Journal of Manipulative & Physiological Therapeutics
Zeynab Azin, MSc
Fahimeh Kamali, PhD
Nasrin Salehi Dehno, PhD
Sara Abolahrari-Shirazi, PhD
Published: September 29, 2023DOI:https://doi.org/10.1016/j.jmpt.2023.06.002
Abstract
Objective
The purpose of this study was to compare the effects of manual therapy to therapeutic exercise on shoulder pain, disability, and range of motion (ROM) in patients with subacromial impingement syndrome (SAIS).
Methods
Sixty patients with SAIS were randomly assigned into the manual therapy (MT) and therapeutic exercise (TE) groups. Patients in the MT group were treated with joint mobilization, which was applied to the glenohumeral, acromioclavicular, sternoclavicular and scapulothoracic joints, and trigger point (TrP) inactivation using ischemic compression. Patients in the TE group performed therapeutic exercises. Shoulder pain, disability and active ROM (elevation, external rotation, and internal rotation) were assessed by the visual analog scale, the Shoulder Pain and Disability Index, and a goniometer, respectively. The outcomes were measured at baseline, after the intervention, and 1 month after the intervention.
Results
After the treatment, both groups had significant improvements in shoulder pain, disability, and ROM (P < .05). The MT group experienced a greater reduction in shoulder pain than the TE group (P < .001). However, in disability and ROM, both groups exhibited similar improvements in post-treatment and follow-up periods.
Conclusion
Both MT and TE were effective in improving shoulder pain, disability, and ROM in patients with SAIS. Greater improvement in shoulder pain was observed in the MT group.
Manual Therapy Group
The patients in the MT group received ischemic compression and joint mobilization techniques. Non-thrust mobilization techniques (Grade I-IV) were used in this study. Joint mobilization techniques were applied to the GH joint, scapulothoracic joint, AC joint, and sternoclavicular joint based on previous studies.29,30 Techniques applied to the GH joint were anterior-posterior glide, lateral glide, and inferior glide. Anterior-posterior glide was performed for the AC joint. Anterior, posterior, and caudal glide were applied to the sternoclavicular joint. For the scapulothoracic joint, superior and inferior glide, medial and lateral glide, and upward and downward rotations were applied (Supplemental file). Grade I to II mobilizations were applied when there was reactivity within the capsular movement. Grade III to IV mobilizations were applied when there was no reactivity but capsular hypomobility.30 Each technique was applied for 30 seconds at a rate of approximately 1 mobilization every 1 to 2 seconds, followed by a 30-second rest.30 Three sets of 30-second mobilization were applied. In addition, shoulder capsular stretch in posterior and inferior directions was performed (Supplemental file). Each stretch was held for 30 seconds and repeated 3 times.
The physiotherapist then performed inactivation of active TrPs in the muscles around the shoulder complex. Active TrPs were identified according to the criteria described by Simons et al17 in the supraspinatus, infraspinatus, upper trapezius, subscapularis, teres minor and major, and anterior and middle deltoid muscles.9,31 It has been shown that a trained physiotherapist can reliably detect TrPs by palpation.32 Ischemic compression technique was performed over each active TrP that was found. A recent systematic review reported the effectiveness of ischemic compression in improving pain and function in individuals with shoulder pain.13 The physiotherapist applied constant, gradually increasing pressure over TrP until an increase in muscle resistance (barrier) was perceived, and the patient felt a certain degree of discomfort or pain. At that point, the pressure was maintained until the therapist perceived release of a taut band or the patient experienced a considerable decline in pain. At this stage, the pressure was increased to return to the previous level of muscle tension, and the process was repeated for 90 seconds (usually 2 to 3 repetitions).16,33 If multiple active TrPs were found in a muscle, the most painful one was selected for receiving ischemic compression.9
The intervention was applied for 3 sessions every other day for 1 week. The approximate length of each treatment session was 30 minutes.