MINORS (Methodological Index for Nonrandomized Studies) scores.

RESULTS

Out of 477 references screened, 76 articles were included for review and grouped into 4 main sections (overlapping pain pathways, differentiating exam findings, concomitant/masquerading pathology, and cervical spine-based etiology of shoulder pathology). There is evidence to suggest cervical spine pathology may cause shoulder pain and that shoulder pathology may cause neck pain. Specific examination tests used to differentiate shoulder and spine pathology are critical as imaging studies may be misleading. Diagnostic injections can be useful to confirm sources of pain as well as predicting the success of surgery in both the shoulder and the spine. There is limited evidence to suggest alterations in the relationship between the spine and the scapula may predispose to shoulder impingement or rotator cuff tears. Moreover, cervical neurological lesions may predispose patients to developing rotator cuff tears. The decision to proceed with shoulder or spine surgery first should be delineated with careful examination and the use of shoulder and spine diagnostic injections.

CONCLUSION

Shoulder and spine pathology commonly overlap. Knowledge of anatomy, pain referral patterns, shoulder kinematics, and examination techniques are invaluable to the clinician in making an appropriate diagnosis and guiding treatment. In this review, we present an algorithm for the identification and treatment of shoulder and cervical spine pathology.

An evaluation of two types of exercise classes, containing shoulder exercises or a combination of shoulder and thoracic exercises, for the treatment of nonspecific shoulder pain: A case series

STUDY DESIGN

A case series was carried out.

INTRODUCTION

There is a lack of evidence exploring the effectiveness of group exercise classes for people with nonspecific shoulder pain (NSSP). Also, there is a lack of research that measures potential reductions in thoracic kyphosis after exercise interventions in people with NSSP.

PURPOSE OF THE STUDY

To observe changes in shoulder pain, disability, and thoracic kyphosis in 2 groups of people with NSSP, after 2 different types of group exercise classes.

METHODS

People with NSSP received a 6-week block of exercises classes containing either shoulder exercises alone (shoulder group, n = 20) or a mixture of shoulder and thoracic extension exercises (thoracic group, n = 19). The Disabilities of the Arm, Shoulder and Hand questionnaire for disability and the Numeric Rating Scale for pain were measured at baseline, 6 weeks, and 6 months. Thoracic kyphosis was measured at baseline and 6 weeks using the manual inclinometer.

RESULTS

Significant and clinically meaningful improvements in Numeric Rating Scale and Disabilities of the Arm, Shoulder and Hand were demonstrated in both groups at 6-week and 6-month follow-up (P < .001). Effect sizes ranged from 0.78-1.16 in the shoulder group and 0.85-1.88 in the thoracic group. Thoracic kyphosis did not change beyond measurement error in either group.

DISCUSSION/CONCLUSION

Group exercise classes can improve shoulder pain and disability in people with NSSP. Resting thoracic kyphosis did not change after either exercise intervention, which suggests that the treatment effect was not due to a change in static thoracic spine posture.

Physiotherapist survey: Increasing thoracic spine movement within the management of chronic subacromial impingement syndrome

AIMS

This study's primary aim is to address two questions. Firstly; what evidence exists regarding the inclusion of increasing thoracic movement within the management of subacromial impingement syndrome SIS?; and secondly, what proportion of Society of Musculoskeletal Medicine (SOMM) physiotherapists use this form of treatment within SIS management?

METHODS

An online survey was conducted using a questionnaire incorporating a vignette describing a patient with chronic SIS. The SOMM physiotherapy members were sampled using convenience sampling.

FINDINGS

This study has identified some evidence supporting increasing movement of the thoracic spine in the management of patients with SIS. No study or guideline protocols have been identified that advocate the use of this form of treatment, nor research identified that investigates physiotherapists' use of this form of treatment within SIS management. Of the 1340 physiotherapists surveyed, 52 responded of which 79% stated that they would use treatment aimed at increasing movement of the thoracic spine within SIS management. Chi Square analysis suggests no significant association between using this treatment and number of years experience (p value = 0.15) or courses attended (p = 0.62).

CONCLUSIONS

Evidence suggests it is beneficial to include treatment to increase thoracic spine mobility within SIS management. This study highlights the need for the clinician to be aware of the role of the thoracic spine in relation to the biomechanics of the shoulder complex. Of the sample of SOMM physiotherapists obtained, the majority stated that they would use this form of treatment. Further research is recommended.

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.

Management of thoracic spine pain and dysfunction: A survey of clinical practice in the UK

BACKGROUND

The thoracic spine (TS) is relatively under-researched compared to the neck and low back. As the challenge of managing spinal pain persists, understanding current physiotherapy clinical practice for TS pain and dysfunction is necessary to inform future research in this area.

OBJECTIVE

To investigate physiotherapy practice for managing thoracic spine pain and dysfunction (TSPD) in the UK, with a secondary focus on examining differences across settings and expertise.

DESIGN AND METHOD

A cross sectional e-survey informed by existing evidence was designed. Comprising closed and open questions, the survey is reported in line with Checklist for Reporting Results of Internet E-Surveys. Eligible participants were UK-trained physiotherapists managing patients with TSPD, recruited for 9 weeks up to 8/2/16. Data analysis included descriptive analyses (closed questions) and thematic analysis (open questions).

RESULTS

From the 485 respondents, fulfilling the required sample size, key findings included.

EXAMINATION

Active motion testing, palpation and postural assessment was 'always' undertaken by >89% of respondents.

MANAGEMENT

Active (exercises) and passive (e.g. mobilisations) techniques were used by >85% of respondents, with ∼50% using manipulation, taping and acupuncture. Practice settings: Although broadly similar passive techniques were used more in private practice and sport. Expertise: Broadly similar patterns were seen for use of exercise across levels of expertise, although differences observed for electrotherapy and manipulation.

CONCLUSION

Despite limited research exercise is widely used in all areas of practice and across all level of expertise. Further research is required to investigate exercise prescription for TSPD and implementation of evidence-based practice.

Immediate Effects of Thoracic Spine Manipulation Upon Shoulder Functionality in Patients With Sutured Rotator Cuff Repair: A Prospective Study

OBJECTIVES

The purpose of this study was to evaluate the immediate effect of thoracic spine manipulation upon active flexion and abduction mobility of the shoulder, spine temperature, and the size of the subacromial space as measured by ultrasound in 3 positions (internal, neutral, and external rotation) of the glenohumeral joint in patients who have undergone surgery because of subacromial impingement.

METHODS

Quasi-experimental, prospective, short-term effect study with consecutively sampled participants. Thirty-two patients had undergone subacromial decompression together with supraspinatus tendon suture. The following variables were studied: age, sex, dominant shoulder, presurgery evolution time, working status, surface temperature of dorsal segment with limited mobility, premanipulation functional assessment using the Spanish version of the Upper Limb Functional Index Scale, goniometric range of motion measurement at glenohumeral joint before and after manipulation, and ultrasound measurement of subacromial space before and after manipulation.

RESULTS

Significant differences and small effect size were found in measurements for flexion and abduction movements after thoracic spine manipulation (P > .001; ES > 0.2) and subacromial space measurements in neutral rotation and external rotation (P > .001), but without clinical relevance effect size (<0.2).

CONCLUSIONS

Active shoulder flexion and abduction mobility increase after manipulation of thoracic spine in patients who have undergone surgery for rotator cuff suture. Subacromial space increases significantly with shoulder in neutral and external rotation position after manipulation. No differences were found regarding surface temperature of manipulated area.

What is the effect of prolonged sitting and physical activity on thoracic spine mobility? An observational study of young adults in a UK university setting

OBJECTIVE

Sedentary behaviour has long been associated with neck and low back pain, although relatively little is known about the thoracic spine. Contributing around 33% of functional neck movement, understanding the effect of sedentary behaviour and physical activity on thoracic spinal mobility may guide clinical practice and inform research of novel interventions.

DESIGN

An assessor-blinded prospective observational study designed and reported in accordance with Strengthening the Reporting of Observational Studies in Epidemiology.

SETTING

UK university (June-September 2016).

PARTICIPANTS

A convenience sample (18-30 years) was recruited and based on self-report behaviours, the participants were assigned to one of three groups: group 1, sitters-sitting >7 hours/day+physical activity<150 min/week; group 2, physically active-moderate exercise >150 min/week+sitting <4 hours/day and group 3, low activity-sitting 2-7 hours/day+physical activity <150 min/week.

OUTCOME MEASURES

Thoracic spine mobility was assessed in the heel-sit position using Acumar digital goniometer; a validated measure. Descriptive and inferential analyses included analysis of variance and analysis of covariance for between group differences and Spearman's rank correlation for post hoc analysis of associations.

RESULTS

The sample (n=92) comprised: sitters n=30, physically active n=32 and low activity n=30. Groups were comparable with respect to age and body mass index.Thoracic spine mobility (mean (SD)) was: group 1 sitters 64.75 (1.20), group 2 physically active 74.96 (1.18) and group 3 low activity 68.44 (1.22). Significant differences were detected between (1) sitters and low activity, (2) sitters and physically active (p<0.001). There was an overall effect size of 0.31. Correlations between thoracic rotation and exercise duration (r=0.67, p<0.001), sitting duration (r=-0.29, p<0.001) and days exercised (r=0.45, p<0.001) were observed.

CONCLUSIONS

Findings evidence reduced thoracic mobility in individuals who spend >7 hours/day sitting and <150 min/week of physical activity. Further research is required to explore possible causal relationships between activity behaviours and spinal musculoskeletal health.

Shoulder impingement syndrome: a systematic review of clinical trial participant selection criteria

BACKGROUND

Shoulder impingement syndrome (SIS) is a common diagnosis for patients with pain and dysfunction of the shoulder. Variations in the signs and symptoms might lead to uncertainty regarding the definition of SIS. The aim of this review is to explore the participant selection criteria used in the literature when investigating SIS and to assess differences in criteria among treating professions.

METHODS

This is a PRISMA systematic review of publications from 2009 to 2014 from MEDLINE, PubMed, The Cochrane Library, Embase, Scopus and CINAHL.

RESULTS

Ninety-seven articles met inclusion criteria for this review. Twenty-five different surgical and nonsurgical treatments were investigated. Impingement-specific index tests were used in all studies. Exclusion index tests were used in 62% of studies. Twenty index tests were identified. Radiological investigations were reported in 53% of all studies, of which a further 53% reported using two or more radiological investigations.

CONCLUSIONS

This systematic review has illustrated that studies investigating SIS test for various signs and symptoms, which is in keeping with describing the condition as a 'syndrome'. However, there are inconsistencies in participant selection criteria between health disciplines, highlighting a need for harmonization of the selection criteria in the form of an international editorial consensus.

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

OBJECTIVE

The purpose of this study was to investigate changes in pain, disability, and range of movement after cervicothoracic manipulation plus exercise therapy in individuals with unilateral shoulder impingement syndrome.

METHODS

Forty-one patients (30 men, 11 women; aged 47 ± 9) diagnosed with unilateral shoulder impingement syndrome attended 10 sessions for 5 weeks (2 sessions/wk). Eligible patients were randomly allocated to 2 study groups: cervicothoracic manipulation plus exercise therapy (n = 21) or home exercise program (n = 20). The outcomes measures included the visual analog scale (VAS); the Disabilities of the Arm, Shoulder, and Hand score; Shoulder Disability Questionnaire; subacromial impingement syndrome (Hawkins-Kennedy Test and Neer Test); and shoulder active range of motion (movements of flexion, extension, rotation, adduction, and abduction). Assessments were applied at baseline and 24 hours after completing 5 weeks of related interventions.

RESULTS

After 5 weeks of treatment significant between-group differences were observed in the Disabilities of the Arm, Shoulder, and Hand score (P = .012); however, no statistically significant differences were achieved for Shoulder Disability Questionnaire (P = .061) and pain intensity (P = .859). Both groups improved with regard to disability and clinical tests for detecting subacromial impingement syndrome.

CONCLUSIONS

This clinical trial suggests that cervicothoracic manipulative treatment with mobilization plus exercise therapy may improve intensity of pain and range of motion compared with the home exercise group alone; the home exercise group had significant changes for flexion, extension, adduction, and abduction, but not for external and internal rotation movement in patients with shoulder impingement.

Is thoracic spine posture associated with shoulder pain, range of motion and function? A systematic review

INTRODUCTION

Excessive thoracic kyphosis is considered a predisposing factor for shoulder pain, though there is uncertainty about the nature of the relationship between shoulder pain and thoracic spine posture. The aim of this systematic review was to investigate the relationship between thoracic kyphosis and shoulder pain, shoulder range of motion (ROM) and function.

METHODS

Two reviewers independently searched eight electronic databases and identified relevant studies by applying eligibility criteria. Sources of bias were assessed independently by two reviewers using a previously validated tool (Ijaz et al., 2013). Data were synthesised using a level of evidence approach (van Tulder et al., 2003).

RESULTS

Ten studies were included. Four studies were rated as low risk of bias, three at moderate risk of bias and three at high risk of bias. There is a moderate level of evidence of no significant difference in thoracic kyphosis between groups with and without shoulder pain. One study at high risk of bias demonstrated significantly greater thoracic kyphosis in people with shoulder pain (p < 0.05). There is a strong level of evidence that maximum shoulder ROM is greater in erect postures compared to slouched postures (p < 0.001), in people with and without shoulder pain.

CONCLUSIONS

Thoracic kyphosis may not be an important contributor to the development of shoulder pain. While there is evidence that reducing thoracic kyphosis facilitates greater shoulder ROM, this is based on single-session studies whose long-term clinical relevance is unclear. Higher quality research is warranted to fully explore the role of thoracic posture in shoulder pain.

Short-term effects of thoracic spinal manipulations and message conveyed by clinicians to patients with musculoskeletal shoulder symptoms: a randomized clinical trial

STUDY DESIGN

Randomized clinical trial.

OBJECTIVES

To evaluate the effects of high-velocity, low-amplitude thrust manipulations (HVLATMs) and various messages on patients with musculoskeletal shoulder symptoms.

BACKGROUND

Previous studies indicated that HVLATM directed at the thoracic spine and ribs resulted in improvements of shoulder range of motion, pain, and disability in patients with musculoskeletal shoulder symptoms. These studies did not explore if the outcome was dependent on thrust location, clinician communication with the patient, or if there were any lasting effects.

METHODS

A consecutive sample of 100 patients with shoulder pain was randomized into four groups. Patients received one intervention session including: six thoracic HVLATM (spine versus scapula), a message about HVLATM (neutral versus positive), and standardized home exercises. Outcome measures included shoulder Numeric Pain Rating Scale (NPRS), NPRS with impingement testing, and Shoulder Pain and Disability Index (SPADI). Measurements were recorded prior to intervention, immediately following intervention, and at short-term follow-up. Kruskal-Wallis statistics were used for between-group comparisons and Wilcoxon signed ranks for within-group comparisons.

RESULTS

Eighty-eight patients (22 per group) completed the study. Statistically significant differences were found for within-group comparisons for most time points assessed. No statistical differences were found for between-group comparisons.

CONCLUSION

Patients improved following the interventions. Neither the type of HVLATM nor the message conveyed to the patients had a significant effect on the patients' improvements.

LEVEL OF EVIDENCE

1b.

Thoracic Spine Manipulation in Individuals With Subacromial Impingement Syndrome Does Not Immediately Alter Thoracic Spine Kinematics, Thoracic Excursion, or Scapular Kinematics: A Randomized Controlled Trial

STUDY DESIGN

Randomized controlled trial.

OBJECTIVES

To determine if thoracic spinal manipulative therapy (SMT) alters thoracic kinematics, thoracic excursion, and scapular kinematics compared to a sham SMT in individuals with subacromial impingement syndrome, and also to compare changes in patient-reported outcomes between treatment groups.

BACKGROUND

Prior studies indicate that thoracic SMT can improve pain and disability in individuals with subacromial impingment syndrome. However, the mechanisms underlying these benefits are not well understood.

METHODS

Participants with shoulder impingement symptoms (n = 52) were randomly assigned to receive a single session of thoracic SMT or sham SMT. Thoracic and scapular kinematics during active arm elevation and overall thoracic excursion were measured before and after the intervention. Patient-reported outcomes measured were pain (numeric pain-rating scale), function (Penn Shoulder Score), and global rating of change.

RESULTS

Following the intervention, there were no significant differences in changes between groups for thoracic kinematics or excursion, scapular kinematics, and patient-reported outcomes (P>.05). Both groups showed an increase in scapular internal rotation during arm raising (mean, 0.9°; 95% confidence interval [CI]: 0.3°, 1.6°; P = .003) and lowering (0.8°; 95% CI: 0.0°, 1.5°; P = .041), as well as improved pain reported on the numeric pain-rating scale (1.2 points; 95% CI: 0.3, 1.8; P<.001) and function on the Penn Shoulder Score (9.1 points; 95% CI: 6.5, 11.7; P<.001).

CONCLUSION

Thoracic spine extension and excursion did not change significantly following thoracic SMT. There were small but likely not clinically meaningful changes in scapular internal rotation in both groups. Patient-reported pain and function improved in both groups; however, there were no significant differences in the changes between the SMT and the sham SMT groups. Overall, patient-reported outcomes improved in both groups without meaningful changes to thoracic or scapular motion.

LEVEL OF EVIDENCE

Therapy, level 1b-.

Association between kyphosis and subacromial impingement syndrome: LOHAS study

BACKGROUND

Kyphosis is a cause of scapular dyskinesis, which can induce various shoulder disorders, including subacromial impingement syndrome (SIS). This study aimed to clarify the impact of kyphosis on SIS with use of cross-sectional data from the Locomotive Syndrome and Health Outcome in Aizu Cohort Study (LOHAS).

METHODS

The study enrolled 2144 participants who were older than 40 years and participated in health checkups in 2010. Kyphosis was assessed by the wall-occiput test (WOT) for thoracic kyphosis and the rib-pelvic distance test (RPDT) for lumbar kyphosis. The associations between kyphosis, SIS, and reduction in shoulder elevation (RSE) were investigated.

RESULTS

Age- and gender-adjusted logistic regression analysis demonstrated significant association between SIS and WOT (odds ratio, 1.65; 95% confidence interval, 1.02, 2.64; P < .05), whereas there was no significant association between SIS and RPDT. Multivariable logistic regression analysis demonstrated no significant association between SIS and both WOT and RPDT, whereas there was significant association between SIS and RSE.

CONCLUSION

RSE plays a key role in the development of SIS, and thoracic kyphosis might influence the development of SIS indirectly by reducing shoulder elevation induced by the restriction of the thoracic spine extension and scapular dyskinesis.

Validation of a sham comparator for thoracic spinal manipulation in patients with shoulder pain

The evidence to guide use of spinal manipulative therapy (SMT) for patients with shoulder pain is limited. A validated sham comparator is needed to ascertain the unique effects of SMT. We investigated the plausibility of a thoracic sham-SMT comparator for SMT in patients with shoulder pain. Participants (n = 56) with subacromial impingement syndrome were randomized to thoracic SMT or a sham-SMT. An examiner blinded to group assignment took measures pre- and post-treatment of shoulder active range of motion (AROM) and perceived effects of the assigned intervention. Treatment consisted of six upper, middle and lower thoracic SMT or sham-SMT. The sham-SMT was identical to the SMT, except no thrust was applied. Believability as an active treatment was measured post-treatment. Believability as an active treatment was not different between groups (χ(2) = 2.19; p = 0.15). Perceptions of effects were not different between groups at pre-treatment (t = 0.12; p = 0.90) or post-treatment (t = 0.40; p = 0.69), and demonstrated equivalency with 95% confidence between groups at pre- and post-treatment. There was no significant change in shoulder flexion in either group over time, or in the sham-SMT for internal rotation (p > 0.05). The SMT group had an increase of 6.49° in internal rotation over time (p = 0.04). The thoracic sham-SMT of this study is a plausible comparator for SMT in patients with shoulder pain. The sham-SMT was believable as an active treatment, perceived as having equal beneficial effects both when verbally described and after familiarization with the treatment, and has an inert effect on shoulder AROM. This comparator can be considered for used in clinical trials investigating thoracic SMT. IRB number: HM 13182.

Objective assessment, repeatability, and agreement of shoulder ROM with a 3D gyroscope

BACKGROUND

Assessment of shoulder mobility is essential for diagnosis and clinical follow-up of shoulder diseases. Only a few highly sophisticated instruments for objective measurements of shoulder mobility are available. The recently introduced DynaPort MiniMod TriGyro ShoulderTest-System (DP) was validated earlier in laboratory trials. We aimed to assess the precision (repeatability) and agreement of this instrument in human subjects, as compared to the conventional goniometer.

METHODS

The DP is a small, light-weight, three-dimensional gyroscope that can be fixed on the distal upper arm, recording shoulder abduction, flexion, and rotation. Twenty-one subjects (42 shoulders) were included for analysis. Two subsequent assessments of the same subject with a 30-minute delay in testing of each shoulder were performed with the DP in two directions (flexion and abduction), and simultaneously correlated with the measurements of a conventional goniometer. All assessments were performed by one observer. Repeatability for each method was determined and compared as the statistical variance between two repeated measurements. Agreement was illustrated by Bland-Altman-Plots with 95% limits of agreement. Statistical analysis was performed with a linear mixed regression model. Variance for repeated measurements by the same method was also estimated and compared with the likelihood-ratio test.

RESULTS

Evaluation of abduction showed significantly better repeatability for the DP compared to the conventional goniometer (error variance: DP = 0.89, goniometer = 8.58, p = 0.025). No significant differences were found for flexion (DP = 1.52, goniometer = 5.94, p = 0.09). Agreement assessment was performed for flexion for mean differences of 0.27° with 95% limit of agreement ranging from -7.97° to 8.51°. For abduction, the mean differences were 1.19° with a 95% limit of agreement ranging from -9.07° to 11.46°.

CONCLUSION

In summary, DP demonstrated a high precision even higher than the conventional goniometer. Agreement between both methods is acceptable, with possible deviations of up to greater than 10°. Therefore, static measurements with DP are more precise than conventional goniometer measurements. These results are promising for routine clinical use of the DP.

Clinical and radiological investigation of thoracic spine extension motion during bilateral arm elevation

STUDY DESIGN

Single-cohort laboratory-based study.

OBJECTIVES

To measure thoracic spine extension motion during bilateral arm elevation using functional radiography and photographic image analysis.

BACKGROUND

Impairment of thoracic spine extension motion may impact shoulder girdle function. Motion of the thoracic spine during arm movement has not been directly measured using functional radiographic analysis.

METHODS

In 21 asymptomatic men, thoracic kyphosis was measured in neutral standing and in end-range bilateral arm elevation, using lateral radiographs and photographic image analysis. Using both measurement techniques, the difference in thoracic kyphosis between the 2 body positions was used to quantify the range of extension motion of the thoracic spine. Bland-Altman plots were used to examine the agreement between measurement techniques. The relationship between the amount of thoracic kyphosis in neutral standing and kyphosis in full bilateral arm elevation was also examined.

RESULTS

The mean ± SD increase in thoracic extension with bilateral arm elevation was 12.8° ± 7.6° and 10.5° ± 4.4°, when measured from the radiographs and photographs, respectively. There was a significant correlation between the radiographic and photographic measurements of the amount of thoracic kyphosis measured in neutral posture (r = 0.71, P<.01) and for the kyphosis measured in full bilateral arm elevation (r = 0.79, P<.001). The mean difference between the 2 measurement techniques was 2.1° for kyphosis measured in neutral posture and 0.5° when measured in full bilateral arm elevation. The thoracic kyphosis angle measured in neutral posture was strongly correlated with the thoracic kyphosis angle measured in full bilateral arm elevation when measured with both radiographic (r = 0.80, P<.001) and photographic (r = 0.84, P<.001) techniques.

CONCLUSION

In asymptomatic men, bilateral arm elevation is associated with movement of the thoracic spine toward extension, but the amount of movement is variable among individuals.

Test-retest reliability of 3D ultrasound measurements of the thoracic spine

OBJECTIVE

To explore the reliability of the Zebris CMS 20 ultrasound analysis system with pointer application for measuring end-range flexion, end-range extension, and neutral kyphosis angle of the thoracic spine.

SETTING

The study was performed within the School of Physiotherapy in cooperation with the Orthopedic Department at a University Hospital.

PARTICIPANTS

The thoracic spines of 28 healthy subjects were measured.

METHODS

Measurements for neutral kyphosis angle, end-range flexion, and end-range extension were taken once at each time point. The bone landmarks were palpated by one examiner and marked with a pointer containing 2 transmitters using a frequency of 40 kHz. A third transmitter was fixed to the pelvis, and 3 microphones were used as receiver. The real angle was calculated by the software. Bland-Altman plots with 95% limits of agreement, intraclass correlations (ICC), standard deviations of mean measurements, and standard error of measurements were used for statistical analyses. The test-retest reliability in this study was measured within a 24-hour interval.

MAIN OUTCOME MEASUREMENTS

Statistical parameters were used to judge reliability.

RESULTS

The mean kyphosis angle was 44.8° with a standard deviation of 17.3° at the first measurement and a mean of 45.8° with a standard deviation of 16.2° the following day. The ICC was high at 0.95 for the neutral kyphosis angle, and the Bland-Altman 95% limits of agreement were within clinical acceptable margins. The ICC was 0.71 for end-range flexion and 0.34 for end-range extension, whereas the Bland-Altman 95% limits of agreement were wider than with the static measurement of kyphosis. Compared with static measurements, the analysis of motion with 3-dimensional ultrasound showed an increased standard deviation for test-retest measurements.

CONCLUSIONS

The test-retest reliability of ultrasound measuring of the neutral kyphosis angle of the thoracic spine was demonstrated within 24 hours. Bland-Altman 95% limits of agreement and the standard deviation of differences did not appear to be clinically acceptable for measuring flexion and extension.

The quality of evidence of psychometric properties of three-dimensional spinal posture-measuring instruments

BACKGROUND

Psychometric properties include validity, reliability and sensitivity to change. Establishing the psychometric properties of an instrument which measures three-dimensional human posture are essential prior to applying it in clinical practice or research.

METHODS

This paper reports the findings of a systematic literature review which aimed to 1) identify non-invasive three-dimensional (3D) human posture-measuring instruments; and 2) assess the quality of reporting of the methodological procedures undertaken to establish their psychometric properties, using a purpose-build critical appraisal tool.

RESULTS

Seventeen instruments were identified, of which nine were supported by research into psychometric properties. Eleven and six papers respectively, reported on validity and reliability testing. Rater qualification and reference standards were generally poorly addressed, and there was variable quality reporting of rater blinding and statistical analysis.

CONCLUSIONS

There is a lack of current research to establish the psychometric properties of non-invasive 3D human posture-measuring instruments.