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SPT Abstract – CERVICOTHORACIC MANUAL THERAPY PLUS EXERCISE VERSUS EXERCISE THERAPY ALONE IN THE MANAGEMENT OF INDIVIDUALS WITH SHOULDER PAIN: A MULTICENTER RANDOMIZED CONTROLLED TRIAL

Mintken, PE; McDevitt, AW; Cleland, J; Boyles, RE; Beardslee, AR; Burns, SA; Haberl, MD; Hinrichs, LA; Michener, LA. Journal of Orthopaedic & Sports Physical Therapy. 46(8): 617-628, A1-A8.

Abstracted by: John Chatwell, SPT at Missouri State University, Springfield, Missouri

This multicenter, randomized controlled trial objective was to compare the effects of cervicothoracic manual therapy techniques paired with exercise therapy versus exercise therapy, alone, in the treatment of shoulder patient using two groups, respectively. One-hundred forty participants met the following inclusion criteria: were 18-65 years of age with primary complaint of shoulder pain, and scored greater than a 20% on the Shoulder Pain and Disability Index (SPADI). Exclusion criteria included present contraindications for manipulation techniques or demonstrated severe pathology.

Participant preliminary assessments and outcomes were assessed using the SPADI, the Disabilities of the Arm, Shoulder, and Hand score (QuickDASH), and a numeric pain scale rating (NPSR) (0-10 rating scale), to determine pain, disability, and limitations of function of their upper extremities. Secondary outcomes, the global rating of change (GROC) scale and Patient Acceptable Symptom State (PASS), were conducted to determine “patient perceived recovery” following treatment.

Each group was treated twice a week for four weeks. The “exercise only” group was treated with cervicothoracic range of motion exercises for the first two sessions and received strengthening exercises the following six.  The “manual therapy and exercise” group was treated with “high dose” cervicothoracic manual therapy techniques for the first two treatment sessions and received the same exercise therapies prescribed to the “exercise only” group. The cervicothoracic manual therapy techniques included a gamut of high and low velocity thrust and traction techniques at mid- to end-ranges, developed per Mintken.

Diagnosis and Management Info for Cervical Spine Pain

Baseline outcomes at weeks one and four and six months between the primary outcomes (SPADI, QuickDASH, and NPSR) demonstrated no significant difference between the two treatment groups, remarking that manual therapy techniques did not add any additional benefits to shoulder pain and dysfunction. However, the PASS demonstrated significantly increased values at four weeks and the GROC demonstrated significant improvement at four weeks and six months, demonstrating increased “patient perceived improvement” and “patient-perceived acceptability of symptoms and improvement”, respectively.

In summation the authors acknowledged that manual therapy may improve “patient-perceived acceptability of symptoms and improvement”, without adding any measurable difference to pain and dysfunction, as demonstrated by the primary outcomes. It’s proposed that centralization of chronic pain and disallowing clinical reasoning to adjust techniques and therapy regimens specifically to patient needs could have restricted pain and function improvement due to therapy.

Commentary Notes:

Manual therapy manipulation and soft tissue techniques have been widely utilized and studied with development of various models of treatment since the 1950’s (Pettman, 2007 ) Manual therapy manipulation, has been shown to demonstrate improved pain within 48 hours of treatment of the thoracic spine (Boyles, et al., 2009) and the use of manual therapy may improve recovery speed in shoulder pain patients and improve pain and function compared to that of usual care (Peek, Miller, & Heneghan, 2015). .  Sobel et al. reported that 40% of patients with chronic shoulder pain demonstrated cervicothoracic and adjacent ribs impairments with their pain.  The study implies that manipulative manual therapy, in a fixed standard presentation, provided significantly increased “perceived patient recovery”, implying increased patient comfort and satisfaction with treatment and recovery.  This could imply greater positive outlook of the patient on therapy services and return to activities of daily living with increased comfort regarding the treated upper extremity.
References

  • Boyles, R., Ritland, B., Miracle, B., Barclay, D., Faul, M., Moore, J., & Koppenhaver, S. W. (2009). The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Manual Therapy, 14(4): 375-380.
  • Peek, A., Miller, C., & Heneghan, N. (2015). Thoracic Manual Therapy in the management of non-specific shoulder pain: a systematic review . Journal of Manual and Manipulative Therapy , 23(4): 176-187.
  • Pettman, E. (2007 ). A History of Manipulative Therapy. Journal of Manual and Manipulative Therapy , (15)3: 165-174.
  • Sobel, J., Kremer, I., Winters, J., Arendzen, J., & de Jong, B. (1996). The influence of the mobility in the cervicothoracic spine and the upper ribs (shoulder girdle) on the mobility of the scapulohumeral joint. Journal of Manipulative and Physiological Therapeutics , 19(7): 469-474.

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