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[ research report ]

PAULA R. CAMARGO, PT, PhD1 FRANCISCO ALBURQUERQUE-SENDN, PT, PhD2 MARIANA A. AVILA, PT, PhD1
MELINA N. HAIK, PT, MS1 AMILTON VIEIRA, MS1 TANIA F. SALVINI, PT, PhD1

Effects of Stretching and Strengthening


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Exercises, With and Without Manual


Therapy, on Scapular Kinematics,
Function, and Pain in Individuals
With Shoulder Impingement:
A Randomized Controlled Trial
Copyright 2015 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

S
houlder impingement
TTSTUDY DESIGN: Randomized controlled trial. TTRESULTS: Independent of the intervention
syndrome (SIS) is a
TTOBJECTIVE: To evaluate the effects of an ex- group, small, clinically irrelevant changes in
ercise protocol, with and without manual therapy, scapular kinematics were observed postinterven- common condition of
on scapular kinematics, function, pain, and tion. A significant group-by-time interaction effect shoulder pain associated
mechanical sensitivity in individuals with shoulder (P = .001) was found for scapular anterior tilt
impingement syndrome. during elevation in the sagittal plane, with a 3.0 with repetitive work performed
TTBACKGROUND: Stretching and strengthening
increase (95% confidence interval [CI]: 1.5, 7.5) at or above shoulder level and
Journal of Orthopaedic & Sports Physical Therapy

relative to baseline in the exercise-plusmanual


exercises have been shown to effectively decrease participation in sports involving
therapy group compared to a decrease of 0.3
pain and disability in individuals with shoulder
(95% CI: 4.2, 4.8) in the exercise-alone group. frequent overhead motions.7,44,60
impingement syndrome. There is still conflicting
evidence regarding the efficacy of adding manual Pain, mechanical sensitivity, and the DASH score
improved similarly for both groups by the end of Studies have found SIS to be related to im-
therapy to an exercise therapy regimen.
the intervention period. pairments in scapular kinematics,58 alter-
TTMETHODS: Forty-six patients were assigned to
1 of 2 groups, one of which received a 4-week inter- TTCONCLUSION: Adding manual therapy to an ations in rotator cuff and scapulothoracic
vention of stretching and strengthening exercises exercise protocol did not enhance improvements in muscular activation,48 poor posture,35 and
(exercise alone) and the other the same interven- scapular kinematics, function, and pain in individu- tightness of the posterior and anterior
tion, supplemented by manual therapy targeting als with shoulder impingement syndrome. The shoulder.39,52 Recent investigations have
the shoulder and cervical spine (exercise plus noted improvements in pain and function are not also linked SIS to peripheral1 and central
manual therapy). All outcomes were measured likely explained by changes in scapular kinematics.
sensitization processes.32 However, there
preintervention and postintervention at 4 weeks. The study is registered at www.clinicaltrials.gov
Outcome measures were scapular kinematics (NCT02035618). is not a clear pattern of alterations in pain
processing in this population.14
TTLEVEL OF EVIDENCE: Therapy, level 1b.
in the scapular and sagittal planes during arm
elevation, function as determined through the
J Orthop Sports Phys Ther 2015;45(12):984-997.
Alterations in scapular motion and
Disabilities of the Arm, Shoulder and Hand (DASH) position have been called scapular dyski-
Epub 15 Oct 2015. doi:10.2519/jospt.2015.5939
questionnaire, pain as assessed with a visual ana-
TTKEY WORDS: mobilization, rehabilitation,
nesis, a condition that has been observed
log scale, and mechanical sensitivity as assessed
with pressure pain threshold. rotator cuff, sensitization, subacromial in individuals with SIS and may be the
cause or the result of SIS.36 In general,

1
Department of Physical Therapy, Federal University of So Carlos, So Carlos, Brazil. 2Department of Physical Therapy, University of Salamanca, Salamanca, Spain. This study was
supported by Coordenao de Aperfeioamento de Pessoal de Nvel Superior and Conselho Nacional de Desenvolvimento Cientfico e Tecnolgico. This study was approved by the
Institutional Review Boards of the Federal University of So Carlos and by the Ethics Committee of the Federal University of So Carlos (number 270/2010). This study is registered
at www.clinicaltrials.gov (NCT02035618). The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in
the subject matter or materials discussed in the article. Address correspondence to Dr Paula Rezende Camargo, Departamento de Fisioterapia, Universidade Federal de So Carlos,
Rodovia Washington Luis, km 235, CEP 13565-905, So Carlos, SP, Brazil. E-mail: prcamargo@ufscar.br t Copyright 2015 Journal of Orthopaedic & Sports Physical Therapy

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Assessed for eligibility, n = 93
Enrollment

Excluded, n = 47
Did not meet inclusion criteria, n = 25
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Other reasons, n = 22

Randomized, n = 46
Allocation

Allocated to exercise-plusmanual Allocated to exercise-alone group,


therapy group, n = 23 n = 23

Excluded from PPT and VAS due Excluded from PPT and VAS due
to BDI greater than 9 points, to BDI greater than 9 points,
n=2 n=3
Copyright 2015 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

Preintervention Preintervention
DASH, n = 23 DASH, n = 23
PPT and VAS, n = 21 PPT and VAS, n = 20
Scapular kinematics, n = 23 Scapular kinematics, n = 23

Intervention (4 wk)

Discontinued intervention Discontinued intervention


Journal of Orthopaedic & Sports Physical Therapy

(personal reasons), n = 1 (personal reasons), n = 1

Postintervention Postintervention
DASH, n = 23 DASH, n = 23
Analysis

PPT and VAS, n = 21 PPT and VAS, n = 20


Scapular kinematics, n = 22 Scapular kinematics, n = 22
Intention to treat (scapular Intention to treat (scapular
kinematics), n = 1 kinematics), n = 1

FIGURE 1. Flow diagram representing enrollment, allocation, follow-up, and analysis for both groups. Abbreviations: BDI, Beck Depression Inventory; DASH, Disabilities of the
Arm, Shoulder and Hand questionnaire; PPT, pressure pain threshold; VAS, visual analog scale.

a pattern of increased scapular internal Many conservative interventions have strength in this population.2,13,53 However,
rotation and decreased scapular upward been proposed to address the aforemen- 2 recent systematic reviews16,22 have shown
rotation and posterior tilt has been ob- tioned factors.2,6,7,15,27,37,41,51,55,56 Systematic limited evidence for the effectiveness of
served in individuals with SIS.58 In addi- reviews have indicated that stretching manual therapy as an add-on therapy to
tion, SIS symptoms have been associated and strengthening exercises are effective exercises in the treatment of SIS to reduce
with altered activation of the scapular in decreasing pain and disability in indi- pain and enhance function. Given the
and rotator cuff muscles.48 Based on these viduals with SIS.22,37,45 Three studies have conflicting results, additional studies are
findings, it is believed that therapeutic demonstrated that the addition of manu- necessary to determine if adding manual
exercises designed to improve scapular al therapy to an exercise-based program therapy techniques to a standardized exer-
control might be effective in reducing is superior to exercise alone in improv- cise program is better than exercises alone
pain and enhancing function. ing pain, function, range of motion, and in the treatment of individuals with SIS.16

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[ research report ]
Considering that individuals with
SIS present with alterations in scapular Demographic Characteristics
TABLE 1
kinematics, it would also be interesting of the Participants
to know if exercises and manual therapy
affect how the scapula moves during el- Exercise-PlusManual Therapy Group (n = 23) Exercise-Alone Group (n = 23)
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evation of the arm. Few investigations Age, y* 35.96 12.08 32.65 10.73
have assessed whether changes occur in Sex, n
scapular kinematics after a rehabilitation
Male 10 14
protocol in individuals with SIS,41,51,55,63
Female 13 9
and the results are unclear.
This study evaluated the effects of Mass, kg* 67.04 13.12 68.35 10.79
stretching and strengthening exercises, Height, m* 1.69 0.12 1.69 0.02
with and without manual therapy, on Involved shoulder, n
scapular kinematics, function, pain, and Dominant 14 11
mechanical sensitivity in individuals with
Nondominant 9 12
SIS. We hypothesized that manual therapy
Duration of pain, mo 47.09 57.82 (2-204) 38.39 51.10 (2-240)
combined with a protocol of therapeutic
exercises would result in greater benefit *Values are mean SD.

Values are mean SD (range).
as compared to exercises alone. Scapular
Copyright 2015 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

kinematics was considered to be the pri-


mary outcome and upper-limb function, was performed by using a computer- test54; a positive sulcus or apprehension
pain, and mechanical sensitivity were con- generated, randomized list, created by a test indicative of glenohumeral joint
sidered to be secondary outcomes. person not involved in the recruitment laxity42; a positive drop arm test40 sug-
of the participants. After completing all gestive of full-thickness tear; a systemic
METHODS preintervention measurements, the first illness; a corticosteroid injection within
author opened the sealed, opaque enve- 3 months prior to the intervention; or
Design lope and assigned the individual to one of physical therapy within 6 months prior

T
his study was a randomized clin- the intervention groups. The demograph- to the intervention.7 Individuals with a
Journal of Orthopaedic & Sports Physical Therapy

ical trial with 1 blinded assessor. One ic characteristics of the participants are Beck Depression Inventory score higher
examiner, who was blinded to group provided in TABLE 1. than 9 (cutoff score for screening depres-
assignment, assessed mechanical sensi- Shoulder impingement syndrome was sion status)21 were excluded from pain
tivity and pain using a visual analog scale diagnosed based on clinical examination and mechanical sensitivity assessments.11
(VAS). Two additional examiners, who and patient self-report. To be classified This study was registered at www.
were not blinded to group assignment, as having SIS, the participants had to clinicaltrials.gov (NCT02035618) and
collected scapular kinematics data, 1 of have a history of nontraumatic onset of approved by the Ethics Committee of
them performing all palpations during shoulder pain, painful arc during active the Federal University of So Carlos
the digitization process and the other op- elevation of the arm, 1 or more positive (number 270/2010). All participants
erating the computer to collect kinematic SIS tests (Hawkins-Kennedy, Jobe, Neer) received verbal and written explanation
data. All of the participants completed or pain during passive30 or isometric re- of the objectives and methodology of the
the Disabilities of the Arm, Shoulder and sisted external rotation of the arm at 90 study, and those who agreed to partici-
Hand (DASH) questionnaire without of abduction,49,56 and pain with palpa- pate signed an informed-consent agree-
help from the examiners and were blind- tion of the rotator cuff tendons. A com- ment. All outcomes were collected at the
ed to the results of their previous assess- bination of shoulder tests is suggested to Laboratory of Analysis and Intervention
ments throughout the study. provide better diagnostic accuracy.28 All of the Shoulder Complex at the Federal
individuals had to be able to reach 150 University of So Carlos. Interventions
Participants of arm elevation as determined by visual were provided at the university clinics by
Forty-six individuals were randomly as- observation. physical therapists.
signed to 1 of 2 groups: those treated ex- Individuals were excluded if they had
clusively with exercises and those treated a history of clavicle, scapula, or humerus Scapular Kinematics
with the same exercises (FIGURE 1), supple- fracture; a history of rotator cuff surgery; The Flock of Birds (miniBIRD) hardware
mented with manual therapy. Prior to the numbness or tingling of the upper limb (Ascension Technology Corporation,
beginning of the study, group allocation reproduced by the cervical compression Shelburne, VT) integrated with Motion-

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(negative) or posterior (positive) tilt. The were instructed to say stop when the
humeral position with reference to the sensation of pressure changed to pain.9
trunk was determined using the y-x-y Three repetitions were performed, with
sequence. The first rotation defined the a 30-second rest between measurements.
plane of elevation, the second defined the The mean of the 3 repetitions was used
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humeral elevation angle, and the third for the analysis. Pressure pain thresholds
defined internal/external rotation. were assessed bilaterally over the supra-
Considering the standard error of spinatus, infraspinatus, upper trapezius,
measurement observed in a previous levator scapulae, middle deltoid, articu-
study,26 a between-day difference of 4 or lar pillar of the C5-6 zygapophyseal joint
more in scapular kinematics was consid- (assessed due to its relationship with the
ered clinically relevant. shoulder1,18), and tibialis anterior, as a
remote site.1 The exact testing location
Function for each muscle is described elsewhere.1
The Brazilian version of the DASH ques- The reliability of the data obtained with
tionnaire was used to assess function this methodology is considered to be high
of the upper limbs.47 Scores range from (ICC = 0.91; 95% confidence interval
FIGURE 2. Methods for the assessment of scapular 0 to 100, with higher scores indicating [CI]: 0.82, 0.97).10 The order of sides and
kinematics. a worse condition. This version of the locations to be assessed was randomized
Copyright 2015 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

DASH questionnaire has been shown to among individuals.


Monitor software (Innovative Sports be valid and highly reliable, with intrao-
Training, Inc, Chicago, IL) was used to bserver and interobserver intraclass cor- Assessment Procedures
capture and analyze the kinematic data. relation coefficients (ICCs) greater than The participants were assessed within
The 3-D position and orientation of each 0.90.47 A recent study20 showed that a a week before the intervention (prein-
sensor were tracked simultaneously at a decrease of 10 points on the DASH ques- tervention) and at the end of the 4-week
sampling rate of 100 Hz. In a metal-free tionnaire can be considered a clinically intervention (postintervention). At each
environment, within 76 cm of the trans- important improvement. assessment, respondents reported their
mitter, the root-mean-square accuracy of shoulder function by completing the
Journal of Orthopaedic & Sports Physical Therapy

the system is 0.5 for orientation and 0.18 Pain and Mechanical Sensitivity DASH questionnaire, followed by data
cm for position, as reported by the man- Pain was assessed with a VAS, with scores collection of scapular kinematics, pain,
ufacturer. The electromagnetic sensors ranging from 0 (no pain) to 10 (maxi- and PPTs. The PPT assessment was con-
were attached with double-sided adhe- mum pain). Current pain at rest, pain ducted on both the involved and unin-
sive tape to the sternum, to the acromion during shoulder movement, greatest pain volved sides, with the participant seated
of the scapula, and to a thermoplastic cuff during the prior week, and least pain dur- and the region of interest exposed. For all
secured to the distal humerus to track ing the prior week were all assessed. The other assessments, only the involved side
humeral motion, as previously described VAS has been shown to be a reliable and of each participant was measured.
(FIGURE 2).4,25,26,50 The individual stood valid instrument to assess changes in Scapular kinematics was assessed with
with arms relaxed at the side in a neutral pain intensity. Test-retest reliability has the individuals in a relaxed standing posi-
position, with the transmitter directly be- been reported to be between 0.95 and tion in front of the transmitter. Kinematic
hind the shoulder to be tested, while bony 0.97.3,43 A change of 1 point or a percent- motion analysis consisted of selecting the
landmarks on the thorax, scapula, and age change of 15% to 20% is considered scapular data at 30, 60, 90, and 120
humerus were palpated and digitized to clinically important.17 of humerothoracic elevation for both sag-
allow transformation of the sensor data Mechanical sensitivity was measured ittal and scapular plane arm elevation.
to a local anatomically based coordinate with pressure pain threshold (PPT), The sagittal and scapular planes were
system, as recommended by the Interna- which is defined as the minimum pres- standardized using a flat surface to guide
tional Society of Biomechanics.64 sure at which the sensation of pressure movement and ensure the proper plane of
The y-x-z sequence was used to de- changes to pain.19 An algometer (Pain arm elevation. During elevation, individ-
scribe scapular motions relative to the Diagnosis and Treatment Inc, Great uals were instructed to keep their thumb
trunk. The rotations were described as Neck, NY) with a 1-cm2 rubber-tipped pointing toward the ceiling, to slide their
internal (positive) or external (negative) plunger was used to measure PPTs. Pres- hand on the board, and to elevate their
rotation, upward (positive) or down- sure was applied at a rate of 30 kPa/s. arm at a rate such that full elevation
ward (negative) rotation, and anterior For each testing location, the individuals was accomplished over approximately 3

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[ research report ]
seconds. Three complete cycles of move-
A B
ment were completed. Sensors were not
removed or replaced between trials, but
were removed between the preinterven-
tion and postintervention measurement
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sessions. This procedure has been shown


to be reliable during elevation and lower-
ing of the arm in asymptomatic individu-
als and individuals with SIS.26

Interventions
Therapeutic Exercises The therapeutic C D
exercise intervention included 3 stretch-
ing and 3 strengthening exercises (FIGURE
3), performed for both the involved and
uninvolved sides. All exercises were su-
pervised by a physical therapist with at
least 6 years of clinical experience. The
stretching exercises targeted the upper
Copyright 2015 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

trapezius (FIGURE 3A), the pectoralis minor


(FIGURE 3B), and the posterior region of the
shoulder (FIGURE 3C), and were performed E F
as suggested by Camargo et al.7 Each
stretch consisted of 3 repetitions of 30
seconds, with 30 seconds between repeti-
tions.6 The stretches were selected on the
basis of evidence that increased activation
of the upper trapezius and pectoralis mi-
Journal of Orthopaedic & Sports Physical Therapy

nor and posterior shoulder tightness have


been associated with abnormal scapular
kinematics and shoulder pain.5,41,59
FIGURE 3. Stretching exercises: (A) upper trapezius stretch, (B) pectoralis minor stretch, and (C) posterior
Following the stretching exercises,
shoulder stretch. Strengthening exercises: (D) shoulder external rotation, (E) shoulder extension targeting lower
strengthening exercises were completed trapezius strengthening, and (F) shoulder protraction targeting serratus anterior strengthening.
by using 1-m color-coded elastic resis-
tance bands (TheraBand; The Hygenic the maximum amount of external rota- session lasted approximately 45 minutes,
Corporation, Akron, OH) at 3 progres- tion that they were able to. For the lower and the manual therapy techniques were
sive levels of resistance, as indicated by trapezius muscle (FIGURE 3E), the partici- only applied to the involved side. The ap-
the color of the band (red, green, or blue). pants were instructed to perform shoul- plied manual therapy techniques were
Three sets of 10 repetitions for each exer- der extension37 in the prone position. For grade III and IV mobilizations29 that in-
cise were completed, with 1 minute of rest the serratus anterior muscle (FIGURE 3F), cluded arthrokinematic and osteokine-
between sets.7 When the 3 sets were per- the exercise was performed in the supine matic movements for the glenohumeral,
formed easily (without muscle fatigue re- position, with the arm at 90 of flexion scapulothoracic, acromioclavicular, and
ported by the individual), the resistance and the elbow in full extension,38 by hav- sternoclavicular joints and cervical spine,29
was increased by changing the elastic ing the participant protract the scapula and soft tissue techniques (deep frictions,
band. The following exercises were per- and pull the band in the superior direc- kneading), proprioceptive neuromuscu-
formed: external rotation of the shoul- tion. These exercises were selected be- lar facilitation, rhythmic stabilizations,
der7,38 (FIGURE 3D), starting with the elbow cause the evidence supports decreased strain/counterstrain, and contract/relax
in 90 of flexion and the shoulder in ap- activation in these muscles in individu- techniques applied to the affected mus-
proximately 45 of internal rotation, with als with SIS.48 All participants were in- cles. These techniques have been previ-
the arm abducted in the scapular plane structed to perform the exercises in the ously employed to treat SIS.2,37,53
with the aid of a ball.7 In this position, the maximal pain-free range of motion. The manual therapy techniques fo-
participants were instructed to perform Manual Therapy Each manual therapy cused on the shoulder complex, primarily

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a difference in scapular upward rotation
A B
65 65 of 4, with a standard deviation of 4.5.26
Scapular Internal Rotation, deg

Scapular Internal Rotation, deg


60 60 Based on these criteria, at least 21 par-
55 55
ticipants with SIS were required in each
50 50
group. To account for a withdrawal rate
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of 10%, 23 participants were included in


45 45
each group.
40 40
Statistical analysis was conducted
35 35
with SPSS 17.0 software (SPSS Inc, Chi-
30 30
30 60 90 120 30 60 90 120 cago, IL). The Kolmogorov-Smirnov test
Humeral Elevation, deg Humeral Elevation, deg was used to evaluate the distribution of
C D
50 50
data, and all variables showed P>.05. A
2-factor analysis of variance (ANOVA)
Scapular Upward Rotation, deg

Scapular Upward Rotation, deg

40 40
was conducted for the DASH, pain, and
30 30
PPT data, with time (preintervention and
20 20 postintervention) as the within-subject
10 10 factor and group (exercise plus manual
0 0
therapy and exercise alone) as the be-
tween-subject factor. If no group-by-time
Copyright 2015 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

10 10
30 60 90 120 30 60 90 120 interaction was observed, the main effect
Humeral Elevation, deg Humeral Elevation, deg of time was analyzed. A separate 3-factor
E F
20 20
ANOVA was conducted for each scapular
15 15
rotation, with time (preintervention and
Posterior

Posterior

10 10
postintervention) and angle (30, 60,
Scapular Tilt, deg

Scapular Tilt, deg

90, and 120) as within-subject factors


5 5
and group (exercise plus manual therapy
0 0
and exercise alone) as the between-sub-
5 5
Anterior

Anterior

ject factor. If no interactions (time by


Journal of Orthopaedic & Sports Physical Therapy

10 10
angle by group, group by time, angle by
15 15
30 60 90 120 30 60 90 120 time) were observed, the main effect of
Humeral Elevation, deg Humeral Elevation, deg time was analyzed. The Tukey and dk
tests were used for post hoc analysis
Preintervention Postintervention
when necessary. The level of significance
FIGURE 4. Preintervention and postintervention scapular internal rotation (A and B), upward rotation (C and D), was set at .05 for all statistical analyses.
and anterior/posterior tilt (E and F) during elevation of the arm in the sagittal plane for the exercise-plusmanual In cases of missing data due to discon-
therapy group (left) and the exercise-alone group (right). Values are mean SD. tinuation of treatment, the data were an-
alyzed with an intention-to-treat analysis
to address limitations of the glenohumer- were needed.29 Both the assessments and (expectation-maximization method).
al and scapulothoracic joints. However, the application of manual therapy were Between- and within-group effect
the techniques were also provided to the performed by a physical therapist with sizes for all quantitative variables were
shoulder girdle, cervical spine, and upper a manual therapy certification from the measured with the Cohen d coefficient.
thoracic spine, including the costotrans- Madrid Osteopathic School DO (equiva- An effect size greater than 0.8 was con-
verse joints, when necessary.62 lent to 2000 hours of postgraduate train- sidered large, around 0.5 moderate, and
The manual therapy techniques were ing) and more than 5 years of clinical less than 0.2 small.12
implemented according to the clini- experience in treating shoulder patholo-
cal presentation of each individual. The gies with this approach. RESULTS
progression of treatment, as well as the
time ratio between the joint and soft Statistical Analysis Scapular Kinematics

F
tissue procedures, depended on assess- Sample size was determined using ENE IGURES 4 and 5 show the data for
ments during each session, indicating 3.0 software (GlaxoSmithKline, Madrid, scapular kinematics during elevation
when changes in the technique and/or Spain), and was based on a significance of the arm in the sagittal and scapu-
the intensity of the applied technique level of .05 and a power of 0.80 to detect lar planes, respectively, for both groups.

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[ research report ]
TABLE 2 shows the results of the scapular
A B
kinematics data. 55 55

Scapular Internal Rotation, deg

Scapular Internal Rotation, deg


Elevation of the Arm in the Sagittal 50 50
Plane For scapular internal rotation, 45 45
the 3-factor interaction was not signifi- 40 40
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cant (P = .98), nor were the 2-factor in-


35 35
teractions of angle by time (P = .17) and
30 30
group by time (P = .45). The main effect
25 25
of time was significant (P = .01), with less
20 20
internal rotation postintervention. The 30 60 90 120 30 60 90 120
Cohen d coefficient showed small with- Humeral Elevation, deg Humeral Elevation, deg
C D
in- and between-group effect sizes of the 50 50
interventions.
Scapular Upward Rotation, deg

Scapular Upward Rotation, deg


40 40
For scapular upward rotation, the
30 30
3-factor interaction was not significant
(P = .95), nor were the 2-factor interac- 20 20

tions of angle by time (P = .45) and group 10 10


by time (P = .73). The main effect of time 0 0
was significant (P = .02), with greater
Copyright 2015 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

10 10
upward rotation postintervention. The 30 60 90 120 30 60 90 120
Cohen d coefficient showed small with- Humeral Elevation, deg Humeral Elevation, deg
E F
in- and between-group effect sizes of 20 20
interventions. 15 15
Posterior

Posterior
For scapular tilt, the 3-factor inter- 10
Scapular Tilt, deg

Scapular Tilt, deg


10
action was not significant (P = .52), nor
5
was the 2-factor interaction of angle by 5
0
time (P = .74). There was a significant 0
5
Anterior

Anterior
interaction of group by time (P = .001), 5
Journal of Orthopaedic & Sports Physical Therapy

10
where the exercise-plusmanual ther-
15 10
apy group showed more anterior tilt 30 60 90 120 30 60 90 120
at postintervention compared to pre- Humeral Elevation, deg Humeral Elevation, deg
intervention. The Cohen d coefficient
Preintervention Postintervention
showed moderate and small effects
of intervention for the exercise-plus FIGURE 5. Preintervention and postintervention scapular internal rotation (A and B), upward rotation (C and D),
manual therapy group and the exercise- and anterior/posterior tilt (E and F) during elevation of the arm in the scapular plane for the exercise-plusmanual
alone group, respectively. The effect therapy group (left) and the exercise-alone group (right). Values are mean SD.
size of intervention between groups was
moderate. actions of angle by time (P = .70) and small within-group effect of intervention
Elevation of the Arm in the Scapular group by time (P = .87). The main effect for both groups and moderate between-
Plane For scapular internal rotation, the of time was also not significant (P = .06). group effects of intervention.
3-factor interaction was not significant The Cohen d coefficient showed small
(P = 1.00), nor were the 2-factor inter- within- and between-group effect sizes Function of the Upper Limbs
actions of angle by time (P = .23) and of intervention. TABLE 2 shows the results of the DASH
group by time (P = .98). The main effect For scapular tilt, the 3-factor inter- questionnaire. The 2-factor ANOVA re-
of time was significant (P<.001), with action was not significant (P = .51), nor vealed no interaction of group by time
less internal rotation postintervention. was the 2-factor interaction of angle by for the DASH score (P = .25). However,
The Cohen d coefficient showed small time (P = .97). There was a significant the main effect of time was significant
within- and between-group effect sizes group-by-time interaction (P = .01), (P<.001), with lower scores postinterven-
of intervention. where the exercise-plusmanual therapy tion. The Cohen d coefficient showed a
For scapular upward rotation, the group showed more anterior tilt at post large within-group effect of intervention
3-factor interaction was not significant intervention compared to preinterven- and a moderate between-group effect of
(P = 1.00), nor were the 2-factor inter- tion. The Cohen d coefficient showed a intervention.

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Scapular Kinematics During Elevation
TABLE 2 in the Sagittal and Scapular Planes and DASH Score
at Preintervention and Postintervention Evaluations
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Between-Group
Within-Group Within-Group Effect Differences in Between-Group
Movement/Outcome/Group* Preintervention Postintervention Changes Sizes, Cohen d Change Scores Effect Sizes, Cohen d
Sagittal plane elevation
Scapular internal rotation 0.8 (3.5, 5.1) 0.11 (0.47, 0.69)
Exercise plus MT 46.4 8.9 45.3 9.4 1.1 (6.4, 4.3) 0.12 (0.70, 0.46)
Exercise alone 48.3 7.6 46.4 7.4 1.9 (6.4, 2.6) 0.25 (0.83, 0.33)
Scapular upward rotation 0.4 (5.2, 4.4) 0.05 (0.63, 0.53)
Exercise plus MT 19.9 14.8 21.5 14.7 1.6 (7.1, 10.3) 0.11 (0.47, 0.68)
Exercise alone 18.4 13.0 19.6 14.6 1.2 (7.0, 9.4) 0.09 (0.49, 0.66)
Scapular tilt
3.3 (7.2, 0.6) 0.50 (1.08, 0.09)
Exercise plus MT 0.3 8.4 3.3 6.6 3.0 (7.5, 1.5) 0.40 (0.97, 0.19)
Exercise alone 0.6 7.1 0.9 7.9 0.3 (4.2, 4.8) 0.03 (0.54, 0.62)
Copyright 2015 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

Scapular plane elevation


Scapular internal rotation 0.0 (4.4, 4.3) 0.01 (0.58, 0.57)
Exercise plus MT 36.9 8.3 34.8 9.8 2.1 (7.5, 3.3) 0.23 (0.81, 0.35)
Exercise alone 38.0 6.4 35.9 6.3 2.1 (5.9, 1.7) 0.33 (0.91, 0.26)
Scapular upward rotation 0.2 (5.5, 5.0) 0.02 (0.60, 0.55)
Exercise plus MT 20.5 15.2 21.9 15.1 1.4 (7.6, 10.4) 0.09 (0.49, 0.67)
Exercise alone 20.1 13.5 21.3 15.2 1.2 (7.3, 9.7) 0.08 (0.50, 0.66)
Scapular tilt 2.5 (6.5, 1.5) 0.37 (0.95, 0.22)
Journal of Orthopaedic & Sports Physical Therapy

Exercise plus MT 0.1 8.1 2.2 7.0 2.1 (6.6, 2.4) 0.28 (0.85, 0.31)
Exercise alone 1.6 7.3 1.9 8.3 0.4 (4.3, 4.9) 0.04 (0.62, 0.54)
DASH score 3.9 (10.5, 2.8) 0.34 (0.92, 0.25)
Exercise plus MT 25.3 16.1 12.4 12.3 12.9 (17.6, 8.2) 0.90 (1.49, 0.28)
Exercise alone 20.8 10.4 11.7 9.5 9.1 (13.8, 4.3) 0.91 (1.50, 0.29)
Abbreviations: DASH, Disabilities of the Arm, Shoulder and Hand questionnaire; MT, manual therapy.
*23 patients in each group.

Values are mean SD degrees.

Values in parentheses are 95% confidence interval.

Negative numbers indicate anterior tilt of the scapula.

Pain Intensity pain was less postintervention. The VAS In contrast, there was a group-by-
Two patients from the exercise-plus scores for current pain at rest were under time interaction for least pain during
manual therapy group and 3 from the 20 mm on average, and the within-group the last week (P = .02). The post hoc
exercise-alone group were excluded from effect size for pain at rest was moderate, analyses indicated a decrease in pain
the pain and PPT analyses due to high with the lower bound of the 95% CI close level postintervention for the exercise-
scores on the Beck Depression Inventory. to the absence of effect, and there was a plusmanual therapy group only. The
The 2-factor ANOVA revealed no group- small effect size between groups. There Cohen d coefficient showed an absence
by-time interaction for current pain at were large within-group effect sizes and of effect for the exercise-alone group, a
rest (P = .38), pain during movement (P a nonexistent between-group effect size moderate effect for the exercise-plus
= .94), and greatest pain during the last for the variables of pain during move- manual therapy group, and a moderate
week (P = .71). For all 3 outcomes, there ment and greatest pain during the last effect size for the between-group com-
was a main effect of time (P<.01), where week (TABLE 3). parison (TABLE 3).

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[ research report ]
Pain and Pressure Pain Thresholds at Preintervention
TABLE 3
and Postintervention Evaluations

Between-Group
Within-Group Within-Group Effect Differences in Between-Group
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Measure/Outcome/Group* Preintervention Postintervention Changes Sizes, Cohen d Change Scores Effect Sizes, Cohen d
Pain VAS (0-100), mm
Current pain at rest 6.3 (20.9, 8.1) 0.28 (0.89, 0.34)
Exercise plus MT 19.3 27.6 6.3 11.6 13.0 (25.5, 0.5) 0.61 (1.22, 0.02)
Exercise alone 10.3 14.1 3.6 6.1 6.7 (19.5, 6.2) 0.62 (1.24, 0.03)
Pain during movement 0.6 (17.3, 18.3) 0.02 (0.59, 0.63)
Exercise plus MT 41.0 35.2 16.2 27.4 24.8 (40.1, 9.4) 0.80 (1.40, 0.14)
Exercise alone 38.8 21.1 13.4 12.3 25.4 (41.1, 9.7) 1.47 (2.14, 0.75)
Greatest pain last week 2.9 (18.5, 12.7) 0.12 (0.73, 0.50)
Exercise plus MT 53.9 33.0 23.6 29.5 30.3 (43.7, 16.8) 0.97 (1,59, 0.31)
Exercise alone 54.2 19.5 26.8 22.5 27.4 (41.2, 13.6) 1.31 (1.96, 0.61)
Least pain last week 9.6 (17.7, 1.5) 0.75 (1.37, 0.10)
Copyright 2015 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

Exercise plus MT 15.6 17.7 5.4 9.4 10.2 (17.2, 3.2) 0.72 (1.33, 0.08)
Exercise alone 6.4 7.3 5.8 7.7 0.7 (7.8, 6.5) 0.09 (0.70, 0.54)
Pressure pain threshold, kg/cm 2

Involved upper trapezius 0.5 (0.3, 1.2) 0.41 (0.21, 1.03)


Exercise plus MT 2.9 1.6 3.0 1.9 0.1 (0.5, 0.8) 0.07 (0.55, 0.66)
Exercise alone 3.1 1.9 3.8 1.6 0.6 (0.0, 1.3) 0.39 (0.24, 1.02)
Uninvolved upper trapezius 0.1 (1.0, 0.8) 0.09 (0.70, 0.52)
Journal of Orthopaedic & Sports Physical Therapy

Exercise plus MT 2.8 1.5 3.3 1.8 0.5 (0.3, 1.3) 0.30 (0.31, 0.91)
Exercise alone 3.4 2.1 3.9 1.4 0.5 (0.3, 1.3) 0.29 (0.35, 0.90)
Involved infraspinatus 1.4 (0.5, 2.3) 0.96 (0.30, 1.59)
Exercise plus MT 4.2 1.7 4.2 1.8 0.1 (0.9, 0.8) 0.01 (0.60, 0.60)
Exercise alone 4.1 1.8 5.5 2.5 1.4 (0.5, 2.2) 0.64 (0.01, 1.26)
Uninvolved infraspinatus 0.5 (0.3, 1.3) 0.43 (0.20, 1.04)
Exercise plus MT 4.0 1.8 4.3 1.7 0.3 (0.3, 1.0) 0.18 (0.44, 0.77)
Exercise alone 4.7 1.9 5.5 2.2 0.8 (0.1, 1.5) 0.42 (0.24, 1.01)
Involved supraspinatus 0.1 (1.1, 1.3) 0.06 (0.55, 0.67)
Exercise plus MT 3.3 1.9 4.1 2.8 0.9 (0.2, 1.9) 0.35 (0.28, 0.94)
Exercise alone 4.0 2.5 5.0 2.1 1.0 (0.1, 2.1) 0.44 (0.19, 1.05)
Table continues on page 993.

Pressure Pain Threshold side (involved or uninvolved) tested. The pattern was for the involved infraspinatus
The 2-factor ANOVAs consistently re- within-group effect sizes were higher for PPT, which showed a significant group-
vealed no group-by-time interaction and the exercise-alone group, although all by-time interaction (P = .004), with no
a significant main effect of time for PPTs Cohen effect-size indices of this group change between preintervention and
measured in the shoulder region, ex- and of the between-group comparisons postintervention being noted for the ex-
cept for the involved-side infraspinatus. could be considered small, with the lower ercise-plusmanual therapy group; there
The main effect of time was a result of bound of the 95% CI being below zero, was a significant increase in PPT (P<.01)
the PPTs being higher postintervention, as can be observed in the within-group and a moderate within-group effect size
independent of the group (exercise plus effect sizes of the exercise-plusmanual for the exercise-alone group. For this site,
manual therapy or exercise alone) or therapy group. The only exception to this the between-group difference was 1.4 kg/

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Pain and Pressure Pain Thresholds at Preintervention
TABLE 3
and Postintervention Evaluations (continued)

Between-Group
Within-Group Within-Group Effect Differences in Between-Group
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Measure/Outcome/Group* Preintervention Postintervention Changes Sizes, Cohen d Change Scores Effect Sizes, Cohen d
Uninvolved supraspinatus 0.5 (0.2, 1.3) 0.48 (0.15, 1.09)
Exercise plus MT 3.5 1.6 3.8 2.1 0.4 (0.3, 1.0) 0.17 (0.45, 0.76)
Exercise alone 4.0 2.2 5.1 2.0 1.1 (0.4, 1.7) 0.51 (0.12, 1.14)
Involved deltoid 0.1 (0.5, 0.6) 0.08 (0.54, 0.69)
Exercise plus MT 2.1 1.6 2.6 1.8 0.5 (0.0, 1.0) 0.30 (0.32, 0.90)
Exercise alone 3.0 1.5 3.6 1.7 0.6 (0.1, 1.1) 0.36 (0.26, 0.99)
Uninvolved deltoid 0.3 (0.4, 0.9) 0.20 (0.42, 0.81)
Exercise plus MT 2.2 1.4 2.5 1.9 0.3 (0.3, 0.9) 0.20 (0.43, 0.78)
Exercise alone 3.0 1.5 3.6 1.7 0.7 (0.0, 1.3) 0.39 (0.26, 0.99)
Involved levator scapulae 0.2 (0.4, 0.8) 0.18 (0.43, 0.79)
Exercise plus MT 2.6 1.4 3.3 1.7 0.7 (0.2, 1.3) 0.46 (0.17, 1.05)
Copyright 2015 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

Exercise alone 3.2 1.5 4.1 1.6 0.9 (0.3, 1.5) 0.59 (0.06, 1.20)
Uninvolved levator scapulae 0.1 (0.5, 0.6) 0.06 (0.55, 0.67)
Exercise plus MT 2.8 1.5 3.3 1.6 0.5 (0.0, 0.9) 0.30 (0.29, 0.92)
Exercise alone 3.5 1.2 4.0 1.4 0.5 (0.0, 1.0) 0.39 (0.25, 1.00)
Involved C5-6 0.7 (0.1, 1.2) 0.70 (0.05, 1.31)
Exercise plus MT 1.7 1.1 1.7 1.2 0.1 (0.5, 0.5) 0.00 (0.60, 0.60)
Exercise alone 1.9 1.1 2.5 0.9 0.6 (1.3, 2.5) 0.62 (0.05, 1.22)
Journal of Orthopaedic & Sports Physical Therapy

Uninvolved C5-6 0.6 (0.2, 1.0) 1.03 (0.36. 1.66)


Exercise plus MT 1.8 1.2 1.8 1.2 0.0 (0.4, 0.3) 0.00 (0.60, 0.60)
Exercise alone 1.9 1.0 2.5 0.9 0.6 (0.2, 0.9) 0.62 (0.02, 1.25)
Involved tibialis anterior 0.2 (1.4, 1.8) 0.09 (0.52, 0.70)
Exercise plus MT 5.1 2.2 5.8 3.3 0.7 (0.7, 2.0) 0.24 (0.36, 0.85)
Exercise alone 5.9 2.0 6.8 2.3 0.9 (0.5, 2.3) 0.41 (0.22, 1.04)
Uninvolved tibialis anterior 0.6 (0.5, 1.8) 0.36 (0.26, 0.97)
Exercise plus MT 5.0 1.9 5.0 2.1 0.0 (1.0, 0.9) 0.00 (0.61, 0.61)
Exercise alone 5.8 2.0 6.4 2.5 0.6 (0.4, 1.6) 0.27 (0.36, 0.88)
Abbreviations: MT, manual therapy; VAS, visual analog scale.
* Exercise plus MT, n = 21; exercise alone, n = 20.

Values are mean SD.

Values in parentheses are 95% confidence interval.

cm2, with a large effect size. All data for P = .01; uninvolved side, P<.01) and a for the exercise-alone group and non-
PPTs are provided in TABLE 3. significant difference between groups existent for the exercise-plusmanual
There was a significant group-by-time postintervention (involved side, P = .017; therapy group. For the between-group
interaction for PPTs measured over C5-6 uninvolved side, P = .049), where the comparisons, the differences were 0.6 kg/
on both the involved and uninvolved PPTs of the exercise-alone group were cm2 or greater, and the Cohen index was
sides (P = .03 and P = .04, respectively). significantly higher than those of the moderate for the involved side and large
For both sides, post hoc analyses indi- exercise-plusmanual therapy group. for the uninvolved side.
cated a significant increase in PPTs for The preintervention-to-postintervention Finally, PPTs measured over the an-
the exercise-alone group (involved side, within-group effect sizes were moderate terior tibialis muscle bilaterally showed

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[ research report ]
neither a significant interaction (in- group during humeral elevation in the Although studies have supported
volved, P = .77; uninvolved, P = .25) nor sagittal plane is noteworthy. An increase the use of manual therapy in addition
a main effect of time (involved, P = .06; in anterior tilt has been suggested to to an exercise protocol as a way to de-
uninvolved, P = .32). Accordingly, with- increase the contact forces between the crease pain in individuals with shoulder
in- and between-group effect sizes were posterosuperior labrum and rotator pain,2,13,53 the results of the present study
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small or nonexistent. cuff.58 Although the current study did not do not support this premise. Overall, in
use thrust manipulation techniques, a re- the literature, there continues to be a lack
DISCUSSION cent study27 has shown greater scapular of agreement about the effectiveness of
anterior tilt immediately after thoracic manual therapy as a component of treat-

T
his study showed that the addi- manipulation in asymptomatic individu- ment for SIS.8,16,34
tion of manual therapy to an exercise als. As such, potential effects of different Mechanical sensitivity in the shoul-
protocol does not further enhance manual therapy techniques on scapular der region improved bilaterally in both
improvements in pain, function, or scap- tilt deserve future attention, as results groups after the 4-week intervention, in-
ular kinematics after 4 weeks of interven- from the present study are not conclusive dependent of the intervention, again in-
tion in individuals with SIS. In fact, for in suggesting that manual therapy may dicating that manual therapy provided no
most outcomes, the exercise-alone group cause biomechanical harm to the scapula. additional benefits. Pressure pain thresh-
tended to demonstrate greater improve- old over the tibialis anterior, considered
ment than the exercise-plusmanual Function of the Upper Limbs a remote location, did not change over
therapy group. However, caution should The outcomes of the DASH question- time, which may indicate the absence of
Copyright 2015 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

be taken when interpreting the results, naire showed significantly better func- widespread sensitivity alterations in these
because the wide CIs of some variables tion of the involved upper extremity after patients or the inability of the interven-
indicate that individuals may or may not the intervention for both groups. How- tions to alter PPTs at a remote location.
benefit from adding manual therapy to an ever, only the change for the exercise- Walton et al61 established a minimal
exercise program. Previous studies have plusmanual therapy group (mean, 12.9 detectable change of between 0.45 and
shown greater decreases in pain when points) exceeded the minimal detectable 1.13 kg/cm2 for locations over the upper
exercises were combined with techniques change reported by Franchignoni et al.20 trapezius and between 1.0 and 1.7 kg/cm2
of manual therapy.2,53 To our knowledge, It is important to consider that the ex- for locations over the tibialis anterior for
no previous studies have analyzed the ef- ercise-alone group started with a lower individuals with neck pain. In the pres-
Journal of Orthopaedic & Sports Physical Therapy

fects of the combination of exercise and score on the DASH questionnaire, result- ent study, differences in PPTs between
manual therapy on scapular kinematics ing in less room for improvement. preintervention and postintervention for
and mechanical hypersensitivity. shoulder and C5-6 locations bilaterally
Pain were within or above the upper trapezius
Scapular Kinematics Patients in both intervention groups re- PPT relevant differences,61 but differenc-
Studies have assessed the effects of physi- ported decreased pain after the interven- es for measurements over the tibialis an-
cal therapy intervention on scapular ki- tion. The least pain during the past week terior did not achieve the lower bound of
nematics.27,31,41,46,51,55,63 Although these was the only variable that showed greater the reported minimal detectable change.
investigations used different interven- benefits from adding the manual therapy The mechanical sensitivity of the
tions and methodologies, most showed techniques. Although the pain level for shoulder has been reported to be altered
either no evidence of improvement in the patients in the exercise-plusmanual in shoulder pain conditions,33 specifically
scapular motion31,41,63 or changes that therapy group decreased by more than 1 in SIS.1 Both peripheral1 and central sen-
could not be considered clinically im- point (10 mm), the low initial pain value sitization33 processes, which are contribu-
portant.27,46 In the present investigation, for the exercise-alone group (6.4 mm) tors to the development and maintenance
changes in scapular kinematics after the may explain the significant interaction. of chronic pain,23 have been reported in
4-week intervention are inconclusive due For the current level of pain during individuals with SIS. It should be high-
to the wide CIs. movement and the greatest amount of lighted that both interventions applied in
Although some statistically signifi- pain during the prior week, preinterven- the present study reduced mechanical hy-
cant differences were found in scapular tion-to-postintervention improvements peralgesia, resulting in PPT scores within
kinematics from preintervention to post exceeded the reported minimal clinically normal values based on a similar control/
intervention, these were not considered important change,17 with differences of asymptomatic sample,1 postintervention.
clinically meaningful. However, the in- more than 2.5 points (25 mm). This is an Thus, the results of the present study are
crease in anterior scapular tilt observed improvement of better than 50%, which consistent with the presence and resolu-
for the exercise-plusmanual therapy corresponds to large effect sizes. tion of segmental (C5-6 PPT effect for

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the exercise-alone group) and bilateral with the exception of scapular tilt during dx.doi.org/10.1097/AJP.0b013e3182652d65
sensitization (decrease of PPTs in both arm elevation in the sagittal plane. 2. B  ang MD, Deyle GD. Comparison of supervised
involved and uninvolved sides), and show exercise with and without manual physical
no evidence of the presence of central CONCLUSION therapy for patients with shoulder impinge-
ment syndrome. J Orthop Sports Phys Ther.
sensitization (absence of PPT changes 2000;30:126-137. http://dx.doi.org/10.2519/

T
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over the tibialis anterior). Although the he findings of this study indi- jospt.2000.30.3.126
lack of benefits of adding manual therapy cate that the addition of manual 3. Bijur PE, Silver W, Gallagher EJ. Reliability of the
visual analog scale for measurement of acute
was an unexpected result, other authors therapy to an exercise protocol does
pain. Acad Emerg Med. 2001;8:1153-1157.
have previously reported a similar lack of not provide added benefits to improving 4. Borstad JD, Ludewig PM. Comparison of scapu-
effects of manual therapy (mobilization pain and function in individuals with SIS. lar kinematics between elevation and lowering
with movement) in altering PPTs in in- Given the large improvement in pain and of the arm in the scapular plane. Clin Biomech
(Bristol, Avon). 2002;17:650-659.
dividuals with SIS.57 function and the absence of changes in
5. Borstad JD, Ludewig PM. The effect of long
This study has some limitations. Indi- scapular kinematics postintervention, versus short pectoralis minor resting length on
viduals with different baseline conditions it appears that improvements in pain scapular kinematics in healthy individuals. J Or-
may respond differently to treatments, and function are not likely explained by thop Sports Phys Ther. 2005;35:227-238. http://
dx.doi.org/10.2519/jospt.2005.35.4.227
as described when peripheral or central changes in scapular motion. However,
6. Camargo PR, Alburquerque-Sendn F, Salvini TF.
sensitization processes exist.24 Further, it is possible that some individuals may Eccentric training as a new approach for rota-
the interventions have shown differ- or may not benefit from the addition tor cuff tendinopathy: review and perspectives.
ent effects depending on the outcome. of manual therapy due to the wide CIs World J Orthop. 2014;5:634-644. http://dx.doi.
found for the scapular kinematic data. t
Copyright 2015 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

org/10.5312/wjo.v5.i5.634
It remains unknown if a longer period
7. Camargo PR, Haik MN, Ludewig PM, Filho
of intervention could lead to clinically RB, Mattiello-Rosa SM, Salvini TF. Effects
meaningful effects on kinematics. Stud- KEY POINTS of strengthening and stretching exercises
ies with different periods of intervention FINDINGS: The findings of this study indi- applied during working hours on pain and
physical impairment in workers with sub-
may help to clarify this point. One may cate that the addition of manual therapy
acromial impingement syndrome. Physiother
argue that not blinding the examiners to an exercise protocol does not provide Theory Pract. 2009;25:463-475. http://dx.doi.
collecting kinematic data can be a limi- added benefits to improving pain and org/10.3109/09593980802662145
tation. We believe that this fact hardly function in individuals with SIS. The 8. Camarinos J, Marinko L. Effectiveness of
manual physical therapy for painful shoul-
introduced bias into the results, because absence of change in scapular kinematics
der conditions: a systematic review. J Man
Journal of Orthopaedic & Sports Physical Therapy

the data were not collected directly by the postintervention suggests that improve- Manip Ther. 2009;17:206-215. http://dx.doi.
examiner but had to undergo computer ments in pain and function are not likely org/10.1179/106698109791352076
processing, decreasing the examiners explained by changes in scapular motion. 9. Chesterton LS, Barlas P, Foster NE, Baxter
GD, Wright CC. Gender differences in pres-
ability to influence the outcomes. Future IMPLICATIONS: The results suggest that an
sure pain threshold in healthy humans. Pain.
research should also include assessment exercise-based program should be the 2003;101:259-266.
of muscle activation. primary intervention for this condition 10. Chesterton LS, Sim J, Wright CC, Foster NE.
There is limited knowledge with re- and that the addition of manual therapy Interrater reliability of algometry in measur-
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[ research report ]
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88-94. [CrossRef]
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