Effectiveness of thoracic manipulations on shoulder pain: A Case Report

Original Editor - Rucha Gadgil Top Contributors - Rucha Gadgil  

Abstract

The objective of the study was to explore the effects of manipulations to the cervicothoracic junction on clinical outcomes in patients with rotator cuff pathology.

Multiple reports in recent peer-reviewed literature state that manipulative techniques aimed at the thoracic spine used in conjunction with exercise produce superior benefits in patients with shoulder impingement and/or rotator cuff pathology. The quality of evidence in this area is limited and further research is warranted to determine the extent and nature of the relationship between thoracic manipulation and shoulder pain.

F.B, a 58 year-old male, was admitted to physical therapy after a two-month history of shoulder pain. Interventions were aimed at strengthening the periscapular musculature and rotator cuff, improving range of motion, decreasing pain, and returning to a pre-morbid level of injury. Manipulations to the cervicothoracic junction were performed in conjunction with exercise interventions. Outcomes included, changes in the VAS (visual analog pain scale), patient rating of overall improvement, and Quick DASH measurement. At the time of discharge, F.B. was determined to have a successful outcome based on decreased pain to 2/10 on the VAS and reports of 60% overall improvement. These tools are both found to be valid and reliable when used as acute subjective measures.

This case report indicates manipulations directed to the thoracic spine may be a useful adjunct to pragmatic treatment for patients with shoulder pain.

Introduction

Shoulder pain is one of the most common diagnoses seen in a physical therapy setting. Approximately 16% to 20% of the population experiences shoulder pain, making it the second most common musculoskeletal condition following low back pain. Recent discussions in the physical therapy community have been targeted towards addressing the thoracic spine for patients with shoulder impairments, particularly those with signs and symptoms of subacromial impingement. The need for evidence to support these interventions is apparent through the increased use of manual and manipulative therapy by practicing therapists globally. A key notion discussed among research of thoracic manipulations is the concept of regional interdependence. Wainner and colleagues describe regional interdependence as “the concept that seemingly unrelated impairments in a remote anatomical region may contribute to, or be associated with, the patient’s primary complaint.” This perception suggests that interventions targeting adjacent anatomical areas may directly affect the outcomes of the involved joint.

A review of the evidence was performed using the University of Texas Medical Branch’s library website, which allows access to a variety of sources. The search began using the PubMed (Medline) database with a topic of “thoracic manipulation,” which resulted in 879 results. The search was then narrowed to include “thoracic manipulation and shoulder”, which produced 29 results. Of the 29 articles, 5 were reviewed and later included in the annotated bibliography. Additional resources were reviewed including the public website “Physiopedia”, an online database for sharing information amongst rehabilitation professionals worldwide. Additional sources (CINHAL, Cochrane Database) were examined using the same key words (MeSH terms “thorax” and “shoulder”) and produced minimal findings as compared to PubMed. A review of shared material on the use of thoracic manipulations for shoulder impairments was performed and additional articles were then reviewed, although later excluded due to inclusion and exclusion factors. After reviewing all of the sources, twelve articles were selected and considered for the report. These articles were analyzed based on the inclusion and/or exclusion of several key factors. Inclusion factors were the mention of thoracic manipulations, higher levels of evidence, published within the last five years, access to full article, and shoulder impingement being the primary diagnosis. Exclusion factors included if the article was published greater than five years ago, abstract only, not related to physical therapy, no mention of thoracic manipulation, and the primary diagnosis was not shoulder impingement.

Case Description

Consecutive patients presenting to an outpatient orthopedic clinic with shoulder pain were evaluated for inclusion into the case study. The inclusion criteria used to determine if the patient was suitable for a possible manipulative technique was decreased shoulder ROM, pain with active shoulder movements, positive Neer impingement test, positive Hawkins-Kennedy test, pain with resisted abduction, IR, or ER, and pain with resisted empty can test. “Exclusion criteria included post-surgical patients, previous shoulder rehabilitation for this episode of shoulder pain, a positive Spurling test, traumatic shoulder dislocation or instability within the past 3 months, reproduction of shoulder pain with active or passive cervical range of motion, or a clinical presentation of adhesive capsulitis defined as a loss in passive shoulder range of motion greater than 50% as compared to the uninvolved side in at least 2 shoulder movements.” The patient had to meet four of the six inclusion criteria and none of the exclusion criteria in order to qualify for the case study. This resulted in one subject, F.B., a 58 year-old male, presenting to physical therapy with a medical diagnosis of rotator cuff syndrome of his left shoulder.

Outcome Measures

The outcome measures used for this case study included pain according the visual analog scale (VAS), overall rating of change, and the Disabilities of the Arm, Shoulder, and Hand (Quick DASH) questionnaire. Pain intensity was rated using the VAS, which rates pain on a scale from 0 to 10, with 0 being no pain and 10 being very high pain levels. The visual analog scale has been shown to be a reliable and valid tool for assessing immediate changes in pain intensity, with a test-retest reliability of between 0.95-0.97 and the minimally clinically important difference of 12 mm (+/- 3 mm at a 95% CI). An overall rating of change was measured at discharge by asking the patient to rate their global improvement since beginning physical therapy, as 0% being no improvement and 100% being completely asymptomatic and fully functional. This can be compared to a global rate of change scale, which is considered to be a valid reference for establishing a successful outcome. The final outcome measure used was the Quick DASH questionnaire, which is a measure of overall upper extremity function and can be interpreted by the patient to target the shoulder, elbow, or hand. This questionnaire has been modified from the original 30-question assessment (DASH), and now includes eleven questions targeting disability and symptoms, four optional work –related questions, and four optional performing arts/sports module questions. The Quick DASH score ranges from 0 to 100 points, with 0 reflecting no disability. Correlations between the DASH and the Quick DASH assessments have been reported to be extremely high: 0.97 The DASH has been found to be valid for specific shoulder impairments including rotator cuff syndromesand has demonstrated excellent reliability (ICC= 0.92, 0.96) and responsiveness.