[ research report ]

PAUL E. MINTKEN, DPT1,2 • AMY W. MCDEVITT, DPT1,3 • JOSHUA A. CLELAND, PT, PhD4
ROBERT E. BOYLES, PT, DSc5 • AMBER R. BEARDSLEE, DPT6 • SCOTT A. BURNS, DPT7,8
MATTHEW D. HABERL, DPT9 • LAUREN A. HINRICHS, DPT10 • LORI A. MICHENER, PT, PhD11

Cervicothoracic Manual Therapy Plus

Exercise Therapy Versus Exercise Therapy
Alone in the Management of Individuals
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With Shoulder Pain: A Multicenter

Randomized Controlled Trial

T
he point prevalence of
TTSTUDY DESIGN: Multicenter randomized using the global rating of change (GROC) and the
shoulder pain has been re­
controlled trial. Patient Acceptable Symptom State (PASS), using
Copyright © 2016 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

ported to range from 7%

TTBACKGROUND: 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.
TTOBJECTIVES: To compare the effects of cervi-
cothoracic manual therapy and exercise therapy to
those of exercise therapy alone in individuals with
shoulder pain.
Journal of Orthopaedic & Sports Physical Therapy®
chi-square tests of independence.
TTRESULTS: There were no significant 2-way to 26% in the general pop­
interactions of group by time or main effects by ulation, with a lifetime prevalence
group for pain or disability. Both groups improved
significantly on the SPADI, numeric pain-rating of up to 67%.40 Furthermore, several au-
scale, and QuickDASH. Secondary outcomes thors have reported low rates of perceived
of success on the GROC and PASS significantly recovery for individuals with shoulder
favored the manual therapy–plus-exercise group at
pain.7,16,73,78 The prognosis is generally
4 weeks (P = .03 and P<.01, respectively) and on
the GROC at 6 months (P = .04).
poor, with recovery rates ranging from

49% to 59% at an 18-month follow-up.16,78

TTMETHODS: 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 exer-
cise 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
TTCONCLUSION: Adding 2 sessions of high-dose
cervicothoracic manual therapy to an exercise pro-
gram 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.
TTLEVEL 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
TTKEY WORDS: clinical trial, manipulation,
mobilization, rehabilitation
Rekola et al57 reported that 25% of indi-
viduals with neck/shoulder pain expe-
rienced a recurrence within 12 months.
This is important, as the direct costs for
the treatment of shoulder dysfunction in
the United States in 2000 totaled $7 bil-
lion,43 and Kuijpers et al38 reported that
chronic shoulder pain accounts for 74% of
the total shoulder-pain health care costs.
Exercise has been a mainstay in the
treatment of shoulder disorders, with
several systematic reviews reporting sta-
tistically and clinically important effects
of exercise on pain and disability in indi-

1
Department of Physical Therapy, University of Colorado School of Medicine, Aurora, CO. 2Wardenburg Health Center at the University of Colorado Boulder, Boulder, CO. 3University
of Colorado Health, Sports Physical Therapy, and Rehabilitation at the University of Colorado Hospital, Denver, CO. 4Department of Physical Therapy, Franklin Pierce University,
Manchester, NH. 5School of Physical Therapy, University of Puget Sound, Tacoma, WA. 6Northern Navajo Medical Center, Shiprock, NM. 7Department of Physical Therapy, Temple
University, Philadelphia, PA. 8Select Medical Inc, Conshohocken, PA. 9Sports Medicine Physical Therapy Department, Gundersen Health System, La Crosse, WI. 10Cascade Sports
Injury Prevention, Arvada, CO. 11COOR Laboratory, Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA. Funding was provided by
the Orthopaedic Section of the American Physical Therapy Association. The funding agency had no role in the study design, writing the manuscript, or the decision to submit for
publication. This study was approved by the Colorado Multiple Institutions Review Board, Temple University Institutional Review Board, and the Northern Navajo Medical Center
Institutional Review Board. This trial was registered at ClinicalTrials.gov (NCT01571674). 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 Paul Mintken, University of Colorado
School of Medicine, 13121 East 17th Avenue, C-244, Aurora, CO 80045. E-mail: Paul.mintken@ucdenver.edu t Copyright ©2016 Journal of Orthopaedic & Sports Physical Therapy®

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 [ research report
viduals with shoulder pain.1,36,37 The most
recent systematic review by Abdulla et al1
found that supervised strengthening and
stretching were as effective as corticoste-
roid injections or multimodal care in the
management of impingement and non-
specific shoulder pain. Multimodal care,
which includes manual therapy and ex-
ercise, has also been reported to improve
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outcomes in individuals with shoulder
pain.3,18,26,70 Traditionally, the treatment
of shoulder pain has been directed to-
ward the glenohumeral joint, but this
does not take into account the important
role of adjacent structures such as the
cervicothoracic spine and adjacent ribs.
“Regional interdependence” is defined by
Wainner et al74 as “the concept that seem-
ingly unrelated impairments in a remote
Copyright © 2016 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
anatomical region may contribute to, or
be associated with, the patient’s primary
complaint.” There is a growing body of
evidence suggesting that this concept
has some validity in the management of
patients with shoulder pain.2,3,5,9,42,46 Indi-
viduals with shoulder pain often present
with impaired mobility in the cervico-
thoracic spine, and these impairments
Journal of Orthopaedic & Sports Physical Therapy®
have been reported to impact patient
outcomes.50-52,55,66,67 Sobel et al66 reported
that over 40% of patients with shoulder
pain had impairments of the cervicotho-
racic spine and adjacent ribs. Addition-
ally, Norlander et al50,51 and Norlander
and Nordgren52 reported a significant
correlation between impaired mobil-
ity in the cervicothoracic spine and the
development of neck/shoulder pain. Im-
pairments in this region triple the risk of
developing shoulder pain and may nega-
tively affect outcomes.5,50-52,66
Current evidence suggests that man-
ual therapy interventions (both high-ve-
locity and low-velocity techniques) may
be helpful in the treatment of individuals
with shoulder pain.3,8-11,13,17,29,35,46,60,61,72,75,77
A recent systematic review by Desjar-
dins-Charbonneau et al17 concluded that
manual therapy may decrease pain in
patients with rotator cuff tendinopathy;
however, it is unclear whether it can im-
prove function. Several studies have in-
618 | august 2016 | volume 46 | number 8 | journal of orthopaedic & sports physical therapy
46-08 Mintken.indd 618
cluded cervicothoracic manual therapy
in addition to other interventions in the
management of individuals with shoul-
der pain.3,5,9,46,58,68,77 Bergman and col-
leagues5 reported increased rates of “full
recovery” and improvement in disability
at 52 weeks when comparing usual med-
ical care by a primary care physician to
usual medical care plus manual therapy
to the cervicothoracic spine and rib cage
in individuals with shoulder pain. Ad-
ditionally, Boyles et al9 found that indi-
viduals with impingement syndrome who
received thoracic spine thrust manipula-
tion demonstrated significant improve-
ments in pain and disability 48 hours
after treatment. Strunce et al68 reported
that thoracic and rib manipulation was
associated with improved pain and range
of motion (ROM) in patients with shoul-
der pain. Mintken et al46 developed a
clinical prediction rule for individuals
with a primary complaint of shoulder
pain who demonstrated meaningful im-
provement in pain and disability follow-
ing cervicothoracic manual therapy. This
prospective single-arm trial found that if
3 or more out of 5 prognostic variables
were present (pain-free shoulder flexion
less than 127°, shoulder internal rota-
tion less than 53° at 90° of abduction,
negative Neer test, no medication use for
shoulder pain, and symptoms present for
less than 90 days), the chance of experi-
encing improvement following manual
therapy improved from 61% to 89% (pos-
itive likelihood ratio  =  5.3). Wassinger et
al76 found that manual therapy directed
at the cervicothoracic region acutely in-
creased pressure pain thresholds and
decreased pain in individuals with ex-
perimentally induced shoulder pain. In
a recent systematic review, Peek et al54
reported that thoracic manual therapy
accelerated recovery and reduced pain
and disability in individuals with shoul-
der pain immediately and for up to 1 year
when compared to usual care. They con-
cluded that further, high-quality random-
ized controlled trials (RCTs) should be
conducted to investigate the effect of tho-
racic manual therapy for the treatment of
]
shoulder pain.54 Brudvig et al10 reported
in a systematic review that current evi-
dence is inconclusive with respect to the
beneficial effects of therapeutic exercise
combined with joint mobilization versus
therapeutic exercise alone for reduc-
ing pain, increasing ROM and function,
and limiting disability in patients with
shoulder dysfunction. To our knowledge,
no studies have compared the effective-
ness of a comprehensive stretching and
strengthening program combined with
cervicothoracic manual therapy to that
of exercise alone in the treatment of
shoulder pain. Therefore, the purpose
and objective of this RCT was to exam-
ine the effects of cervicothoracic manual
therapy plus exercise versus those of ex-
ercise alone in individuals with a primary
complaint of shoulder pain.
METHODS
Participants
C
onsecutive individuals with a
primary complaint of shoulder
pain who presented to 1 of 6 physi-
cal therapy clinics across the United
States (University of Colorado Anschutz
Medical Campus, Aurora, CO; Univer-
sity of Colorado Wardenburg Health
Center, Boulder, CO; Cherry Creek
Wellness Center, Denver, CO; Temple
Faculty Physical Therapy Clinic, Temple
University, Philadelphia, PA; Northern
Navajo Medical Center, Shiprock, NM;
and Gundersen Health Sports Medicine
Clinic, Onalaska, WI) between March
2012 and March 2014 and who met the
inclusion/exclusion criteria were invited
to participate in the study. Inclusion
criteria required participants to be be-
tween the ages of 18 and 65 years, with
a primary report of shoulder pain (de-
fined as pain between the neck and the
elbow at rest or during movement of the
arm) and a baseline Shoulder Pain and
Disability Index (SPADI) score of 20%
or greater. Exclusion criteria were any
contraindication to manipulative thera-
py or serious pathology (tumor, fracture,
metabolic diseases, rheumatoid arthri-
7/20/2016 4:51:49 PM

Consecutive patients with
shoulder pain screened
for eligibility, n = 242
Agreed to participate and
signed informed consent,
n = 140
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Not eligible, n = 102
• SPADI <20%, n = 42
• Unable to comply with
treatment schedule, n = 19
• Refused to participate,
n = 12
• 2 or more neurological
findings, n = 7
• Age <18 or >65 y, n = 5
• Bilateral upper extremity
trial was registered at ClinicalTrials.gov
(NCT01571674).
Examination Procedures
Self-report Measures All individuals
completed self-report instruments to as-
sess pain and shoulder disability for the
primary outcome measures. The primary
outcome measure of shoulder disability

symptoms, n = 4 was the SPADI,59 a 13-item, self-admin-

Randomized, n = 140
Manual therapy plus
exercise, n = 70
Received intervention, n = 63
1-wk Follow-up
Exercise, n = 70
Received intervention, n = 64
• Adhesive capsulitis, n = 3
• Red flags, n = 3
• Contraindications to
manual therapy, n = 2
• Central nervous system
involvement, n = 2
• Trauma to thoracic spine
≤6 wk, n = 1
• Insufficient English-
language skills, n = 1
• Prior surgery, n = 1
istered questionnaire consisting of a pain
domain with 5 questions and a disability
domain with 8 questions. Each section is
scored from 0% to 100%, and sections
are combined for a total score of 0% (no
pain and disability) to 100% (maximum
pain and disability). Test-retest reliability
of the SPADI has been reported to range
from 0.84 to 0.91 and the minimal clini-

Lost to follow-up, n = 7 Lost to follow-up, n = 6

Copyright © 2016 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

• Cost of care, n = 3
• Unable to comply with
treatment schedule, n = 3
• Improved symptoms, n = 1
Received intervention, n = 60
Lost to follow-up, n = 10
• Cost of care, n = 3
4-wk Follow-up
• Unable to comply with cally important difference (MCID) from
treatment schedule, n = 3 8 to 13.2 points.62
• Cost of care, n = 2 A secondary measure of upper extrem-
• Moved, n = 1
ity disability was the shortened version
of the Disabilities of the Arm, Shoulder
and Hand questionnaire (QuickDASH),
Received intervention, n = 60
Lost to follow-up, n = 10 an 11-item, self-report questionnaire that
• Did not return, n = 3 assesses symptoms and physical function

• Improved symptoms, n = 2 • Cost of care, n = 2 in individuals with disorders of the upper

Journal of Orthopaedic & Sports Physical Therapy®

• Did not return, n = 2
• Unable to comply with
treatment schedule, n = 2
• Received injection, n = 1
6-mo Follow-up
• Unable to comply with limb.4 The QuickDASH is scored from
treatment schedule, n = 2
• Moved, n = 1 0% to 100%, with 0% as no disability and
• Received injection, n = 1 100% as maximum disability. The Quick-
• Received surgery, n = 1 DASH has demonstrated reliability, valid-
ity, and responsiveness when used as a tool
to measure dysfunction in individuals with

Assessed, n = 57 Assessed, n = 57 upper extremity disorders,27 with test-

Lost to follow-up, n = 3
• Did not return follow-up
questionnaire, n = 3
FIGURE 1. Flow diagram of subject recruitment and retention. Abbreviation: SPADI, Shoulder Pain and Disability
Index.
tis, osteoporosis, history of prolonged
steroid use) identified during the physi-
cal examination or in the individuals’
medical intake form. Specific exclusion
criteria included recent trauma to the
cervical or thoracic region, acute fracture
in the shoulder and/or thoracic region,
diagnosis of cervical spinal stenosis, bi-
lateral upper extremity symptoms, prior
surgery to the cervical or thoracic spine,
adhesive capsulitis, evidence of central
Lost to follow-up, n = 3
• Did not return follow-up
questionnaire, n = 3
nervous system (CNS) involvement (2
or more positive neurologic signs con-
sistent with nerve root compression), or
the inability to comply with treatment
and follow-up schedule. See FIGURE 1 for
a flow diagram of subject recruitment
and retention. The Institutional Review
Boards at each of the respective clinics
approved the study, and all eligible par-
ticipants provided informed consent pri-
or to their enrollment in the study. This
retest reliability of 0.90 and an MCID of
8.0% in individuals with shoulder pain.48
An 11-point numeric pain-rating scale
(NPRS) was the primary outcome mea-
sure of pain intensity.31 The NPRS was
anchored on the left with the phrase “no
pain” (score of 0) and on the right with
the phrase “worst imaginable pain” (score
of 10). The NPRS has been shown to be
reliable and valid for the assessment of
shoulder pain, with an MCID between
1.1 and 2.2 points.21,31,32,44,56 Individuals
rated their current level of pain, as well
as their lowest and highest pain level in
the previous 24 hours. The average of the
3 ratings was used to represent the indi-
vidual’s level of pain.

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 [ research report
The secondary outcome measure
of the 15-point global rating of change
(GROC) scale, described by Jaeschke et
al,30 was collected at each follow-up pe-
riod. The GROC ranges from –7 (a very
great deal worse) to zero (about the same)
to +7 (a very great deal better). It has
been reported that scores of +4 or higher
indicate moderate to large changes in pa-
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tient status.30 Individuals who rated their
perceived recovery on the GROC as “quite
a bit better” or higher (+5 or higher) at
any of the follow-up periods were catego-
rized as a success. Additionally, at each
follow-up period, individuals completed
a secondary outcome measure, the Pa-
tient Acceptable Symptom State (PASS),
to define the level of symptoms beyond
which patients consider themselves
Copyright © 2016 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
well.71 The PASS question was, “Taking
into account all the activities you have
during your daily life, your level of pain,
and also your functional impairment, do
you consider that your current state is
satisfactory?” Individuals who responded
“yes” were categorized as a success.
History and Physical Examination The
participant history data included age, sex,
Journal of Orthopaedic & Sports Physical Therapy®
employment status, past medical history,
expectations for treatment, mode of on-
set, number of days since onset, location
and nature of the patient’s symptoms, ag-
gravating and relieving factors, number
of previous episodes of shoulder pain,
and treatment for previous episodes. All
patients were screened for evidence of
nerve root compression and CNS involve-
ment. Screening included assessment of
the Hoffmann and Babinski reflexes;
myotomal muscle testing of major mus-
cle groups (C4 through T1); pinprick-
sensation testing of dermatomes from
C4 to T1; and testing the biceps brachii,
brachioradialis, and triceps brachii upper
extremity reflexes.
The physical examination included
tests and measures to assess strength,
flexibility, ROM, and joint mobility, and
special tests to identify specific shoul-
der conditions, such as impingement,
rotator cuff strains/tears, glenohumeral
instability, labral tears, and bicipital ten-
620 | august 2016 | volume 46 | number 8 | journal of orthopaedic & sports physical therapy
46-08 Mintken.indd 620
dinopathy.46 Passive ROM of the shoul-
der was measured according to Norkin
and White.49 The therapist also assessed
the length and strength of the muscles
of the upper quarter.34 Spring testing
and segmental mobility of the cervi-
cal and thoracic spine (C2 through T9)
were assessed for mobility and symptom
reproduction.24
Randomization Concealed allocation was
performed prior to subject recruitment
by an individual not involved in data
collection, using a computer-generated
randomized table of numbers created for
each participating site prior to the begin-
ning of the study. Individual, sequentially
numbered index cards with the random
assignment were prepared, folded, and
placed in sealed opaque envelopes. Once
the baseline examination was complete,
the randomization envelope was handed
to the treating therapist, who was blind-
ed to the initial baseline examination.
Individuals were randomly assigned to
1 of 2 groups: (1) manual therapy plus
an exercise program (manual therapy
plus exercise), or (2) exercise program
alone (exercise). Treatment was initi-
ated immediately following the baseline
examination, unless prohibited by time
constraints. In this case, the first treat-
ment was provided within 24 to 48 hours
of the initial examination.
Treating Physical Therapists Physical
therapists (n = 9) with a mean ± SD of
10.2 ± 5.2 years (range, 4-19 years) of
clinical experience participated in the
recruitment, examination, and treat-
ment of all patients in this study. Eight
of the 9 therapists were board certified
in orthopaedics and 5 had fellowship
training in manual therapy. All physi-
cal therapists underwent a standardized
training regimen that included study-
ing a manual of standard procedures
with the operational definitions of each
examination and treatment procedure.
Participating therapists also watched a
90-minute training video and underwent
a 2-hour hands-on training session pro-
vided by one of the investigators. Manual
therapy techniques were reviewed and
]
checked for accuracy in the training ses-
sion. Treating clinicians were also given
access to online training materials that
contained embedded video footage of
examination and manual intervention
procedures. Competency was assessed
using a standardized test in which all
participating physical therapists had
to score 80% or greater to be included
on the data-collection team. Due to the
nature of the interventions used in this
study, treating physical therapists could
not be blinded. However, physical thera-
pists collecting outcome measures were
blinded to group assignment.
Treatment Procedures
Individuals in both groups attended
treatment 2 times weekly for 4 weeks,
for a total of 8 sessions. For the first 2
sessions, individuals in the manual ther-
apy–plus-exercise group received high-
dose cervicothoracic manual therapy
(APPENDIX A, available at www.jospt.org)
plus cervicothoracic ROM exercises (AP-
PENDIX B, available at www.jospt.org),
while the exercise group received only the
cervicothoracic ROM exercises. During
visits 3 through 8, both groups performed
the same comprehensive stretching and
strengthening exercise program that has
been previously described by Tate et al70
(APPENDIX C, available at www.jospt.org).
The first treatment session was always
performed on the day of the initial ex-
amination, and the subject was scheduled
for a follow-up visit within 2 to 4 busi-
ness days. Patients in both groups were
also advised to maintain usual activities
that did not increase symptoms and to
avoid all activities that exacerbated their
symptoms.
Exercise Group The exercise group was
treated with 2 sessions of cervicothoracic
ROM exercises as described by Mintken
et al46 (APPENDIX B). The first exercise was
a general cervical ROM exercise called
the “3-finger ROM exercise,” originally
described by Erhard.22 The second ex-
ercise was a general thoracic-mobility
exercise performed in supine over a
towel.46 Individuals performed both ex-
7/20/2016 4:51:50 PM
 ercises for 10 repetitions, 3 to 4 times
per day, while participating in the study.
Visits 3 through 8 included instruction
in a stretching and 3-phase progressive
strengthening program, as described by
Tate et al70 (APPENDIX C). The exercise pro-
gram consisted of muscle re-education
exercises for the scapular stabilizers and
rotator cuff, flexibility exercises, and exer-
Downloaded from www.jospt.org at La Trobe University on August 1, 2016. For personal use only. No other uses without permission.
cises to promote an erect posture through
chin tucks and scapular retraction. Indi-
viduals performed strengthening exercis-
es with 2 to 3 sets of 10 repetitions using
latex-free Thera-Bands (The Hygenic
Corporation, Akron, OH). Phase 1 of the
exercise program consisted of strength-
ening of the rotator cuff muscles with the
humerus in neutral, serratus strength-
ening, and motor control training with
Copyright © 2016 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
shoulder elevation while avoiding exces-
sive upper trapezius activation. Phase 2
of the exercise program continued with
strengthening of the rotator cuff muscles
at 45° to 90° of abduction in shoulder
scaption, shoulder elevation exercises,
and the addition of progressive strength-
ening of the serratus and middle and
lower trapezius. Phase 3 included con-
Journal of Orthopaedic & Sports Physical Therapy®
tinuation of all phase 2 exercises with the
addition of higher-level strengthening
exercises, including the lawnmower pull,
protraction plank, and use of the Body-
blade (Mad Dogg Athletics, Inc, Venice,
CA) at multiple angles of shoulder eleva-
tion. Individuals progressed to increased
resistive-band difficulty (in the sequence
yellow, red, green, blue) when they were
able to perform 2 to 3 sets of 10 repeti-
tions with minimal symptoms or fatigue.
Individuals progressed from phase 1 to
phase 2 when they were able to perform
full sets and repetitions of the exercises
with a red resistive band. Individuals
progressed from phase 2 to phase 3 when
they could perform all exercises in phase
2 for 1 week with minimal symptoms.
The comprehensive exercise program is
designed to target the common impair-
ments associated with shoulder pain,
including poor posture, weakness and
imbalance of the rotator cuff and scapu-
lar stabilizing muscles, altered scapular
journal of orthopaedic & sports physical therapy | volume 46 | number 8 | august 2016 | 621
46-08 Mintken.indd 621
dynamics, and decreased joint and soft
tissue flexibility.70
Manual Therapy–plus-Exercise Group
The manual therapy–plus-exercise group
received the same ROM exercises (APPEN-
DIX B) described above, with the addition
of high-dose cervicothoracic manual
therapy (APPENDIX A), during the first 2
treatment sessions, followed by the same
exercise protocol as the exercise group for
visits 3 through 8 (APPENDIX C). The high-
dose cervicothoracic manual therapy dur-
ing the first 2 sessions included 5 thoracic
spine high-velocity, low-amplitude tech-
niques targeting the upper, middle, and
lower thoracic spine and 1 low-velocity
technique directed at the lower cervical
spine, as described by Mintken et al.46
Manual therapy interventions are de-
scribed below using the model proposed
by Mintken et al,47 and pictures and de-
scriptions of the manual therapy inter-
ventions can be found in APPENDIX A.
1. Seated midthoracic technique: a high-
velocity, midrange to end-range trac-
tion force to the midthoracic spine on
the lower thoracic spine in a sitting
position, in slight flexion with the in-
dividual’s arms crossed
2. Supine midthoracic technique: a high-
velocity, end-range, anterior-to-poste-
rior force applied through the elbows
to the flexed middle thoracic spine on
the lower thoracic spine in a supine
position with the individual’s arms
crossed
3. Supine upper thoracic technique: a
high-velocity, end-range, anterior-to-
posterior force applied through the
elbows to the flexed upper thoracic
spine on the middle thoracic spine in
a supine position with the individual’s
arms crossed
4. Supine or seated cervicothoracic junc-
tion technique (therapists could use
either technique)
a. High-velocity, end-range, anteri-
or-to-posterior force through the
elbows to the cervicothoracic junc-
tion on the upper thoracic spine in
a supine bridged position
b. High-velocity, end-range traction
force to the cervicothoracic junc-
tion on the upper thoracic spine in
a sitting position with the individ-
ual’s hands interlaced behind the
neck
5. Prone midthoracic to lower thoracic
technique: a high-velocity, midrange
to end-range, posterior-to-anterior
force to the midthoracic spine on the
individual’s upper thoracic spine in a
prone position
6. Lower cervical technique: a low-ve-
locity, midrange to end-range, left and
right lateral translational force (side
glide) to the individual’s lower cervi-
cal spine on the upper thoracic spine
in a supine position
In order to maximize each subject’s
opportunity for improvement, individu-
als received each high-velocity technique
up to 2 times, unless a cavitation was
noted, for up to 10 high-velocity inter-
ventions per treatment session. All of
the techniques described above were re-
peated at the second visit, which occurred
within 2 to 4 days of the initial visit.
Follow-up Assessments were performed
at 1 week and 4 weeks by the examining
therapist, who was blinded to treatment
allocation, and at 6 months via comple-
tion of the outcome measures online from
a secure link sent by e-mail or on paper
sent via post. At each follow-up, individu-
als completed the SPADI, QuickDASH,
NPRS, PASS, and GROC. Follow-up data
were collected from March 2012 through
December 2014.
Data Analysis
Demographic differences between groups
at baseline were assessed for differences
that could pose a risk of prognostic im-
balance between groups. Linear mixed
models, with repeated-measures analy-
sis and restricted maximum likelihood,
were used to compare groups over time
for each of the primary and secondary
outcome measures. We modeled the ran-
dom effects of individuals and fixed ef-
fects of group and a covariate of baseline
outcome scores to control for baseline
differences between groups. Maximum
7/20/2016 4:51:50 PM
 [ research report
likelihood estimation was used to ac-
count for missing data over time. Com-
parisons were made for the dependent
variables (outcome measures) between
treatment groups (manual therapy plus
exercise and exercise), with the between-
subject factor of time (baseline, 1 week, 4
weeks, or 6 months) as the repeated fac-
tor, with an alpha set at .05. In cases of
Downloaded from www.jospt.org at La Trobe University on August 1, 2016. For personal use only. No other uses without permission.
interactions, effects of group at repeated
factors of time were compared and Bon-
ferroni corrections were used to adjust
for multiple comparisons.
We also compared the frequency of
successful outcomes between the 2 treat-
ment groups (manual therapy plus ex-
ercise versus exercise alone) using the
GROC and PASS. Individuals who rated
their perceived recovery on the GROC
Copyright © 2016 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
as +5 or greater (“quite a bit better” or
higher)30 were classified as having a suc-
cessful outcome, and individuals who re-
ported “yes” on the PASS were classified
as having a successful symptom state.71
Frequencies of success on the PASS and
GROC were compared between treat-
ment groups using chi-square tests of
independence. The numbers needed to
Journal of Orthopaedic & Sports Physical Therapy®
treat (NNT) and 95% confidence inter-
val (CI) were then calculated if significant
differences were identified. Data analysis
was performed using SPSS Version 22
(IBM Corporation, Armonk, NY).
An a priori power analysis was per-
formed for a linear repeated-measures
analysis for between-group comparison
of manual therapy plus exercise versus
exercise alone. The sample size estimated
to achieve 80% power to detect a 10-point
difference between groups on the SPADI,
based on an MCID of 8 to 13.2 points62
with a standard deviation of 13.5 points,
a correlation among repeated measures
of 0.70, and an alpha level of .05, indi-
cated that a sample size of 48 individuals
per group was needed. Accounting for a
20% dropout rate, we estimated that 58
patients per group were needed. We re-
cruited 140 participants in order to per-
form a secondary prediction analysis of
factors related to a favorable response to
manual therapy plus exercise versus ex-
622 | august 2016 | volume 46 | number 8 | journal of orthopaedic & sports physical therapy
46-08 Mintken.indd 622
Baseline Demographic and Self-reported
TABLE 1
Variables of the Participants by Study Group*
Variable
Age, y
Sex (female), n (%)
Onset, wk
Currently working (yes), n (%)
Medication use for shoulder pain (yes), n (%)
SPADI
NPRS
QuickDASH
Abbreviations: NPRS, numeric pain-rating scale; QuickDASH, shortened version of the Disabilities
of the Arm, Shoulder and Hand questionnaire; SPADI, Shoulder Pain and Disability Index.
*Values are mean ± SD unless otherwise indicated.
ercise only. Once the target sample size
of 140 was achieved, the trial was closed.
RESULTS
C
onsecutive patients with shoul-
der pain (n = 242) were screened for
possible eligibility criteria (FIGURE
1). Individuals who satisfied the eligibil-
ity criteria and agreed to participate (n =
140) were randomized to receive manual
therapy plus exercise (n = 70) or exercise
only (n = 70) and are described in TABLE
1. There were no significant differences
between groups on the baseline outcome
measures. The overall 6-month follow-up
response rate was 81.4% for both groups
(FIGURE 1). No adverse events were reported
for either group.
Outcome scores at baseline and each
follow-up period can be found in TABLE 2.
There were no significant 2-way interac-
tions or main effects for group for the
primary outcomes of SPADI disability
scores or NPRS scores for pain, or for
the secondary outcome of QuickDASH
scores for disability (TABLE 2). There were
significant main effects for time for the
primary outcomes of SPADI and NPRS
scores and for the secondary outcome
of QuickDASH scores for arm disability
(P≤.05), indicating that the primary out-
comes were not dependent on the treat-
ment received, as both groups had similar
]
Manual Therapy
Plus Exercise (n = 70) Exercise Only (n = 70)
40.5 ± 11.7 44.8 ± 12.9
40 (57.1) 36 (51.4)
130.7 ± 268.1 114.2  230.6
58 (82.9) 51 (72.9)
44 (62.9) 43 (61.4)
41.2 ± 18.1 46.2  20.0
4.3 ± 1.9 4.6  2.1
30.4 ± 14.9 34.7  18.7
improvements at each follow-up period
for both disability and pain.
For the secondary outcomes of patient-
perceived success and acceptability of
symptoms, we compared groups on the
GROC and PASS, respectively. The per-
centage of individuals in each group experi-
encing a successful outcome on the GROC
was not significantly different at the 1-week
follow-up, but was significant at 4 weeks
and 6 months, with more individuals in the
manual therapy–plus-exercise group expe-
riencing a successful outcome (+5 [quite
a bit better] or greater), as illustrated in
FIGURE 2. The percentage of individuals
reporting “yes” on the PASS, indicating a
successful symptom state, was significantly
greater in the manual therapy–plus-exer-
cise group at 4 weeks, but no differences
were found at 1 week or 6 months (FIGURE
3). The NNT for the manual therapy–plus-
exercise group was 6 (95% CI: 2.8, 38.9) at
the 4-week follow-up and 6 (95% CI: 2.9,
89.7) at the 6-month follow-up, based on
the GROC variable. Both groups improved
on all outcome measures when main ef-
fects over time for pain and disability were
analyzed (FIGURES 4 through 6).
DISCUSSION
T
he present study found no dif-
ferences between manual therapy
plus exercise and exercise alone with
7/20/2016 4:51:50 PM

Disability and Pain Scores for All Groups at Each Follow-up Period, and
TABLE 2
Results of Mixed-Model Analyses of Outcomes Between Treatment Groups

Unadjusted Raw Scores* Adjusted Scores*

Manual Therapy Manual Therapy Between-Group Effect Size,
Outcome/Time Point Plus Exercise Exercise Only Plus Exercise Exercise Only Difference† P Value Cohen d
Disability (SPADI)‡ .70§
Baseline (n = 70) 41. 2  18.1 46.2  20.0 42.2  12.2 43.5  12.2
Downloaded from www.jospt.org at La Trobe University on August 1, 2016. For personal use only. No other uses without permission.

1 wk 30.9  17.3 36.3  19.7 32.2  12.8 34.6  12.8

Change from baseline to 1 wk† 9.9 (6.9, 13.0) 8.9 (5.8, 11.9) 1.1 (–4.7, 6.7)
4 wk 14.6  11.4 23.0  21.0 16.9  13.1 21.1  13.1
Change from baseline to 4 wk† 25.3 (21.5, 29.0) 22.4 (18.6, 26.1) 2.9 (–5.6, 5.5)
6 mo 12.3  14.5 16.1  17.6 15.4  13.7 17.7  13.6
Change from baseline to 6 mo† 26.8 (22.7, 30.8) 25.8 (21.7, 29.9) 1.0 (–6.6, 2.8)
Collapsed across time, baseline to 6 mo 26.7  9.0 29.2  9.0 –2.6 (–5.6, 0.5) .10‖ 0.28
Pain (NPRS) ‡
.83§
Baseline (n = 70) 4.3  1.9 4.6  2.1 4.3  1.5 4.5  1.5
1 wk 3.4  1.8 3.9  1.7 3.5  1.5 3.7  1.6
Copyright © 2016 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Change from baseline to 1 wk† 0.8 (0.4, 1.2) 0.7 (0.3, 1.1) 0.1 (–0.8, 0.7)
4 wk 1.9  1.4 2.6  1.9 2.1  1.6 2.5  1.6
Change from baseline to 4 wk† 2.2 (1.8, 2.7) 2.0 (1.5, 2.5) 0.2 (–0.9, 0.6)
6 mo 1.7  1.8 1.9  1.9 1.9  1.7 2.0  1.7
Change from baseline to 6 mo† 2.4 (1.9, 2.9) 2.4 (1.9, 3.0) –0.04 (–0.9, 0.4)
Collapsed across time, baseline to 6 mo 3.0  1.0 3.2  1.0 –0.2 (–0.5, 0.1) .22‖ 0.20
Disability (QuickDASH) ‡
.92§
Baseline (n = 70) 30.4  14.9 34.7  18.7 30.9  10.7 31.9  10.8
1 wk 28.3  16.6 32.4  16.5 29.8  11.2 30.1  11.2
Journal of Orthopaedic & Sports Physical Therapy®

Change from baseline to 1 wk† 1.1 (–1.8, 4.0) 1.9 (–1.0, 4.8) –0.7 (–4.2, 6.2)
4 wk 16.3  13.3 21.9  17.4 19.0  11.5 19.8  11.5
Change from baseline to 4 wk† 12.0 (8.5, 15.4) 12.1 (8.7, 15.6) –0.2 (–3.4, 6.8)
6 mo 11.5  12.5 15.1  13.9 14.3  12.1 16.4  12.1
Change from baseline to 6 mo† 16.6 (12.9, 20.3) 15.6 (11.9, 19.3) 1.0 (–3.3, 5.7)
Collapsed across time, baseline to 6 mo 23.5  7.4 24.5  7.5 –1.1 (–3.5, 1.4) .41‖ 0.13
GROC, n (% improved) ¶#

1 wk 7 (11.5) 5 (7.9) 7 (11.5) 5 (7.9) ... .51**

4 wk 43 (71.7) 31 (51.7) 43 (69.4) 32 (50.0) ... .03**
6 mo 35 (66.0) 30 (60.4) 42 (65.6) 31 (47.7) ... .04**
PASS, n (% acceptable)#
1 wk 23 (37.7) 14 (22.2) 23 (37.7) 14 (22.2) ... .06**
4 wk 42 (73.7) 27 (46.6) 44 (69.8) 30 (46.9) ... .009**
6 mo 45 (84.9) 41 (74.5) 49 (75.4) 42 (64.6) ... .18**

Abbreviations: GROC, global rating of change; NPRS, numeric pain-rating scale; PASS, Patient Acceptable Symptom State;
QuickDASH, shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire; SPADI, Shoulder Pain and Disability Index.
*Values are mean  SD unless otherwise indicated.
†
Values are adjusted mean change (95% confidence interval). Change from baseline to follow-up time points calculated as manual therapy–plus-exercise group
– exercise group.
‡
Adjusted values from mixed-model analyses with multiple imputation for missing values. SPADI: 0-to-100 scale where 0 is no disability; NPRS, 0-to-10 scale
where 0 is no pain; QuickDASH, 0-to-100 scale where 0 is no disability.
§
Interaction effect.
‖
Group main effect.
¶
Those who reported +5 (“quite a bit better”) were categorized as “improved.”
#
Adjusted values from intention to treat, with last value carried forward for categorical variables. Comparisons were made with chi-square analyses.
**Paired comparisons.

journal of orthopaedic & sports physical therapy | volume 46 | number 8 | august 2016 | 623

46-08 Mintken.indd 623 7/20/2016 4:51:50 PM

 [ research report ]
regard to pain or disability in individuals therapy treatment for shoulder pain,
80
with shoulder pain. Both groups experi- Chester et al12 reported a significant asso-

Improved, %
Participants
60 * *
enced similar improvements in pain and ciation (P≤.05) between longer duration
40
disability ratings at all time points. These of shoulder pain and poorer outcomes. 20
results do not support the addition of cer- A recent meta-analysis17 reported that 0
1 wk 4 wk 6 mo
vicothoracic manual therapy to a stan- manual therapy has a predominant ef-
dardized exercise program to improve fect on pain, and not shoulder function, Manual therapy Exercise
pain and disability in individuals with in patients with shoulder pain. Addition- plus exercise
shoulder pain. Interestingly, the individ- ally, the exclusion criteria did not account
Downloaded from www.jospt.org at La Trobe University on August 1, 2016. For personal use only. No other uses without permission.

uals who received manual therapy plus
exercise did have higher perceived benefit
than those in the exercise group. A great-
er percentage of individuals in the man-
ual therapy–plus-exercise group reported
a successful outcome on the GROC at 4
for the potential inclusion of individuals
with CNS sensitization. Two recent re-
views6,64 suggest that a subgroup of indi-
viduals with shoulder pain may exhibit
hyperexcitability of the CNS. Gwilym and
colleagues28 reported that a subgroup of
FIGURE 2. Global rating of change success (+5 or
greater) by group and time. *Statistically significant
differences between groups.
80
70

Symptom State, %
60
weeks (short term) and 6 months (long individuals with shoulder impingement *

Acceptable
50
term). Moreover, acceptability of symp- syndrome and signs of CNS hyperexcit- 40
30
toms on the PASS was greater for the ability had significantly worse outcomes 20
10
manual therapy–plus-exercise group at 4 postoperatively compared to those with- 0
Copyright © 2016 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

weeks. These results suggest that cervi-
cothoracic manual therapy may improve
patient-perceived acceptability of symp-
toms and improvement.
Multiple studies have reported that
thoracic manual therapy may improve
pain and disability in individuals with
shoulder pain9,46,68,76; however, most of
these studies were single-arm trials, only
Journal of Orthopaedic & Sports Physical Therapy®
1 wk 4 wk 6 mo
out CNS involvement. Due to the chro-
nicity of symptoms in the present study, Manual therapy Exercise
plus exercise
it is likely that some of these individuals
had a component of central sensitization,
which might have impacted the results. FIGURE 3. Patient Acceptable Symptom State
success (response of “yes”) by group and time.
Second, the optimal dosage of manu-
*Statistically significant difference between groups.
al therapy for individuals with shoulder
pain is currently unknown. The current
study only utilized 2 sessions of manual Although there was no statistically

reported short-term outcomes, and did
not include an evidence-based standard-
ized exercise program. It may be that the
observed improvements in pain and dis-
ability in these studies were short lived
and did not result in any meaningful long-
term changes. Wassinger et al76 reported
that manual therapy directed at the cervi-
cothoracic region acutely increased pres-
sure pain thresholds and decreased pain
in individuals with experimentally in-
duced shoulder pain, and recommended
that physical therapists consider the use
of these techniques to achieve short-term
hypoalgesic effects and facilitate the ap-
plication of more active interventions.
There are several potential explana-
tions for the finding of no significant
differences between the intervention
groups. First, the majority of the indi-
viduals in the present trial had chronic
symptoms (greater than 2 years in dura-
tion). In a systematic review examining
the prediction of response to physical
therapy. If there is a treatment effect
with manual therapy, more sessions may
be needed for individuals with chronic
symptoms, or a greater dose may be
needed overall, regardless of chronic-
ity. Appropriate manual therapy dosage
requires further investigation in most
regions of the body, including the cervico-
thoracic spine and shoulder girdle. It may
also be that cervicothoracic manual ther-
apy has a limited effect when combined
with a comprehensive exercise program.
Cook et al14 reported that cervical spine
manual therapy had no value when added
to the treatment of individuals with im-
pingement syndrome. Finally, the manu-
al therapy in this study was delivered in a
prescriptive fashion, with limited clinical
decision making on the part of the thera-
pist. Perhaps a pragmatic approach, in
which the clinician is free to choose the
technique, location, dose, and frequency
based on the clinical examination, would
result in a different outcome.15,41
significant difference between the man-
ual therapy–plus-exercise group and the
exercise group in the primary outcomes
of pain and disability, there was both a
higher symptom state success and pa-
tient-perceived success in the manual
therapy–plus-exercise group. The symp-
tom state success as reported on the PASS
was found to be significantly greater in
the manual therapy–plus-exercise group
at 4 weeks (FIGURE 3). The PASS provides
clinically meaningful information that
can be expressed as a percentage of indi-
viduals who meet the threshold for PASS,
regardless of the change from baseline in
symptoms.20
Success on the GROC was reported
at a higher frequency in the manual
therapy–plus-exercise group at the end
of care (4 weeks) and at a 6-month long-
term follow-up (FIGURE 2). The GROC is
commonly utilized in clinical research to
determine cutoff scores for patient-per-
ceived changes in condition. Jaeschke et

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46-08 Mintken.indd 624 7/20/2016 4:51:51 PM


50
40
Score, %
30
20
10
0 Baseline
Baseline 1 wk
Manual therapy
plus exercise
Downloaded from www.jospt.org at La Trobe University on August 1, 2016. For personal use only. No other uses without permission.
FIGURE 4. Shoulder Pain and Disability Index scores
for both groups across time.
6
5
Score (0-10)
4 quate test-retest reliability, is sensitive to
3 change, and is easy to understand by the
2
1 individual.33
0
Baseline 1 wk
Copyright © 2016 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Manual therapy
plus exercise
FIGURE 5. Numeric pain-rating scale scores for both
groups across time.
al30 suggest that a score of +4 (moderately
better) be used as the cutoff to dichoto-
mize improved versus not improved.
We chose to use +5 (quite a bit better),
Journal of Orthopaedic & Sports Physical Therapy®
as we wanted to determine if substantial
change had occurred.45 Michener et al45
used “quite a bit better” as a suggested
threshold of expected improvement
after a course of care. Schmitt and Ab-
bott65 recently examined the accuracy of
the GROC scale and highlighted several
shortcomings of the GROC as a primary
outcome measure in clinical practice,
particularly when it is administered at
irregular follow-up periods. In clinical
research, where follow-up is more con-
sistent (1 week, 4 weeks, and 6 months
in this study), the GROC may be a useful
tool to determine whether the individual
has improved, stayed the same, or wors-
ened.33 Given that an individual’s GROC
may include constructs in addition to
those measured by other outcome mea-
sures, the open question in the GROC lets
the individual decide what construct(s)
he or she considers important in deter-
mining individual health status. The
GROC is clinically relevant, has ade-
46-08 Mintken.indd 625
40
30
Score, %
20
10
0
1 wk 4 wk
4 wk 6 mo
Manual therapy Exercise
Exercise
plus exercise
FIGURE 6. QuickDASH scores for both groups across
time. Abbreviation: QuickDASH, shortened version
of the Disabilities of the Arm, Shoulder and Hand
questionnaire.
4 wk 6 mo
The results of our study indicated
that, regardless of group allocation, all
Exercise individuals had clinically significant im-
provements in pain and disability with
the interventions, despite the chronic
nature of their symptoms (FIGURES 4
through 6). The average change in SPA-
DI scores exceeded the MCID at 4 weeks
and 6 months for all individuals.53 This
strengthens the argument that conserva-
tive management should be the first line
of treatment for most shoulder condi-
tions, as numerous systematic reviews
and RCTs have shown that operative
treatment is no better than conservative
treatment.19,25,39,63,69
Limitations
Several limitations warrant discussion.
First, we had a higher-than-expected
number of individuals lost to follow-up.
One site in particular, the Northern Na-
vajo Medical Center, had a 64% dropout
rate at 4 weeks, and only a few of these in-
dividuals completed the 6-month follow
up. Much of this was due to real difficul-
ties that the study participants had with
access to care, such as living over an hour
away or simply having no transportation
and/or limited ability to pay for transpor-
tation to attend follow-up appointments.
Second, the participant population in this
study had chronic symptoms. Conducting
a similar trial in a more acute population
may result in different outcomes. Third,
journal of orthopaedic & sports physical therapy | volume 46 | number 8 | august 2016 | 625
it could be argued that the dosage and
prescriptive nature of the manual ther-
apy were insufficient and not reflective
of clinical practice. Our decision to use
2 sessions of protocolized, high-dose cer-
6 mo vicothoracic manual therapy was based
on the previous study by Mintken et al.46
It is possible that an increased frequency
of manual therapy might have led to im-
proved outcomes, as Fernández-de-las-
Peñas et al23 reported that patients with
neck pain receiving thoracic manipula-
tion did not exhibit tolerance to repeat-
ed applications with regard to pain and
mobility measures. Finally, although all
participating therapists had to attend a
training session and pass a written test,
there still might have been variation in
practice in the delivery of care.
CONCLUSION
T
he results of the current study
suggest that the addition of cervi-
cothoracic manual therapy did not
significantly improve pain or disability
in individuals with shoulder pain. Both
groups, on average, had clinically sig-
nificant improvements in pain and dis-
ability, despite the chronic nature of
the symptoms. Cervicothoracic manual
therapy did not add any additional ben-
efit over exercise alone. A greater per-
centage of the individuals in the manual
therapy–plus-exercise group experienced
a successful outcome or acceptability of
symptoms on the GROC and the PASS,
respectively, at 4 weeks, and at 6 months
on the GROC. The NNT for the manual
therapy–plus-exercise group was 6 (95%
CI: 2.8, 38.9) at the 4-week follow-up
and 6 (95% CI: 2.9, 89.7) at the 6-month
follow-up. t
KEY POINTS
FINDINGS: The addition of cervicothoracic
manual therapy to an evidence-based
exercise program did not improve pain
or disability in individuals with shoulder
pain, but seemed to provide a patient-
perceived benefit.
IMPLICATIONS: The results do not support
7/20/2016 4:51:52 PM
 [ research report
the addition of cervicothoracic manual 6. B orstad J, Woeste C. The role of sensitiza-
therapy to an exercise program to de- tion in musculoskeletal shoulder pain. Braz
crease pain and disability in individuals J Phys Ther. 2015;19:251-257. http://dx.doi.
org/10.1590/bjpt-rbf.2014.0100
with shoulder pain; however, manual
7. Bot SD, van der Waal JM, Terwee CB, et al.
therapy may lead to greater rates of Incidence and prevalence of complaints of the
patient-perceived success. neck and upper extremity in general practice.
CAUTION: The population sampled in Ann Rheum Dis. 2005;64:118-123. http://dx.doi.
org/10.1136/ard.2003.019349
this study had chronic symptoms and
8. Boyles RE, Flynn TW, Whitman JM. Manipula-
received only 2 sessions of manual tion following regional interscalene anesthetic
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]
http://dx.doi.org/10.2519/jospt.2015.5455
18. D esmeules F, Côté CH, Frémont P. Therapeutic
exercise and orthopedic manual therapy for im-
pingement syndrome: a systematic review. Clin J
Sport Med. 2003;13:176-182.
19. Dorrestijn O, Stevens M, Winters JC, van der
Meer K, Diercks RL. Conservative or surgi-
cal treatment for subacromial impingement
syndrome? A systematic review. J Shoulder
Elbow Surg. 2009;18:652-660. http://dx.doi.
org/10.1016/j.jse.2009.01.010

therapy, which might not have been an block for shoulder adhesive capsulitis: a case
adequate dosage for this population. series. Man Ther. 2005;10:164-171. http://dx.doi.
org/10.1016/j.math.2004.08.002
9. Boyles RE, Ritland BM, Miracle BM, et al. The
ACKNOWLEDGMENTS: We would like to thank short-term effects of thoracic spine thrust
all of the clinicians who participated in data manipulation on patients with shoulder impinge-
collection and treatment of the individuals ment syndrome. Man Ther. 2009;14:375-380.
http://dx.doi.org/10.1016/j.math.2008.05.005
in this clinical trial, including Justin Dud-
10. Brudvig TJ, Kulkarni H, Shah S. The effect of
ley, Joseph Strunce, Jeffrey Bullock, Steven therapeutic exercise and mobilization on pa-
Spoonemoore, Adrianne Thomas, and Melissa tients with shoulder dysfunction: a systematic
Schossow. We would also like to acknowledge review with meta-analysis. J Orthop Sports
Copyright © 2016 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
20. Dougados M, Moore A, Yu S, Gitton X. Evaluation
of the Patient Acceptable Symptom State in a
pooled analysis of two multicentre, randomised,
double-blind, placebo-controlled studies evalu-
ating lumiracoxib and celecoxib in patients with
osteoarthritis. Arthritis Res Ther. 2007;9:R11.
http://dx.doi.org/10.1186/ar2118
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22. Erhard R. The Spinal Exercise Handbook. A

the University of Colorado Physical Therapy
Program students who volunteered their time,
and Blake Humphrey for the taking and edit-
ing of photographs and figures included in this
manuscript.
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34. Kendall FP, Provance P, McCreary EK. Muscles:
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 APPENDIX A

MANUAL THERAPY TECHNIQUES

Technique 1: seated midthoracic technique. A high-velocity, midrange to end-range traction force

to the midthoracic spine on the lower thoracic spine in a sitting position, in slight flexion with the
patient’s arms crossed. The therapist placed his or her upper chest at the level of the patient’s
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middle thoracic spine and grasped the patient’s elbows. A high-velocity traction force was
performed in an upward direction.
Copyright © 2016 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Technique 2: supine midthoracic technique. A high-velocity, end-range, anterior-to-posterior force

applied through the elbows to the flexed middle thoracic spine on the lower thoracic spine in a
supine position with the patient’s arms crossed. The therapist used his or her hand to stabilize the
inferior vertebra of the targeted motion segment and used his or her body to push down through
the patient’s arms to perform a high-velocity, low-amplitude thrust directed in the direction of the
arrow, toward T5 through T8.
Journal of Orthopaedic & Sports Physical Therapy®

Technique 3: supine upper thoracic technique. A high-velocity, end-range, anterior-to-posterior

force applied through the elbows to the flexed upper thoracic spine on the middle thoracic spine
in a supine position with the patient’s arms crossed. The therapist used his or her hand to
stabilize the inferior vertebra of the targeted motion segment and used his or her body to push
down through the patient’s arms to perform a high-velocity, low-amplitude force directed in
the direction of the arrow, toward T1 through T4.

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 [ research report ]
APPENDIX A

Technique 4A: supine cervicothoracic junction technique. A high-velocity, end-range, anterior-to-

posterior force through the elbows to the cervicothoracic junction on the upper thoracic spine
in a supine bridged position. The therapist used his or her hand to stabilize the T1 segment and
used his or her body to perform a high-velocity, low-amplitude force in the direction of the arrow,
through the patient’s arms.
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Technique 4B: seated cervicothoracic junction technique. A high-velocity, end-range traction force
to the cervicothoracic junction on the upper thoracic spine in a sitting position, with the patient’s
hands interlaced behind the neck. The individual interlocks the fingers at the base of the neck.
The therapist weaves his or her arms through the patient’s relaxed arms and places the fingers
at C7. The therapist supports the patient with compression of the forearms. The therapist leans
Copyright © 2016 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

the individual back until the cervicothoracic junction is perpendicular to the floor. The therapist
produces a high-velocity, low-amplitude vertical traction force in an upward direction.

Technique 5: prone midthoracic to lower thoracic technique. A high-velocity, midrange to end-

range, posterior-to-anterior force to the midthoracic spine on the upper thoracic spine in a prone
Journal of Orthopaedic & Sports Physical Therapy®

position. The therapist achieves a “skin lock” with the pisiforms of each hand over the transverse
processes of the target vertebra, pushing caudal with one hand and cephalad with the other.
The therapist then uses his or her body to push down through the arms to perform a high-velocity,
low-amplitude, posterior-to-anterior force.

Technique 6: lower cervical technique. A low-velocity, midrange to end-range, left and right
lateral translational force (side glide) to the lower cervical spine on the upper thoracic spine
in a supine position. The patient is positioned in supine, in “neutral” first and then in slight
cervical flexion, and low-velocity, midrange to end-range mobilizations are performed. Each
technique is performed for 30 seconds at each cervical level (C5-C7) in “neutral” and slight
cervical flexion (for a total of 6 bouts to the left and 6 to the right).

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 APPENDIX B

CERVICOTHORACIC RANGE-OF-MOTION EXERCISES

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Copyright © 2016 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Active range-of-motion exercises performed by individuals in the study. Three-finger cervical active range of motion and supine thoracic extension over
a towel.
Journal of Orthopaedic & Sports Physical Therapy®

APPENDIX C

EXERCISES USED FOR BOTH GROUPS*

Motor control/strengthening: 2 to 3 sets of 10 repetitions, progressing from yellow to red to green to blue band

Intervention Details Figures

Phase 1
1. Resisted shoulder external rotation (neutral) • Begin with hand in front of the stomach.
Pull away from abdomen, then slowly release.
Can use towel in armpit if more comfortable

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 [ research report ]
APPENDIX C

Intervention Details Figures

2. Resisted shoulder internal rotation (neutral) • Begin with forearm out to the side and elbow
against body. Pull toward your abdomen, then
slowly release. Can use towel in armpit if more
comfortable
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3. Resisted scapular extension • Begin with arms forward flexed about 45°.
Pull band toward you, keeping your elbow bent
Copyright © 2016 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

4. Resisted scapular retraction • Grasp band with both hands and elbows bent.
Pinch your shoulder blades together, which will
stretch the band, then slowly release

5. Resisted scapular protraction supine • Grasp band while lying on your back with arm
Journal of Orthopaedic & Sports Physical Therapy®

flexed to 90°. Punch arm up toward the ceiling

while keeping arm straight. Your shoulder blade
should lift off the table

6. Active elevation with upper trap relaxation • Lift your arm upward while keeping your
shoulder relaxed (avoid shrugging). You may
use a mirror or your other hand to check to see
if your shoulder is lifting up

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Intervention
7. Chin tuck with scapular retraction (postural
exercise)
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Phase 2
1. Shoulder abduction “scaption” (0°-90°)
Copyright © 2016 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
2. Shoulder flexion (0°-90°)
Journal of Orthopaedic & Sports Physical Therapy®
3. Shoulder external rotation with abduction
(45°-90°)
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46-08 Mintken.indd 5
APPENDIX C
Details Figures
• Sitting or standing, tuck your chin and pull
shoulder blades down and back. Avoid tilting
the head back or looking at the ceiling
• Stand on band and grasp other side, thumb
pointing up. Lift band to shoulder level, staying
in a plane of movement midway between front
and side, then slowly lower
• Stand on band and grasp other side, thumb
pointing up. Lift band forward to shoulder level
and slowly release
• Standing facing doorway, with arm at or below
shoulder level and elbow bent 90°. Pull band
away from the door, keeping your elbow bent,
and slowly release
7/24/2016 1:25:56 PM
 [ research report ]
APPENDIX C

Intervention Details Figures

4. Shoulder internal rotation with abduction
(45°-90°)
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• Stand facing away from the doorway, with arm
at or below shoulder level and elbow bent to 90°.
Grasp band and pull palms down toward the
floor. Slowly release

5. Quadruped push-up plus “camel” • Begin on hands and knees with arms shoulder-
width apart. Push downward, causing your upper
back to round, then slowly release

6. Prone shoulder horizontal abduction with • Turn thumb up and lift arm up toward the ceiling
scapular retraction “T” while squeezing shoulder blades toward spine.
Slowly lower
Copyright © 2016 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

7. Prone scapular retraction and shoulder eleva- • Turn thumb up and lift arm diagonally above
tion “Y” shoulder toward the ceiling while squeezing
shoulder blades toward spine. Slowly lower
Journal of Orthopaedic & Sports Physical Therapy®

Phase 3 (continue all exercises from phase 2

and add the following)
1. Bodyblade below 60° • Standing, hold the Bodyblade in the scapular
plane below 60°. Perform exercise on both
vertical and horizontal planes. Progress to above
60° when able to perform exercise pain free
and with good scapular control

2. Bodyblade above 60° • Standing, hold the Bodyblade in the scapular

plane above 60°. Perform exercise on both
vertical and horizontal planes

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 APPENDIX C

Intervention Details Figures

3. Lawnmower pull • Anchor band around a leg of bed or couch.
Begin grasping band from across your body
with hips and knees bent. Pull diagonal overhead
while straightening legs and trunk. Slowly
control return to start position
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4. Forearm push-up plus “protraction plank” • Begin in forearm plank position with upper back
sagged. Push downward through your forearm,
causing your upper back to round, then slowly
release
Copyright © 2016 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Stretching (30 seconds, 3 repetitions)

Journal of Orthopaedic & Sports Physical Therapy®

Intervention Details Figures

1. Thoracic extension towel stretch supine • Lie on top of a towel roll placed vertically
under thoracic spine. Arms out to the side
with palms up

2. Doorway pectoral stretch • Bring arm out to the side with elbow bent
and forearm contacting wall. Turn your body
away from the wall until you feel a stretch

journal of orthopaedic & sports physical therapy | volume 46 | number 8 | august 2016 | A7

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 [ research report ]
APPENDIX C

Intervention Details Figures

3. Cross-body posterior shoulder stretching • Bring arm across your body and use other hand
to apply overpressure, pulling the elbow
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4. Shoulder external rotation cane stretch • Grasp cane with affected elbow bent.
Use unaffected arm to push hand back
Copyright © 2016 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

toward plinth

5. Shoulder internal rotation towel stretch • Grasp towel behind your back with affected
hand below. Use unaffected arm to lift affected
Journal of Orthopaedic & Sports Physical Therapy®

arm until you feel a stretch

6. S
 houlder flexion stretch. Phase 1, supine cane • Phase 1: grasp cane with elbows straight
flexion; phases 2 and 3, standing wall stretch and lift up until you feel a stretch
• Phases 2 and 3: stand facing wall with arm
reaching as high as possible. Slowly walk closer
to the wall to increase your stretch

*Reproduced with permission from Tate et al.70

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