The Comparative Effects of Upper Thoracic Spine Thrust Manipulation Techniques in Individuals With Subacromial Pain Syndrome: A Randomized Clinical Trial

The Addition of Thoracic Spine Manipulation or Mobilization to Exercise in Adults With Subacromial Impingement Syndrome: A Critically Appraised Topic

CLINICAL SCENARIO

Shoulder pain is the third most common musculoskeletal complaint. The most common type of shoulder pain is subacromial impingement syndrome (SIS). The concept of regional interdependence demonstrates that body regions are interrelated, affecting how they function. Previous studies have reported the influence of the thoracic spine on the shoulder.

CLINICAL QUESTION

Does adding thoracic spine manipulation or mobilization to exercise in adults with SIS improve shoulder range of motion (ROM), pain, and disability?

SUMMARY OF KEY FINDINGS

The literature was searched for level 2 evidence or higher that examined the effects of the addition of thoracic mobilization or manipulation to exercises in shoulder ROM, pain, and disability in SIS. Twenty articles related to the clinical question, but only 3 met the inclusion and exclusion criteria. Two studies reported that the combination of thoracic mobilization or manipulation and exercises resulted in more significant improvements in shoulder ROM, pain, and disability compared to exercises alone. One study concluded that the combination of thoracic or shoulder mobilization to exercises was superior to ultrasound or exercises alone.

CLINICAL BOTTOM LINE

There is moderate evidence to support the addition of thoracic manipulation or mobilization to exercise in treating SIS to improve shoulder ROM, pain, and disability.

STRENGTH OF RECOMMENDATION

Grade B evidence supports a multimodal approach using the combination of thoracic mobilization or manipulation and exercises in adults with SIS.

Effect of adding thoracic manipulation for the management of patients with adhesive capsulitis: a randomized clinical trial

BACKGROUND

Research is supporting thoracic spine manipulation (TSM) as an intervention in treating adhesive capsulitis (AC) when coupled with physical therapy interventions.

PURPOSE

To investigate whether TSM improves AC outcomes when combined with physical therapy interventions.

METHOD

A double-blinded, randomized, controlled trial with 40 patients assigned into two groups. The experimental group (EG) received physical therapy intervention and TSM; the control group (CG) had physical therapy with sham manipulation. Both groups received interventions biweekly for 12 weeks. Outcomes included Visual Analogue Scale (VAS), Shoulder Pain and Disability Index (SPADI), scapular upward rotation, and shoulder passive range of motion conducted at baseline, after 1 session, 6 and 12 weeks.

RESULTS

Both groups improved significantly after 6 and 12 weeks in pain, disability (p = 0.01 for both; d = 1.53 and 1.46, respectively), scapular upward rotation, shoulder flexion (p = 0.02 for both; d = 2.2 and 0.92, respectively), abduction (p = 0.04; d = 0.07), and external rotation (p = 0.03; d = 0.7). However, CG showed no significant improvement in pain or disability after one session (p = 0.14 and p = 0.16, respectively; d = 0.46 for both). Between groups, results favored EG significantly in pain, disability, scapular upward rotation, shoulder flexion, and abduction (p = 0.02, p = 0.01, p = 0.02, p = 0.05, and p = 0.04, respectively) at 6 weeks (d = 0.81, d = 0.87, d = 0.67, d = 0.64, and d = 0.69, respectively).

CONCLUSION

The results suggest that adding TSM yielded superior clinical benefits when compared to physical therapy interventions in AC patients. Nevertheless, it is imperative to acknowledge a specific limitation in our study is the omission of passive internal rotation assessment. This aspect represents a notable constraint in our research.

CLINICAL TRIAL REGISTRY NUMBER

Pan African clinical trial registry "PACTR202303495421928".

Thinking outside the shoulder: A systematic review and metanalysis of kinetic chain characteristics in non-athletes with shoulder pain

INTRODUCTION

The kinetic chain is important in the proximal-distal energy transfer along body segments. Although biomechanical impairments in components of the kinetic chain have already been reported in athletes with shoulder pain, such investigations in non-athlete individuals have not yet been synthesized.

OBJECTIVE

To systematically review the literature and analyze the quality of evidence on the characteristics of the kinetic chain of non-athletes with shoulder pain compared to asymptomatic individuals.

METHODS

Studies published until February 2024 (without language restrictions) that quantitatively assessed outcomes related to the kinetic chain of non-athlete individuals were searched in five databases (MEDLINE, CINAHL, Web of Science, EMBASE, and SCOPUS). The risk of bias and quality of evidence were analyzed using the Joanna Briggs Institute Critical Appraisal Tool for Analytical Cross-Sectional Studies and the Grading of Recommendations, Assessment, Development, and Evaluation approach, respectively. To summarize the findings, meta-analyses with random-effects models were performed.

RESULTS

Six cross-sectional studies (n = 562 [282 with shoulder pain], mean age = 48.7 ± 8.1 years) with low risk of bias were included in this review. Very low-quality evidence suggests that individuals with shoulder pain may present a lower active range of motion and muscular endurance/strength in the cervical spine, thoracolumbar region, and hip, as well as deficits in neuromuscular control of the lower extremities. Findings related to thoracic spine posture were conflicting and no differences were found in cervical spine isometric muscular strength between individuals with and without shoulder pain.

CONCLUSION

Individuals with shoulder pain may present alterations in active mobility, muscular endurance, and neuromuscular control in kinetic chain segments. These findings suggest that broader physical assessments considering components of the kinetic chain may be clinically relevant in this population. However, based on the very low quality of evidence, the findings of this review should be interpreted with caution.

Spinal manipulation does not improve short-term pain and function in persons with painful shoulder: a systematic review with meta-analysis

PURPOSE

To investigate the benefit of spinal high-velocity low-amplitude thrust (HVLAT) in improving pain and disability in persons with painful shoulder as primary outcomes. Function, quality of life, persons (and clinicians) satisfaction, adverse events rate, and time for recovery were secondary outcomes.

METHODS

A systematic review with meta-analysis was conducted and MEDLINE, CENTRAL, Embase, and PEDro until 20 September 2023 were investigated. Two thousand eight hundred and ninety-nine records were retrieved and nine studies were included. Risk of bias of included studies was assessed through the Revised Cochrane risk-of-bias tool. The certainty of evidence of the pooled results was graded with GRADE approach.

RESULTS

The analysis included nine studies (441 persons). The pooled results showed non-significant differences between HVLAT versus sham in pain at pre-post follow-up (MD -0.13, 95% confidence interval (CI) -0.60; 0.35; p = 0.61, I2 = 0%), and at <4 days follow-up (SMD 0.16, 95%CI -0.16; 0.48; p = 0.34, I2 = 23%); in function at <4 days follow-up (SMD -0.29, 95%CI -0.69; 0.11; p = 0.16, I2 = 50%). The certainty of evidence ranged from low to very low.

CONCLUSIONS

HVLAT was not more effective than sham in improving pain and function at pre-post and at <4 days follow-up. When used as an "add-on technique", HVLAT did not improve pain nor disability.

Effects of comprehensive physiotherapy compared with routine physiotherapy on pain and function in patients with subacromial pain syndrome: A randomized clinical trial with 6-month follow-up

OBJECTIVE

The present study aimed to compare the effects of two treatment methods, including comprehensive physiotherapy (CPT), and routine physiotherapy (RPT) on pain, function, and quality of life in patients with subacromial pain syndrome (SAPS).

METHODS

Forty patients with SAPS were randomly allocated into two groups. The RPT group (7 males, 13 females), (56.45 ± 9.65 years) received manual therapy and exercise therapy for shoulder joint. The CPT group (8 males, 12 females), (52.20 ± 7.39 years) received the above treatments administered to the RPT group plus scapular muscle stretching and strengthening exercise, scapular muscle motor control retraining, thoracic mobilization, and postural correction. Pain (visual analog scale; VAS), function (shoulder pain and disability index; SPADI and quick version of shoulder and hand questionnaire; quick DASH), and quality of life (Western Ontario rotator cuff questionnaire; WORC) were measured before, immediately, one, and six months after treatment.

RESULTS

Interaction of group by time was significant for pain (VAS) (f = 3.79, p = 0.01, partial eta-squared (ηp 2 = 0.103), quick DASH (f = 5.34, p = 0.003, ηp 2 = 0.139, WORC (f = 3.99, p = 0.01, ηp 2 = 0.207) and was not significant for SPADI total score (f = 2.45, p = 0.07, ηp 2 = 0.069). Although the two groups were similar immediately and 1 month post intervention, the CPT group performed better than the RPT group 6 months after intervention. At 6-month assessment, more patients in the CPT group reached the minimal clinically important differences as compared to control groups.

CONCLUSIONS

After six months, CPT was found to be more effective than RPT in improving pain, function, and quality of life.

Is there 'trustworthy' evidence for using manual therapy to treat patients with shoulder dysfunction?: A systematic review

The primary objective of this review was to create a 'trustworthy,' living systematic review and meta-analysis for the application of manual therapy interventions in treating patients with shoulder dysfunction. Included studies were English-language randomized controlled trials published between 1/1/2010 and 8/3/2023, with searches performed in: PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), CINHAL, ProQuest Nursing & Allied Health, EBSCO Medline, and PEDro. The population of focus included adults 18 years and older with musculoskeletal impairments related to shoulder dysfunction. Our primary outcomes included pain and region-specific outcome measures. We excluded trials, including participants having shoulder dysfunction resulting from surgery, radicular pain, instability/dislocation, fracture, lymphedema, and radiation. Our screening methodology was based upon a previously published 'trustworthy' systematic review protocol. This included the application of our PICOTS criteria in addition to screening for prospective clinical trial registration and following of prospective intent, as well as assessment of PEDro scores, risk-of-bias ratings, GRADE scoring, and examination of confidence in estimated effects. Twenty-six randomized controlled trials met our PICOTS criteria; however, only 15 of these were registered. Only three were registered prospectively. Two of these did not have discussions and conclusions that aligned with their primary outcome. The remaining single study was found to have a high risk-of-bias, meaning the remainder of the protocol could not be employed and that no randomized controlled trials could undergo further assessment or meta-analysis. The results of this systematic review indicate there are no 'trustworthy' randomized controlled trials examining the effectiveness of manual therapy interventions for the treatment of patients with shoulder dysfunction, as defined by the prospectively established methodology. Therefore, these findings signal that creating a 'trustworthy,' living systematic review on this clinically relevant topic is not yet possible due to a lack of 'trustworthy' randomized controlled trials.

Efficacy of Combining Traditional Chinese Manual Therapy (Tuina) and Specific Therapeutic Neck Exercise in Young Adults with Non-Specific Chronic Neck Pain: Study Protocol for a Randomized Controlled Trial

Purpose

Non-specific chronic neck pain (NSCNP) is an increasingly common musculoskeletal disease and an important issue in the global healthcare system. Some studies have shown that the combination of manual therapy and exercise is effective in treating NSCNP but still with several limitations. Traditional Chinese manual therapy (tuina) is a Chinese manual therapy that consists of soft tissue manipulation and spinal manipulation. This study aims to design a randomized controlled trial to assess the effect of a tuina combined with specific therapeutic neck exercise modified protocol for NSCNP patients.

Patients and Methods

This is a study protocol for a randomized, participant-, assessor- and analyst-blinded controlled trial. Eighty-eight eligible NSCNP patients will be randomly allocated into tuina combined with specific therapeutic neck exercise group (TSTE group) and tuina combined with sham therapeutic neck exercise group (TS group) in a ratio of 1:1. All participants will receive 8 treatment sessions applied in 4 weeks and then be followed up for another 12 weeks. Clinical data will be collected at baseline, during treatment phase (at the 2- and 4-week) and at the 8-, 12-, 16-week follow-ups. The primary outcome is the changes in neck pain intensity (visual analogue scale). The secondary outcomes include neck disability (Neck Disability Index), cervical range of motion (ROM), neck muscle endurance, cervical muscle cross-sectional area, cervical curvature and analgesic consumption. Adverse events will be collected and recorded throughout the study.

Conclusion

We will discuss whether our tuina combined with specific therapeutic neck exercise modified protocol is more effective at improving pericervical muscle endurance, ROM, cervical muscle cross-sectional area and cervical curvature than tuina alone, thereby decreases neck pain and disability in individuals with NSCNP more effectively.

Trial Registration

Chinese Clinical Trials Registry, ChiCTR2300067903. Registered on 31 January 2023.

Scapular kinematics and muscle activity during Yi Jin Bang exercises

Introduction: Scapular dyskinesis is commonly associated with subacromial pain syndrome (SAPS). Addressing scapular dyskinesis is widely accepted as an important component of shoulder rehabilitation. Our previous randomized controlled trial showed that Yi Jin Bang (YJB) exercises could effectively manage SAPS, but scapular motions and muscle activity during YJB exercises remain unknown. This study examined scapular kinematics synchronously with scapular muscle activation during YJB exercises. Methods: Thirty healthy participants with no shoulder complaints were enrolled in this study. Three-dimensional (3D) scapular kinematics and electromyography (EMG) activation of the upper trapezius, middle trapezius, lower trapezius, serratus anterior, anterior deltoid, middle deltoid, and posterior deltoid were synchronously measured during nine YJB movements. Results: During all YJB movements, the scapula was upwardly rotated and anteriorly tilted, with more upward rotation and a similar or less anterior tilt than the mean resting scapular angle. Column rotation, arm crossover, shoulder support circle, and armpit support high lift generated more internal rotation than the mean resting scapular angle, with the angles of internal rotation significantly greater than the other five movements (p < 0.001). Regarding EMG activity, all YJB movements elicited low activity (1.42%-19.19% maximal voluntary isometric contraction [MVIC]) from the upper trapezius and posterior deltoid and low to moderate activity (0.52%-29.50% MVIC) from the middle trapezius, lower trapezius, serratus anterior, anterior deltoid, and middle deltoid. Conclusion: YJB exercises could be useful in the middle to later phases of shoulder rehabilitation. For patients with insufficient external rotation, some YJB movements should be prescribed with caution.

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.

Effectiveness of cervicothoracic and thoracic manual physical therapy in managing upper quarter disorders - a systematic review

STUDY DESIGN

Systematic review.

BACKGROUND

Physical therapists often use cervicothoracic and thoracic manual techniques to treat musculoskeletal disorders of the upper quarter ,however, the overall effectiveness of this approach remains to be elucidated.

OBJECTIVE

This systematic review explored studies that examined the short- and long-term effectiveness of manual physical therapy directed at the cervicothoracic and thoracic region in the management of upper quarter musculoskeletal conditions.

METHODS

The electronic databases MEDLINE, AMED, CINAHL, and Embase were searched from their inception through 30 October 2020. Eligible clinical trials included those where human subjects treated with cervicothoracic and/or thoracic manual procedures were compared with a control group or other interventions. The methodological quality of individual studies was assessed using the PEDro scale.

RESULTS

The initial search returned 950 individual articles. After the screening of titles and abstracts, full texts were reviewed by two authors, with 14 articles determined to be eligible for inclusion. PEDro scores ranged from 66 to 10 (out of a maximum score of 10). In the immediate to 52-week follow-up period, studies provided limited evidence that cervicothoracic and thoracic manual physical therapy may reduce pain and improve function when compared to control/sham or other treatments.

CONCLUSIONS

Evidence provides some support for the short-termeffectiveness of cervicothoracic and thoracic manual physical therapy in reducing pain and improving function in people experiencing upper quarter musculoskeletal disorders. Evidence is lacking for long-term effectiveness as only two studies explored outcomes beyond 26 weeks and this was for patient-perceived improvement.

PROSPERO ID

CRD42020219456.

March 2021 Letters to the Editor-in-Chief

Letters to the Editor-in-Chief of JOSPT as follows: "Competing Interests and a Cloudy Clinical Interpretation" "A Vested Interest in the Outcome" J Orthop Sports Phys Ther 2021;51(3):151-153. doi:10.2519/jospt.2021.0201.

Spinal Manipulation and Electrical Dry Needling in Patients With Subacromial Pain Syndrome: A Multicenter Randomized Clinical Trial

OBJECTIVES

To compare the effects of spinal thrust manipulation and electrical dry needling (TMEDN group) to those of nonthrust peripheral joint/soft tissue mobilization, exercise, and interferential current (NTMEX group) on pain and disability in patients with subacromial pain syndrome (SAPS).

DESIGN

Randomized, single-blinded, multicenter parallel-group trial.

METHODS

Patients with SAPS were randomized into the TMEDN group (n = 73) or the NTMEX group (n = 72). Primary outcomes included the Shoulder Pain and Disability Index and the numeric pain-rating scale. Secondary outcomes included the global rating of change scale (GROC) and medication intake. The treatment period was 6 weeks, with follow-ups at 2 weeks, 4 weeks, and 3 months.

RESULTS

At 3 months, the TMEDN group experienced greater reductions in shoulder pain and disability (P<.001) compared to the NTMEX group. Effect sizes were large in favor of the TMEDN group. At 3 months, a greater proportion of patients within the TMEDN group achieved a successful outcome (GROC score of 5 or greater) and stopped taking medication (P<.001).

CONCLUSION

Cervicothoracic and upper-rib thrust manipulation combined with electrical dry needling resulted in greater reductions in pain, disability, and medication intake than nonthrust peripheral joint/soft tissue mobilization, exercise, and interferential current in patients with SAPS. The effects were maintained at 3 months. J Orthop Sports Phys Ther 2021;51(2):72-81. Epub 28 Aug 2020. doi:10.2519/jospt.2021.9785.