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.

Examination

The initial evaluation of F.B. was performed on February 22, 2011, after receiving a prescription by the referring physician on February 14, 2011. The patient was given the Quick DASH measurement prior to beginning the evaluation and completed all required medical history information and intake paperwork. The history portion of the exam was then performed with key emphasis on mechanism of injury, current and most intense pain rating according to the VAS, functional limitations and prior functional status, and patient goals and rehabilitation expectations. F.B. reported that he has experienced a two-month history of posterior shoulder pain that is limiting his functional and recreational activities. The patient also noted that he is currently building an outdoor shower and that overhead activities are increasing his pain. Initial pain ratings are 0/10 currently and 10/10 at worst, which was described as being present with overhead activities. The initial Quick DASH rating of disability was 29/11 or 41% perceived disability score. F.B. stated that his goals were to return to exercise and activities of daily living symptom free and without restrictions or limitations.

Objective measurements included general observation of scapular kinematics with overhead motion, palpation, manual muscle testing of both the left and right upper extremity, active and passive range of motion of the left and right shoulders, cervical clearing exam, and some special tests. There was slight dyskinesia noted with lowering of the left arm indicating some weakness of the scapular stabilizers. Resisted testing and range of motion produced positive findings on the left and can be seen in greater detail in tables 1 and 2 (below) respectively. Palpation of the left posterior shoulder capsule and infraspinatus produced moderate pain. The cervical clearing exam was negative, being that it did not reproduce any of the posterior shoulder symptoms. Special tests performed included the Hawkins-Kennedy impingement test, the Neer impingement test and the empty-can test, all of which have been shown to have good reliability and validity. Symptoms were aggravated by the Hawkins-Kennedy procedure but no symptoms were reproduced with the Neer or empty-can tests.

Table 1

MMT	Left	Right
Scapular Elevation	5/5	5/5
Shoulder Abduction	4/5	5/5
Shoulder Adduction	4/5	5/5
Shoulder ER	4/5	4+/5
Shoulder IR	4/5	4+/5
Elbow Extension	5/5	5/5
Elbow Flexion	5/5	5/5

Table 2

ROM (in degrees)	Left AROM	Right AROM	Left PROM	Right PROM
Flexion	150	180	150	180
Abduction	125	180	125	180
ER -45	50	60	60	75

Interventions

The plan of care was created targeting the impairments of poor muscle strength and performance, decreased functional status, pain, and decreased range of motion. F.B. was given a good prognosis and the expected length of therapy was 2 visits per week for 6 weeks. The intervention program consisted of periscapular strengthening, general upper extremity strengthening, active-assisted range of motion exercises, modalities as need for pain, open and closed chain rotator cuff strengthening, proprioceptive neuromuscular facilitation (PNF) techniques, manipulations targeting the cervicothoracic junction, and patient education. F.B. attended a total of nine therapy sessions. The exercise regimen was divided into three phases, with the initial phase focusing on strengthening the surrounding musculature and normalizing pain levels, the second phase included strengthening targeting the rotator cuff directly and the third phase which included manual PNF techniques targeting end-range activation of the rotator cuff and higher-level closed-chain exercise activities, such as push-ups.

The initial treatment sessions (1-3) began with heat to aid in pain management, active-assisted exercises including the use of a wand and rope and pulley for flexion and external rotation motions, and periscapular and general upper extremity strengthening. The second phase was initiated on visit four and included theraband (level blue resistance) exercises targeting the rotator cuff directly and some closed chain scapular strengthening. This progression was continued and the intensity increased for the remainder of this phase from visits 4-7. The final stage of rehabilitation included the initiation of PNF manual techniques in supine targeting end-range internal and external rotation. Additional advancements included the re-introduction of pre-injury strengthening exercises such as push-ups and weighted overhead activities.

The manual therapy technique of manipulation to the cervicothoracic junction was performed at visits four and seven. The technique included two possible patient positions, one in prone and the other in supine (see Appendix 1). Two attempts were allotted in each position and if cavitations were not produced after those four attempts the treatment was discontinued for that session. A joint assessment of the cervical and thoracic spine was performed prior to each manipulation. The patient was informed of the possible outcomes, including cavitations, prior to the execution of each manipulation. Patient education included the predicted benefits of the manipulative technique and its outcomes. According to Tate et al, “manual therapy has been used in conjunction with an exercise program, and superior outcomes have been reported in comparison to the use of an exercise program alone.” The manipulative technique produced cavitations on the initial attempt, at visit four, but did not produce cavitations at the seventh visit.