Lori A. Michener

Shoulder Pain and Mobility Deficits: Adhesive Capsulitis

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organizations International Classification of Functioning, Disability, and Health (ICF). The purpose of these clinical practice guidelines is to describe the peer-reviewed literature and make recommendations related to adhesive capsulitis. J Orthop Sports Phys Ther 2013;43(5):A1–A31. doi:10.2519/jospt.2013.0302

Visual Scapular Dyskinesis: Kinematics and Muscle Activity Alterations in Patients With Subacromial Impingement Syndrome

OBJECTIVEnTo characterize scapular kinematics and shoulder muscle activity in patients with subacromial impingement syndrome, with and without visually identified scapular dyskinesis.nnnDESIGNnCross-sectional study.nnnSETTINGnLaboratory.nnnPARTICIPANTSnParticipants with subacromial impingement syndrome (N=38) were visually classified using a scapular dyskinesis test with obvious scapular dyskinesis (n=19) or normal scapular motion (n=19).nnnINTERVENTIONSnNot applicable.nnnMAIN OUTCOME MEASURESnAn electromagnetic motion capture system measured 3-dimensional kinematics of the thorax, humerus, and scapula. Simultaneously, surface electromyography was used to measure muscle activity of the upper, middle, and lower trapezius; serratus anterior; and infraspinatus during ascending and descending phases of weighted shoulder flexion. Separate mixed-model analyses of variance for the ascending and descending phases of shoulder flexion compared kinematics and muscle activity between the 2 groups. Shoulder disability was assessed with the Pennsylvania Shoulder Score (Penn).nnnRESULTSnThe group with obvious dyskinesis reported 6 points lower on Penn shoulder function (0-60 points), exhibited a main group effect of less scapular external rotation of 2.1° during ascent and 2.5° during descent, and had 12.0% higher upper trapezius muscle activity during ascent in the 30° to 60° interval.nnnCONCLUSIONSnPatients with obvious dyskinesis and subacromial impingement syndrome have reduced scapular external rotation and increased upper trapezius muscle activity, along with a greater loss of shoulder function compared with those without dyskinesis. These biomechanical alterations can lead to or be caused by scapular dyskinesis. Future studies should determine if correction of these deficits will eliminate scapular dyskinesis and improve patient-rated shoulder use.

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.

Immediate changes in pressure pain sensitivity after thoracic spinal manipulative therapy in patients with subacromial impingement syndrome: A randomized controlled study

BACKGROUNDnThoracic SMT can improve symptoms in patients with subacromial impingement syndrome. However, at this time the mechanisms of SMT are not well established. It is possible that changes in pain sensitivity may occur following SMT.nnnOBJECTIVESnTo assess the immediate pain response in patients with shoulder pain following thoracic spinal manipulative therapy (SMT) using pressure pain threshold (PPT), and to assess the relationship of change in pain sensitivity to patient-rated outcomes of pain and function following treatment.nnnDESIGNnRandomized Controlled Study.nnnMETHODSnSubjects with unilateral subacromial impingement syndrome (n = 45) were randomly assigned to receive treatment with thoracic SMT or sham thoracic SMT. PPT was measured at the painful shoulder (deltoid) and unaffected regions (contralateral deltoid and bilateral lower trapezius areas) immediately pre- and post-treatment. Patient-rated outcomes were pain (numeric pain rating scale - NPRS), function (Pennsylvania Shoulder Score - Penn), and global rating of change (GROC).nnnRESULTSnThere were no significant differences between groups in pre-to post-treatment changes in PPT (p ≥ 0.583) nor were there significant changes in PPT within either group (p ≥ 0.372) following treatment. NPRS, Penn and GROC improved across both groups (p < 0.001), but there were no differences between the groups (p ≥ 0.574).nnnCONCLUSIONnThere were no differences in pressure pain sensitivity between participants receiving thoracic SMT versus sham thoracic SMT. Both groups had improved patient-rated pain and function within 24-48 h of treatment, but there was no difference in outcomes between the groups.

Clinical outcomes of a scapular-focused treatment in patients with subacromial pain syndrome: a systematic review

Objective To systematically review the literature on the clinical outcomes of scapular-focused treatments in participants with subacromial pain syndrome (SPS). Design Systematic literature review. Studies were appraised by two reviewers using the Physiotherapy Evidence Database (PEDro) scale, and a best-evidence synthesis was performed. Data sources The literature search was conducted in the databases PubMed, Embase and Cinahl up to February 2015. Eligibility criteria for selecting studies Randomised controlled trials evaluating the clinical outcomes of a physiotherapeutic scapular-focused treatment in participants with SPS. Results Four studies were included describing various scapular-focused interventions, including scapular-focused exercise therapy, scapular mobilisation and scapular taping. All included studies had a PEDro score of 6 or higher, indicating low risk of bias. There was moderate evidence that scapular-focused treatment compared with other physiotherapeutic treatment is effective in improving scapular muscle strength in participants with SPS. Conflicting evidence was found for improvements in pain, function and clinical measures of scapular positioning. No evidence was found for improvements in shoulder range of motion or rotator cuff muscle strength. Conclusions There is some support for the use of scapular-focused exercise therapy in patients with SPS. Owing to the low number of studies, no firm conclusions can be drawn. Therefore, more randomised controlled trials are needed to determine the clinical outcomes of scapular-focused exercise therapy, scapular mobilisation techniques and scapular taping in patients with SPS.

Staged Approach for Rehabilitation Classification: Shoulder Disorders (STAR–Shoulder)

Shoulder disorders are a common musculoskeletal problem causing pain and functional loss. Traditionally, diagnostic categories are based on a pathoanatomic medical model aimed at identifying the pathologic tissues. However, the pathoanatomic model may not provide diagnostic categories that effectively guide treatment decision making in rehabilitation. An expanded classification system is proposed that includes the pathoanatomic diagnosis and a rehabilitation classification based on tissue irritability and identified impairments. For the rehabilitation classification, 3 levels of irritability are proposed and defined, with corresponding strategies guiding intensity of treatment based on the physical stress theory. Common impairments are identified and are used to guide specific intervention tactics with varying levels of intensity. The proposed system is conceptual and needs to be tested for reliability and validity. This classification system may be useful clinically for guiding rehabilitation intervention and provides a potential method of identifying relevant subgroups in future research studies. Although the system was developed for and applied to shoulder disorders, it may be applicable to classification and rehabilitation of musculoskeletal disorders in other body regions.

Shoulder pain: can one label satisfy everyone and everything?

The labelling of non-traumatic shoulder pain related to the structures of the subacromial space has been debated for many years. Historically, labelling of shoulder diagnoses and exploring theories about the underlying causes of shoulder pain are interrelated. Many authors use the phrase ‘syndrome’ describing a combination of findings, often occurring together, with an unknown or heterogeneous underlying pathogenesis. As such, Dr Charles Neer introduced the diagnostic label of ‘subacromial impingement syndrome’ (SIS) of the shoulder in 1972. This label was based on the mechanism of structural impingement of the structures of the subacromial space. This concept has been the dominant theory of injury to the rotator cuff tendons and other structures in the subacromial space, and has served as the rationale for clinical tests, surgical procedures and rehabilitation protocols.nnHowever, the label of SIS is now controversial, as recent evidence suggests that this concept does not fully explain the mechanism.1–3 Until a few years ago, SIS was a widely accepted ‘umbrella’ term for a number of possible underlying structural or biomechanical causes. Throughout the years, the description progressed from SIS to ‘impingement related shoulder pain’, with the growing opinion that ‘impingement’ represents a cluster of symptoms and a possible mechanism for the pain, rather than a pathoanatomic diagnose itself. The …

Relative scapular muscle activity ratios are altered in subacromial pain syndrome

BACKGROUNDnCoordinated muscle activity is needed for synchronized joint motion and stability. Characterizing relative scapular muscle activity deficits in participants with shoulder pain will provide foundational knowledge to develop rehabilitation programs.nnnMETHODSnParticipants were recruited with subacromial pain syndrome and an asymptomatic control group matched for age, gender, and dominant arm (Nu2009=u200956). Surface electromyographic muscle activity was recorded from the upper, middle, and lower trapezius (UT, MT, LT) and serratus anterior (SA) during 5 repetitions of a weighted arm elevation task. Muscle activity was normalized to a reference contraction and then expressed as UT/MT, UT/LT, UT/SA, and LT/SA ratios. Ratios were compared between groups and across 3 arm angle intervals during ascending and descending elevation.nnnRESULTSnA 2u2009×u20093 mixed-model analysis of variance yielded a group main effect for the UT/LT ratio, with a higher ratio in the subacromial pain group during ascending (mean difference,u20090.92; Pu2009=u2009.008) and descending (mean difference,u20090.70; Pu2009=u2009.030). For the LT/SA ratio, there was a group effect: a lower ratio in the subacromial group during ascending (mean difference,u2009-0.25; Pu2009=u2009.026) and descending (mean difference,u2009-0.51; Pu2009=u2009.032). There were no differences for the UT/MT or UT/SA.nnnDISCUSSIONnThere is a disruption in coordination between the LT and SA and the UT and LT during an arm elevation task in patients with subacromial pain syndrome. The LT was part of both altered ratios, indicating the relative importance of the LT. Future research should determine if exercises aimed at restoring the dysfunctional LT/SA and UT/LT force couples are beneficial to reduce shoulder pain and disability in patients with unilateral shoulder pain.

Cervicothoracic Manual Therapy Plus Exercise Therapy Versus Exercise Therapy Alone in the Management of Individuals With Shoulder Pain: A Multicenter Randomized Controlled Trial

Study Design Multicenter randomized controlled trial. Background Cervicothoracic manual therapy has been shown to improve pain and disability in individuals with shoulder pain, but the incremental effects of manual therapy in addition to exercise therapy have not been investigated in a randomized controlled trial. Objectives To compare the effects of cervicothoracic manual therapy and exercise therapy to those of exercise therapy alone in individuals with shoulder pain. Methods Individuals (n = 140) with shoulder pain were randomly assigned to receive 2 sessions of cervicothoracic range-of-motion exercises plus 6 sessions of exercise therapy, or 2 sessions of high-dose cervicothoracic manual therapy and range-of-motion exercises plus 6 sessions of exercise therapy (manual therapy plus exercise). Pain and disability were assessed at baseline, 1 week, 4 weeks, and 6 months. The primary aim (treatment group by time) was examined using linear mixed-model analyses and the repeated measure of time for the Shoulder Pain and Disability Index (SPADI), the numeric pain-rating scale, and the shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH). Patient-perceived success was assessed and analyzed using the global rating of change (GROC) and the Patient Acceptable Symptom State (PASS), using chi-square tests of independence. Results There were no significant 2-way interactions of group by time or main effects by group for pain or disability. Both groups improved significantly on the SPADI, numeric pain-rating scale, and QuickDASH. Secondary outcomes of success on the GROC and PASS significantly favored the manual therapy-plus-exercise group at 4 weeks (P = .03 and P<.01, respectively) and on the GROC at 6 months (P = .04). Conclusion Adding 2 sessions of high-dose cervicothoracic manual therapy to an exercise program did not improve pain or disability in patients with shoulder pain, but did improve patient-perceived success at 4 weeks and 6 months and acceptability of symptoms at 4 weeks. More research is needed on the use of cervicothoracic manual therapy for treating shoulder pain. Level of Evidence Therapy, level 1b. Prospectively registered March 30, 2012 at www.ClinicalTrials.gov (NCT01571674). J Orthop Sports Phys Ther 2016;46(8):617-628. doi:10.2519/jospt.2016.6319.

The Comparative Effects of Spinal and Peripheral Thrust Manipulation and Exercise on Pain Sensitivity and the Relation to Clinical Outcome: A Mechanistic Trial Using a Shoulder Pain Model

STUDY DESIGNnSingle-blind randomized trial.nnnOBJECTIVESnTo compare the effects of cervical and shoulder thrust manipulation (TM) and exercise on pain sensitivity, and to explore associations with clinical outcomes in patients with shoulder pain.nnnBACKGROUNDnExperimental studies indicate that spinal TM has an influence on central pain processes, supporting its application for treatment of extremity conditions. Direct comparison of spinal and peripheral TM on pain sensitivity has not been widely examined.nnnMETHODSnSeventy-eight participants with shoulder pain (36 female; mean ± SD age, 39.0 ± 14.5 years) were randomized to receive 3 treatments of cervical TM (n = 26), shoulder TM (n = 27), or shoulder exercise (n = 25) over 2 weeks. Twenty-five healthy participants (13 female; mean ± SD age, 35.2 ± 11.1 years) were assessed to compare pain sensitivity with that in clinical participants at baseline. Primary outcomes were changes in local (eg, shoulder) and remote (eg, tibialis anterior) pressure pain threshold and heat pain threshold occurring over 2 weeks. Secondary outcomes were shoulder pain intensity and patient-rated function at 4, 8, and 12 weeks. Analysis-of-variance models and partial-correlation analyses were conducted to examine comparative effects and the relationship between measures.nnnRESULTSnAt baseline, clinical participants demonstrated lower local (mean difference, - 1.63 kg; 95% confidence interval [CI]: -2.40, -0.86) and remote pressure pain threshold (mean difference, -1.96 kg; 95% CI: -3.09, -0.82) and heat pain threshold (mean difference, -1.15°C; 95% CI: -2.06, -0.24) compared to controls, suggesting enhanced pain sensitivity. Following intervention, there were no between-group differences in pain sensitivity or clinical outcome (P>.05). However, improvements were noted, regardless of intervention, for pressure pain threshold (range of mean differences, 0.22-0.32 kg; 95% CI: 0.03, 0.43), heat pain threshold (range of mean differences, 0.30-0.58; 95% CI: 0.06, 0.96), pain intensity (range of mean differences, -1.79 to -1.45; 95% CI: -2.34, -0.94), and function (range of mean differences, 3.15-3.82; 95% CI: 0.69, 6.20) at all time points. We did not find an association between pain sensitivity changes and clinical outcome (P>.05). Conclusion Clinical participants showed enhanced pain sensitivity, but did not respond differently to cervical or peripheral TM. In fact, in this sample, cervical TM, shoulder TM, and shoulder exercise had similar pain sensitivity and clinical effects. The lack of association between pain sensitivity and clinical pain and function outcomes suggests different (eg, nonspecific) pain pathways for clinical benefit following TM or exercise.nnnLEVEL OF EVIDENCEnTherapy, level 1b.