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{{DISPLAYTITLE:Thoracic Manipulation for Shoulder Dysfunction}}
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'''Original Editor '''- [[User:Carla Benton |Carla Benton]]
'''Original Editor '''- [[User:Carla Benton|Carla Benton]]  


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== Thoracic manipulation with treatment of shoulder dysfunction<br> ==
== Introduction ==
[[File:Shoulder pain.jpg|thumb]]
Shoulder pain is a common musculoskeletal disorder encountered in primary care.<ref>Tekavec E, Jöud A, Rittner R, Mikoczy Z, Nordander C, Petersson IF, Englund M. Population-based consultation patterns in patients with shoulder pain diagnoses. BMC musculoskeletal disorders. 2012 Dec;13(1):1-8.</ref> For the treatment of shoulder pain, physiotherapy is recommended as an initial form of conservative treatment.<ref>Littlewood C, Malliaras P, Chance-Larsen K. Therapeutic exercise for rotator cuff tendinopathy: a systematic review of contextual factors and prescription parameters. International Journal of Rehabilitation Research. 2015 Jun 1;38(2):95-106.</ref> Of the various interventions provided, thoracic [[Spinal Manipulation|manipulation]] (movement of high speed and low amplitude) may be applied. The latest research demonstrates that thoracic spinal manipulation yields a decrease in shoulder pain and overall improvements in function of the shoulder.<ref>Haik MN, Alburquerque-Sendín F, Silva CZ, Siqueira-Junior AL, Ribeiro IL, Camargo PR. Scapular kinematics pre–and post–thoracic thrust manipulation in individuals with and without shoulder impingement symptoms: a randomized controlled study. Journal of orthopaedic & sports physical therapy. 2014 Jul;44(7):475-87.</ref>


In the orthopedic physical therapy setting, shoulder pain and dysfunction is a common diagnosis. Whether the cause may be a rotator cuff, bursa inflammation, degenerative changes in the glenohumeral joint, or spurring, our choices of treatment are varied. Now there is evidence to support the use of manual therapy, that includes thoracic spine thrust manipulation (TSTM). The clinical rationale for the use of thoracic manipulation with shoulder patients is based on regional interdependence (Wainner et al, 2001). This basically states that one area directly affects another. If one area, such as the thoracic spine is dysfunctional, it may affect the mobility of the shoulder as well, and create shoulder pain and limitations in function of the upper extremity. <br>
== Factors to Consider  ==
'''Range of Motion ([https://physio-pedia.com/Range_of_Motion ROM]):'''


In a recent study performed by Boyles et al<ref name="Boyles">Boyles RE, Bradley BM, Miracle BM, Barclay DM, Faul MS, Moore JH, Koppenhaver SL, Wainner RS. The short-term effects of thoracic spine thrust manipulation om patients with shoulder impingement syndrome. Manual Therapy 2009; 14:375-380.</ref> 56 patients with shoulder impingement, were treated with thoracic spine thrust manipulation. Upon completion of the physical exam, all of the patients received a high velocity, low amplitude thoracic spine thrust manipulation with focus on the mid-thoracic and cervicothoracic junctional areas. These patients demonstrated statistically significant changes in pain and disability scores at 48 hours. It was mentioned above that regional interdependence may be one reason this intervention is so successful when used with shoulder patients; however another possible reason for changes may be the effects that thoracic posture has on shoulder pain (Bulloch et al, 2005; Lewis et al, 2005). It seems that postural correction in the thoracic spine decreases shoulder pain, and assists with increasing overall shoulder mobility.&nbsp;<ref name="Boyles" /> <br>
Generally, patients with shoulder pain present with decreased active range of motion, yielding a decrease in functional mobility and capability.<ref>MacDermid JC, Ramos J, Drosdowech D, Faber K, Patterson S. The impact of rotator cuff pathology on isometric and isokinetic strength, function, and quality of life. Journal of Shoulder and Elbow Surgery. 2004 Nov 1;13(6):593-8.</ref>Maintaining shoulder ROM is an important factor for maintaining good functional capacity and improving a patient's level of independence.


Other research has shown a relationship between scapular positional dysfunction and shoulder dysfunction and pathology (Kibler, 1998; Lukasiewicz et al, 1999; Ludewig and Cook, 2000; Laudner et al, 2006). So basically the position of the scapula on the thoracic wall affects posture, which could affect shoulder function.<br>Another explanation for use of TSTM with shoulder patients by Bergman et al<ref name="Bergman">Bergman GJD, Winters JC, van der Heijden, JMG, Postema K, Meyboom-de Jong B. Groningen Manipulation Study. The effect of manipulation of the structures of the shoulder girdle as additional treatment for symptom relief and for prevention of chronicity or recurrence of shoulder symptoms. Design of a randomized controlled trial within a comprehensive prognostic cohort study. Journal of Manipulative and Physiological Therapeutics 2002;November/December :543-549.</ref> describes the relationship of restoring mobility between adjacent vertebrae which may be blocked by entrapment of a meniscoid. The relationship between reduced mobility of the cervicothoracic spine and shoulder pain could be explained by this reflexogenic mechanism. Abnormal biomechanical relationship between adjacent vertebra can also compress nerve roots, which can affect associated segmental muscular function, such as muscle spasms.<ref name="Bergman" /> This can cause abnormal movement patterns in the shoulder complex , including the scapulohumeral joint. Use of manipulative treatment can help our patients not only improve their shoulder mobility, but improve their overall functional performance.<br>
'''Thoracic Spine:''' 


Another study initiated by Rainbow et al<ref name="Rainbow">Rainbow DM, Weston JP, Brantingham JW, Globe G, Lee F. A prospective clinical trial comparing chiropractic manipulation and exercise therapy vs. chiropractic mobilization and exercise therapy for treatment of patients suffering from adhesive capsulitis/frozen shoulder. Journal of the American Chiropractic Association 2008; September/October: 12-28.</ref> compared the effects of shoulder, cervical, and thoracic spine high velocity, low-amplitude (HVLA) chiropractic manipulative therapy in the treatment of frozen shoulder. Group 1 received HVLA chiropractic manipulative therapy for 6 weeks to the glenohumeral joint, cervical, and thoracic spines, along with were given home exercise program. Group 2 received grade 4 glenohumeral joint mobilization for 6 weeks with a home exercise program. Both groups were given the same home program. The outcome measure used to measure change was the Shoulder Pain and Disability Index (SPADI). Greater than a 10 point decrease in SPADI score is considered clinically significant and meaningful. Initial scores of SPADI for Group 1=68.3, and Group 2=65.2. After 6 weeks of treatment, the chiropractic manipulative treatment group decreased to 14.1, while the Mobilization group of glenohumeral decreased to 35. Both showed clinically meaningful changes in reduced pain and disability; however, the manipulative group improved by an additional 24 points compared to Group 2. Is there any difference in chiropractic manipulative therapy and physical therapy manipulative care?<br>  
The shoulder, or [[Glenohumeral Joint|glenohumeral joint]], is affected by neighboring joints. It articulates  with the rib cage via the scapula and is connected to the thoracic spine through various muscles. The thoracic spine forms a key link in the kinematic sequence of arm elevation. The position of the thoracic spine significantly affects scapular kinematics during scapular plane abduction. A slouched posture is associated with decreased shoulder range of motion and muscle force.<ref>Functional Anatomy of the Shoulder [Internet]. Physiopedia. Available from: <nowiki>https://www.physio-pedia.com/Functional_Anatomy_of_the_Shoulder</nowiki></ref>  


The final study that I wanted to discuss was a study by Menck et al<ref name="Menck">Menck JY, Requejo SM, Kulig K. Thoracic spine dysfunction in upper extremity complex regional pain syndrome Type I. Journal of Orthopaedic and Sports Physical Therapy 2000; 30:401-409.fckLRCarla Benton</ref> that used the treatment of the thoracic spine in the management of patients who suffered from upper extremity Complex Regional Pain Syndrome Type I (CRPS-I). This was a case study in which a 38 year old woman suffered from a traumatic injury to her left hand. She was treated for 36 visits in 3 months with treatment other than thoracic manipulation. Then T3-4 vertebral manipulation was implemented and immediately there was a significant increase in the left hand’s skin temperature. Shoulder range of motion increased from 135 to 175 degrees, and the patient reported decreased pain from 6/10 to 3/10. The authors hypothesized that there may be a relationship between symptoms of the upper extremity CRPS and the thoracic spine. They , too, discuss the abnormal posturing caused by disuse of the upper extremity, leading to thoracic hypomobility. Thoracic joint manipulation improved spinal mobility, and also assisted in decreasing distal and autonomic symptoms. This helped to improve overall functional performance of this patient’s upper extremity. This patient was discharged with full return to independence .<br>  
Thoracic side bending and rotation are caused my unilateral humeral motions. Thoracic rotation and glenohumeral external rotation indicate significant coupling of these segmental movements. <ref>Crosbie J, Kilbreathe SL, Hooman L, York S. Scapulohumeral rhythm and associated spinal motion. Clin Biomechan. 2008; 23: 184-192.</ref>  


One can distinguish from the evidence that our approach to treatment of the shoulder patient should include thoracic manipulation. Many physical therapists are not comfortable with manipulation; however, as one can see, it is becoming mandatory to gain these manual skills to deliver successful treatment for our patients. Attending continuing education courses, as well as completing residencies, such as Evidence in Motion, can help us stay up with the evidence, and continue to grow our profession as manual experts. The challenge is on for all of us, young and old, to become recognized as experts in the treatment of musculoskeletal dysfunctions. We cannot do this without continuing to learn and grow, and using the evidence to help guide our interventions.<br>
*Another explanation for use of thoracic manipulation with shoulder patients is the relationship of restoring mobility between adjacent vertebrae which may be blocked by entrapment of a meniscoid.
*The relationship between reduced mobility of the cervicothoracic spine and shoulder pain could be explained by this reflexogenic mechanism.
*Abnormal biomechanical relationship between adjacent vertebra can also compress nerve roots, which can affect associated segmental muscular function, such as muscle spasms. This can cause abnormal movement patterns in the shoulder complex, including the scapulohumeral joint.
*Use of manipulative treatment can help our patients not only improve their shoulder mobility, but improve their overall functional performance.
[[File:Chris-benson-yx-iJFybOBQ-unsplash.jpg|right|frameless]]
'''Postural Dysfunctions'''


== Resources<br>  ==
Posture and related impairments may affect shoulder pain and the thoracic spine. The [[Upper-Crossed Syndrome|upper crossed postural syndrome]], including [[Forward Head Posture|forward head posture]], is defined by the presence of weak deep neck flexors along with weak rhomboids and lower trapezius. Tight pectoralis muscles along with a tight upper trapezius muscle can affect the position of the scapula, consequently affecting shoulder function.


#Boyles RE, Bradley BM, Miracle BM, Barclay DM, Faul MS, Moore JH, Koppenhaver SL, Wainner RS. The short-term effects of thoracic spine thrust manipulation om patients with shoulder impingement syndrome. Manual Therapy 2009; 14:375-380.<br>  
'''Regional Interdependence'''
#Bergman GJD, Winters JC, van der Heijden, JMG, Postema K, Meyboom-de Jong B. Groningen Manipulation Study. The effect of manipulation of the structures of the shoulder girdle as additional treatment for symptom relief and for prevention of chronicity or recurrence of shoulder symptoms. Design of a randomized controlled trial within a comprehensive prognostic cohort study. Journal of Manipulative and Physiological Therapeutics 2002;November/December&nbsp;:543-549.<br>  
 
#Rainbow DM, Weston JP, Brantingham JW, Globe G, Lee F. A prospective clinical trial comparing chiropractic manipulation and exercise therapy vs. chiropractic mobilization and exercise therapy for treatment of patients suffering from adhesive capsulitis/frozen shoulder. Journal of the American Chiropractic Association 2008; September/October: 12-28.<br>  
The clinical rationale for the use of thoracic manipulation with shoulder patients is based on regional interdependence. This is defined as the 'concept that seemingly unrelated impairments in a remote anatomical region may contribute to, or be associated with, the patient's primary complaint'.<ref name=":0">Wainner RS, Whitman JM, Cleland JA, Flynn TW. Regional interdependence: a musculoskeletal examination model whose time has come. Journal of orthopaedic & sports physical therapy. 2007 Nov;37(11):658-60.</ref> Thus, thoracic spine dysfunction can affect shoulder mobility. It can create shoulder pain and limitations in function of the upper extremity. <ref name=":0" /><br>
#Menck JY, Requejo SM, Kulig K. Thoracic spine dysfunction in upper extremity complex regional pain syndrome Type I. Journal of Orthopaedic and Sports Physical Therapy 2000; 30:401-409.  
[[File:4 Prone extension-closing manipulation.jpg|right|frameless]]
 
===Body Response to Manipulation===
Overall, short term pain relief is observed post-spinal manipulation, reinforcing the concept of central nervous system's role in pain control.<ref>Santos-Júnior FF, Rossi DM, de Freitas LJ, Martins J, de Oliveira AS. Spinal manipulation combined with exercise therapy could be more effective than exercise therapy alone for shoulder pain and disability: A systematic review and meta-analysis. International Journal of Osteopathic Medicine. 2023 Sep 30:100688.</ref> There is also increased scapular strength with manipulation leading to overall improvement of long term strength. There is an immediate short-term reduction in the numeric pain rating score (NPRS) and shoulder pain and disability index (SPADI) score following thoracic manipulation.<ref>Rainbow DM, Weston JP, Brantingham JW, Globe G, Lee F. A Prospective Clinical Trial Comparing Chiropractic Manipulation and Exercise Therapy vs. Chiropractic Mobilization and Exercise Therapy for Treatment of Patients Suffering from Adhesive Capsulitis/Frozen Shoulder. Journal of the American Chiropractic Association. 2008 Sep 1;45(7).</ref> Postural correction in the thoracic spine decreases shoulder pain and assists with increasing overall shoulder mobility. Thoracic joint manipulation improved spinal mobility and assisted in decreasing distal and autonomic symptoms.<ref>Hegarty AK, Hsu M, Roy JS, Kardouni JR, Kutch JJ, Michener LA. Evidence for increased neuromuscular drive following spinal manipulation in individuals with subacromial pain syndrome. Clinical Biomechanics. 2021 Dec 1;90:105485.</ref>
 
== Intervention  ==
 
[[Manual Techniques for the Cervicothoracic Spine]]
 
== Case Studies  ==
 
[[Effectiveness of thoracic manipulations on shoulder pain: A Case Report|The effectiveness of thoracic manipulations on shoulder pain: A Case Report]]


== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
<div class="researchbox">
<rss>http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1vaAFBuRYujs7YrKbvkMD-5McuDePd2_6FJwe97xx4L8Qo9Mtc|charset=UTF-8|short|max=10</rss>
</div>
== References  ==
== References  ==


References will automatically be added here, see [[Adding References|adding references tutorial]].
<references />
 
[[Category:Cervical Spine]]
[[Category:Thoracic Spine]]
[[Category:Shoulder]]
[[Category:Interventions]]
[[Category:Thoracic Spine - Interventions]]


<references />
[[Category:Cervical Spine - Interventions]]
[[Category:Thoracic Spine - Interventions]]
[[Category:Shoulder - Interventions]]
{{DEFAULTSORT:Thoracic_Manipulation_for_Shoulder_Dysfunction}}

Latest revision as of 18:52, 17 January 2024

Original Editor - Carla Benton

Top Contributors - Kim Jackson, Maram Salem, Admin, Dana Tew, Lucinda hampton, WikiSysop and Carla Benton

Introduction[edit | edit source]

Shoulder pain.jpg

Shoulder pain is a common musculoskeletal disorder encountered in primary care.[1] For the treatment of shoulder pain, physiotherapy is recommended as an initial form of conservative treatment.[2] Of the various interventions provided, thoracic manipulation (movement of high speed and low amplitude) may be applied. The latest research demonstrates that thoracic spinal manipulation yields a decrease in shoulder pain and overall improvements in function of the shoulder.[3]

Factors to Consider[edit | edit source]

Range of Motion (ROM):

Generally, patients with shoulder pain present with decreased active range of motion, yielding a decrease in functional mobility and capability.[4]Maintaining shoulder ROM is an important factor for maintaining good functional capacity and improving a patient's level of independence.

Thoracic Spine:

The shoulder, or glenohumeral joint, is affected by neighboring joints. It articulates with the rib cage via the scapula and is connected to the thoracic spine through various muscles. The thoracic spine forms a key link in the kinematic sequence of arm elevation. The position of the thoracic spine significantly affects scapular kinematics during scapular plane abduction. A slouched posture is associated with decreased shoulder range of motion and muscle force.[5]

Thoracic side bending and rotation are caused my unilateral humeral motions. Thoracic rotation and glenohumeral external rotation indicate significant coupling of these segmental movements. [6]

  • Another explanation for use of thoracic manipulation with shoulder patients is the relationship of restoring mobility between adjacent vertebrae which may be blocked by entrapment of a meniscoid.
  • The relationship between reduced mobility of the cervicothoracic spine and shoulder pain could be explained by this reflexogenic mechanism.
  • Abnormal biomechanical relationship between adjacent vertebra can also compress nerve roots, which can affect associated segmental muscular function, such as muscle spasms. This can cause abnormal movement patterns in the shoulder complex, including the scapulohumeral joint.
  • Use of manipulative treatment can help our patients not only improve their shoulder mobility, but improve their overall functional performance.
Chris-benson-yx-iJFybOBQ-unsplash.jpg

Postural Dysfunctions

Posture and related impairments may affect shoulder pain and the thoracic spine. The upper crossed postural syndrome, including forward head posture, is defined by the presence of weak deep neck flexors along with weak rhomboids and lower trapezius. Tight pectoralis muscles along with a tight upper trapezius muscle can affect the position of the scapula, consequently affecting shoulder function.

Regional Interdependence

The clinical rationale for the use of thoracic manipulation with shoulder patients is based on regional interdependence. This is defined as the 'concept that seemingly unrelated impairments in a remote anatomical region may contribute to, or be associated with, the patient's primary complaint'.[7] Thus, thoracic spine dysfunction can affect shoulder mobility. It can create shoulder pain and limitations in function of the upper extremity. [7]

4 Prone extension-closing manipulation.jpg

Body Response to Manipulation[edit | edit source]

Overall, short term pain relief is observed post-spinal manipulation, reinforcing the concept of central nervous system's role in pain control.[8] There is also increased scapular strength with manipulation leading to overall improvement of long term strength. There is an immediate short-term reduction in the numeric pain rating score (NPRS) and shoulder pain and disability index (SPADI) score following thoracic manipulation.[9] Postural correction in the thoracic spine decreases shoulder pain and assists with increasing overall shoulder mobility. Thoracic joint manipulation improved spinal mobility and assisted in decreasing distal and autonomic symptoms.[10]

Intervention[edit | edit source]

Manual Techniques for the Cervicothoracic Spine

Case Studies[edit | edit source]

The effectiveness of thoracic manipulations on shoulder pain: A Case Report

References[edit | edit source]

  1. ↑ Tekavec E, Jöud A, Rittner R, Mikoczy Z, Nordander C, Petersson IF, Englund M. Population-based consultation patterns in patients with shoulder pain diagnoses. BMC musculoskeletal disorders. 2012 Dec;13(1):1-8.
  2. ↑ Littlewood C, Malliaras P, Chance-Larsen K. Therapeutic exercise for rotator cuff tendinopathy: a systematic review of contextual factors and prescription parameters. International Journal of Rehabilitation Research. 2015 Jun 1;38(2):95-106.
  3. ↑ Haik MN, Alburquerque-Sendín F, Silva CZ, Siqueira-Junior AL, Ribeiro IL, Camargo PR. Scapular kinematics pre–and post–thoracic thrust manipulation in individuals with and without shoulder impingement symptoms: a randomized controlled study. Journal of orthopaedic & sports physical therapy. 2014 Jul;44(7):475-87.
  4. ↑ MacDermid JC, Ramos J, Drosdowech D, Faber K, Patterson S. The impact of rotator cuff pathology on isometric and isokinetic strength, function, and quality of life. Journal of Shoulder and Elbow Surgery. 2004 Nov 1;13(6):593-8.
  5. ↑ Functional Anatomy of the Shoulder [Internet]. Physiopedia. Available from: https://www.physio-pedia.com/Functional_Anatomy_of_the_Shoulder
  6. ↑ Crosbie J, Kilbreathe SL, Hooman L, York S. Scapulohumeral rhythm and associated spinal motion. Clin Biomechan. 2008; 23: 184-192.
  7. ↑ 7.0 7.1 Wainner RS, Whitman JM, Cleland JA, Flynn TW. Regional interdependence: a musculoskeletal examination model whose time has come. Journal of orthopaedic & sports physical therapy. 2007 Nov;37(11):658-60.
  8. ↑ Santos-Júnior FF, Rossi DM, de Freitas LJ, Martins J, de Oliveira AS. Spinal manipulation combined with exercise therapy could be more effective than exercise therapy alone for shoulder pain and disability: A systematic review and meta-analysis. International Journal of Osteopathic Medicine. 2023 Sep 30:100688.
  9. ↑ Rainbow DM, Weston JP, Brantingham JW, Globe G, Lee F. A Prospective Clinical Trial Comparing Chiropractic Manipulation and Exercise Therapy vs. Chiropractic Mobilization and Exercise Therapy for Treatment of Patients Suffering from Adhesive Capsulitis/Frozen Shoulder. Journal of the American Chiropractic Association. 2008 Sep 1;45(7).
  10. ↑ Hegarty AK, Hsu M, Roy JS, Kardouni JR, Kutch JJ, Michener LA. Evidence for increased neuromuscular drive following spinal manipulation in individuals with subacromial pain syndrome. Clinical Biomechanics. 2021 Dec 1;90:105485.
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