Journal of Sport Rehabilitation, 2015, 24, 116 -129 http://dx.doi.org/10.1123/jsr.2013-0120 © 2015 Human Kinetics, Inc.
Original Research Report
The Effects of Scapular Mobilization in Patients With Subacromial Impingement Syndrome: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial Aydan Aytar, Gul Baltaci, Tim Uhl, Handan Tuzun, Pinar Oztop, and Metin Karatas Objective: To determine the effects of scapular mobilization on function, pain, range of motion, and satisfaction in patients with subacromial impingement syndrome (SAIS). Design: Randomized, double-blind, placebocontrolled clinical trial. Setting: University hospital clinics in Turkey. Participants: 66 participants (mean ± SD age 52.06 ± 3.71 y) with SAIS. Interventions: Participants were randomized into 3 groups: scapular mobilization, sham scapular mobilization, and supervised exercise. Before the interventions transcutaneous electrical stimulation and hot pack were applied to all groups. Total intervention duration for all groups was 3 wk with a total of 9 treatment sessions. Main Outcome Measures: Shoulder function and pain intensity were primary outcome measures; range of motion and participant satisfaction were secondary outcome measures. Shoulder function was assessed with the short form of the Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH). A visual analog scale was used to evaluate pain severity. Active range of motion was measured with a universal goniometer. A 7-point Likert scale was used to evaluate satisfaction. Outcome measurements were performed at baseline, before visits 5 and 10, 4 wk after visit 9, and 8 wk after visit 9. Results: There was no group difference for DASH score (P = .75), pain at rest (P = .41), pain with activity (P = .45), pain at night (P = .74), and shoulder flexion (P = .65), external rotation (P = .63), and internal rotation (P = .19). There was a significant increase in shoulder motion and function and a significant decrease in pain across time when all groups were combined (P < .001). The level of satisfaction was not significantly different for any of the questions about participant satisfaction between all groups (P > .05). Conclusion: There was not a significant advantage of scapular mobilization for shoulder function, pain, range of motion, and satisfaction compared with sham or supervised-exercise groups in patients with SAIS. Keywords: shoulder, rehabilitation, pain, function, satisfaction Shoulder pain is a common problem in both sporting and working populations.1,2 Approximately 1% of adults consult a general medical practitioner with an episode of shoulder pain each year.1,2 The most frequent cause of shoulder pain is subacromial impingement syndrome (SAIS), accounting for 44% to 65% of all complaints of shoulder pain.3,4 There are many treatment methods prescribed for SAIS, incorporating 4 primary areas: modalities,5–10 manual therapy,11–13 therapeutic strengthening,14–17 and flexibility exercises.11,16 Physiotherapy agents such as Aytar is with the Dept of Physiotherapy and Rehabilitation, and Oztop and Karatas, the Dept of Physical Medicine and Rehabilitation, Baskent University School of Medicine, Ankara, Turkey. Baltaci is with the School of Physiotherapy, Hacettepe University, Ankara, Turkey. Uhl is with the Div of Athletic Training, University of Kentucky, Lexington, KY. Tuzun is with the Dept of Physiotherapy and Rehabilitation, Kirikkale University, Ankara, Turkey. Address author correspondence to Aydan Aytar at [email protected].
116
transcutaneous electrical stimulation (TENS) and hot packs are generally used in physiotherapy clinics.5–10 The application of heat and TENS could help reduce pain, soreness, and stiffness and so help improve function; in addition to these effects they enhance plasticity of connective tissue.18,19 These modalities could help relax and prepare patients for interventions before exercising or using manual techniques in rehabilitation. Different physiotherapy applications such as manual therapy are used with other interventions to regain motion and improve function.2,20 Physiotherapists usually use mobilization in association with other physiotherapy interventions to regain normal shoulder and scapular function.5,21–24 Manual therapy often is a combination of joint mobilization to a specific joint and various forms of massage. There is limited but supporting evidence that indicates that manual therapy is beneficial in this patient population when integrated with other interventions.11–13,20 Shoulder-impingement disorders are classified as primary or secondary. Primary shoulder impingement occurs when the rotator-cuff tendons, long head of the biceps tendon, glenohumeral (GH) joint capsule, and/
Downloaded by Univ of Florida on 09/16/16, Volume 24, Article Number 2
The Effects of Scapular Mobilization 117
or subacromial bursa becomes impinged between the humeral head and anterior acromion. Primary impingement may be due to intrinsic factors: rotator-cuff weakness, chronic inflammation of the rotator-cuff tendons and/or subacromial bursa, rotator-cuff degenerative tendinopathy, and posterior-capsule tightness leading to abnormal anterosuperior translation of the humeral head. It may also be due to extrinsic factors: possession of a curved or hooked acromion, acromial spurs, or postural dysfunction. Secondary shoulder impingement is defined as a relative decrease in the subacromial space due to GH-joint instability or abnormal scapulothoracic kinematics.25 The anatomy and function of the shoulder girdle depend on the function of 3 synovial joints (GH, acromioclavicular, and sternoclavicular) and 1 pseudo-joint (scapulothoracic).26 The relationship of scapular motion to GH motion is termed scapulohumeral rhythm. During normal shoulder abduction (or flexion), a natural 2:1 ratio or rhythm exists between the GH and scapulothoracic joints.21 This means that for every 2° of GH abduction, the scapula must simultaneously upwardly rotate roughly 1°. Based on this rhythm, a full arc of 180° of shoulder abduction is the result of a simultaneous 120° of GH abduction and 60° of scapulothoracic upward rotation.27 Therefore, scapular-movement abilities in many directions are important for shoulder range of motion, and it is important to remember the overall relationship between humeral and scapular motion when considering the full 180° of shoulder abduction. There is substantial evidence of scapular kinematic abnormalities in persons with shoulder pain.21 Alteration of scapular kinematics can be a key component in the production of the symptoms associated with impingement.28 However, the manual-therapy techniques have primarily focused on mobilization of the GH joint in patients with SAIS.11–13 To date, limited studies have examined the effectiveness of scapular mobilization.20,29 Therefore, the purpose of this study was to determine the immediate and lasting effects of scapular mobilization in patients with SAIS.
following findings: a positive Neer impingement test, a positive Hawkins impingement test, a positive painfularc sign (60–120° of elevation), pain with palpation of the rotator-cuff tendons, pain with isometric resisted abduction, and pain at the shoulder region.23,30,31 On confirmation of these findings, participants were further screened for participation in this study by meeting the following criteria: score of the Disabilities of the Arm, Shoulder and Hand Questionnaire (Quick DASH) >20, pain for ≥6 months, and pain with activity between 2 and 8 on a 10-cm visual analog scale. Participants were excluded from this study if they demonstrated any of the following symptoms: signs of a rotator-cuff tear or rupture (a positive lag sign such as a drop-arm or lift-off sign); positive shoulder anterior, posterior, and inferior instability tests (a positive anterior and posterior apprehension test, relocation and sulcus sign, drawer test, load and shift test); cervical neurologic symptoms (symptom reproduction from a Spurling test, light touch deficits in a particular dermatome); current trauma such as fractures or dislocations; or previous history of surgery in the affected shoulder. This study was carried out at the Baskent University Physical Medicine and Rehabilitation Outpatient Clinic. All participants provided written informed consent before this study, which was approved by an ethics board (University of Baskent).
Materials and Methods
Before the study began randomization procedure was performed using an online random-allocation software program32 by the treating physical therapist with 69 participants in case of dropout. Participants were randomized into 1 of 3 groups: scapular mobilization (SM) (n = 23), sham SM (SSM) (n = 23), or supervised exercise (SE) (n = 23), but 3 participants did not receive interventions, so 66 participants were divided into 1 of 3 groups: SM (n = 22), SSM (n = 22), and SE (n = 22) (Figure 1).
Participants Before the study began, 69 participants were screened in case of dropout. Three participants did not receive interventions. Sixty-six (15 male, 51 female) participants (mean ± SD = 52.06 ± 3.71 y) enrolled for this study at baseline (0 wk) and before the fifth visit (2 wk) and the tenth visit (3 wk). Some participants were lost to follow-up. Sixty participants were enrolled at 4 weeks after the ninth visit (7 wk), and 31 participants were enrolled at 8 weeks after ninth visit (11 wk). Statistical analyses were done considering this dropout. A flow diagram is provided to show how participants progressed through this study (Figure 1). Study participants were referred from a physician with the diagnosis of SAIS. To confirm this evaluation, potential participants demonstrated at least 3 of the
Sample Size The sample size required to detect significant differences was determined using statistical software (N-Query Advisor, Statistical Solutions, Saugus, MA). Effect size was based on change scores from clinical data of 20 subjects with signs of impingement using the quick DASH, which is highly correlated with the DASH. The sample size was determined as 18 patients in each group with the alpha level set at .05 to achieve 90% power.
Randomization Procedures
Interventions and Blinding Procedures Before the interventions 1 physical therapist (PT) was designated as Evaluator PT. Evaluator PT performed all measurements for this study. A second PT was designated as Treating PT. Treating PT performed all treatments for this study. Evaluator PT and patients were blinded to the group allocations during the course of treatment.
JSR Vol. 24, No. 2, 2015
Downloaded by Univ of Florida on 09/16/16, Volume 24, Article Number 2
118 Aytar et al
Figure 1 — A flow diagram of the study. Abbreviations: SM, scapular mobilization; SSM, sham scapular mobilization; SE, supervised exercise.
Evaluator PT filled out a questionnaire at the beginning of study. This questionnaire included physical characteristics of participants, contact numbers, and mail addresses. Also, primary and secondary outcome measurements were taken before the interventions by Evaluator PT. Before the interventions, Treating PT applied hot pack and TENS for all study participants. The aim of this
application was to relax and prepare participants for interventions. Hot pack and conventional TENS (frequency = 100 Hz, pulse duration = 60 μs) were applied to all study participants (SM, SSM, and SE groups) for 20 minutes per treatment session. TENS electrodes and a hot pack were placed on shoulder joint. Interventions were designated into 3 groups: SM, SSM, and SE. Participants
JSR Vol. 24, No. 2, 2015
The Effects of Scapular Mobilization 119
were placed in only 1 of these 3 groups according to the randomization by Treating PT. Frequencies of all these interventions were approximately 12 minutes and 3 times per week for all groups. In addition to all interventions, some recommendations were made (sleeping position, load carrying, and daily living) were given to all groups for education at baseline and during all the intervention sessions.24,33,34 Total intervention duration for all groups was 3 weeks with a total of 9 treatment sessions. At the tenth visit all participants were retested with all measures and given the same home-exercise brochure.
Downloaded by Univ of Florida on 09/16/16, Volume 24, Article Number 2
SM Group
Figure 4 — Position for the distraction.
SM consisted of the application of superior and inferior gliding, rotations, and distraction to the scapula of affected shoulder.6,20,29 All interventions were applied in side-lying position with the involved extremity accessible to the PT. The PT grasped the superior and inferior angle of scapula and moved the scapula superiorly and inferiorly for superior and inferior glide (Figure 2) and then rotated it upward and downward for scapular rotation (Figure 3). Second, the PT grasped the inferior angle and vertebral border of the scapula and with both hands tilted the scapula away from the thoracic wall along with distraction of the scapula (Figures 4 and 5). Each application was applied 3 times for 10 repetitions and a rate of 1 cycle per 6 seconds, with a 30-second interval between sets.
Figure 5 — Application of scapular distraction.
SSM Group SSM replicated the treatment condition except for the hand positions and pressure. Borders of scapula were not grasped. Hands were randomly put on the scapula, and then just skin was moved in the superoinferior, mediolateral, and rotation directions with minimal pressure to make a sham application.29 Each application was applied 3 times for 10 repetitions and a rate of 1 cycle per 6 seconds with 30-second intervals between sets.
SE Group Figure 2 — Application of superior and inferior glide mobilization.
Figure 3 — Application of scapular upward and downward rotation.
Stretching (posterior capsule, external rotation, flexion and abduction stretch, pectoral stretch) and strengthening (serratus anterior, external rotation, and inferior glide) exercises were performed in front of the mirror with supervision of the PT. Participants performed stretching exercises 4 times for 30 seconds. They performed 2 sets of 10 repetitions of strengthening exercises, holding for 5 seconds at the end of each repetition. Between stretching and strengthening exercises, a 30-second interval was given. According to participants’ strength, suitable Thera-Band and weight were chosen by PT at the beginning of the treatment. Suitable Thera-Band and weight were determined by participants’ performing 10 repetitions of exercises with proper form and without pain or fatigue. Thera-Band or weight was progressed weekly. Stretching exercises were as follows: • The posterior-capsule stretch was performed by participants’ standing and holding the affected elbow with the opposite hand in front of the body
JSR Vol. 24, No. 2, 2015
120 Aytar et al
Downloaded by Univ of Florida on 09/16/16, Volume 24, Article Number 2
and slowly pulling the elbow across the body until they felt a comfortable stretch (Figure 6). • The external-rotation stretch was performed by participants’ placing the affected hand with elbow in 90° flexion on a cornered wall and turning their body until they felt a stretch (Figure 7). • The flexion and abduction stretch was performed by participants’ placing the affected hand with the elbow extended onto a table and reaching forward until stretch was felt (Figures 8 and 9).
• The pectoralis minor stretch was performed by participants’ placing each hand at shoulder height on adjacent walls of a corner and leaning into the corner (Figure 10). Strengthening exercises were as follows: • Strengthening for the serratus anterior muscle was performed participants ling supine and performing a scapular punch with scapular protraction against resistance of a handheld weight (Figure 11). • Strengthening for external rotation was performed by participants standing with both elbows bent by their sides. Holding a Thera-Band with both hands for resistance, they then retracted both scapulae while performing external rotation (Figure 12).
Figure 6 — Posterior-capsule stretch exercise.
Figure 9 — Abduction stretch exercise.
Figure 7 — External-rotation stretch exercise.
Figure 8 — Flexion stretch exercise.
Figure 10 — Pectoralis minor stretch exercise.
JSR Vol. 24, No. 2, 2015
The Effects of Scapular Mobilization 121
• Inferior glide was performed with the shoulder in scaption. Participants adducted into an inflated ball placed on a table with force applied through the hand while retracting the scapula (Figure 13).
Home Exercise For home exercise, the same exercises as done in the SE group were prescribed at the end of the 3 weeks for all groups (SM, SSM, and SE) to be performed at home.
Outcome Measures In this study, shoulder function and pain intensity at rest, at night, and during activity were used as a primary outcome measures. Range of motion and participant satisfaction were used as secondary outcome measures. Primary and secondary outcome measurements were taken at baseline (0 wk), before the fifth visit (2 wk) and tenth visit (3 wk), 4 weeks after the ninth visit (7 wk), and 8 weeks after the ninth visit (11 wk).
Downloaded by Univ of Florida on 09/16/16, Volume 24, Article Number 2
Primary Outcome Measures
Figure 11 — Serratus anterior strengthening exercise.
Figure 12 — External-rotation strengthening exercise.
Function. Shoulder function was assessed with the Turkish version of the Quick DASH.35 The Quick DASH is a shortened version of the DASH outcome measure. Instead of 30 items, the Quick DASH uses 11 items to measure physical function and symptoms in people with any of multiple musculoskeletal disorders of the upper limb during the preceding week. Each item has 5 response scores, and the scores for all items are used to calculate a scale score ranging from 0 (no disability) to 100 (most-severe disability).36–38 Pain. Pain intensity at rest, at night, and during activity was evaluated by using a visual analog scale. Participants were asked to indicate intensity by marking a 10-cm-long horizontal line that was labeled with the anchors on one end no pain and worst pain possible at the other end. This required participants to be able to equate the length of the line (as measured from the left-hand side to the point marked) with the amount of pain they were experiencing.39
Secondary Outcome Measures
Figure 13 — Inferior glide exercise.
Range of Motion. A universal goniometer was used to measure active shoulder range of motion while subjects were in supine position. Participants moved the affected extremity (thumb pointing upward) to the end of active range of shoulder flexion. The flexion angle was formed by aligning the goniometer with the lateral epicondyle of the humerus, the middle of the glenoid fossa, and a vertical line in the coronal plane. The external- and internal-rotation (90° GH-joint abduction, 90° elbow flexion, neutral forearm position) angle was formed by aligning the goniometer with the ulnar styloid process; the olecranon process of the ulna was the center of rotation, with a horizontal line in the transverse plane. This measurements have interrater and intrarater reliability. Hayes et al40 determined that for flexion, abduction, and external rotation, fair to good reliability was demonstrated for the goniometer (interrater rho = .64–.69, intrarater rho = .53–.65).
JSR Vol. 24, No. 2, 2015
122 Aytar et al
Participant Satisfaction. A 7-point point Likert scale was used to evaluate participants’ satisfaction with the physical therapy interventions. The scale included the anchors completely dissatisfied on the left equaling 0 and the right anchor completely satisfied equaling 7. Questions about participant satisfaction were satisfaction with the amount of pain relief from therapy, satisfaction with the amount of increase in function from therapy, overall satisfaction with therapy, and overall satisfaction with the therapist. To avoid bias, the questionnaire was administered by an independent staff member from the physical therapy department at the tenth visit.41
Downloaded by Univ of Florida on 09/16/16, Volume 24, Article Number 2
Statistical Analysis Comparison of demographics between the 3 groups for age, height, and weight were performed using 1-way ANOVA for each variable to demonstrate homogeneity of 3 groups and that the randomization procedure evenly distributed the subjects. Comparison of outcome variables at baseline was performed to confirm equality between groups using ANOVA as the data were normally distributed as determined by a Levene test. A linear mixed model was used to evaluate the change of the 3 groups across the 5 assessment time points for each dependent measure separately. A mixed model was used, as we had most but not all data points at each time point from all participants (Figure 1). The factors of interest were group (SM, SSM, and SE) and time (baseline and 2, 3, 7, 11 wk after initiation of the intervention). Patient satisfaction was evaluated at the end of therapeutic interventions at week 3. The 4 constructs of satisfaction were compared with ANOVA. All statistical analysis was set a priori at an alpha level of P < .05. If significance was found, post hoc analysis with a Bonferroni correction for multiple comparisons was used to determine differences between specific factors.
All analysis was performed using SPSS version 18 (IBM, Armonk, NY, USA).
Results Demographic and clinical characteristics of study participants are presented in Table 1. There were no significant differences between groups for demographic characteristics (Table 1). Comparison of baseline outcome variables for function, pain, and range of motion revealed no significant differences, indicating that patients were basically at the same level of dysfunction at the outset of the intervention (Table 2). The descriptive data that were normally distributed (P < .05) for the primary and secondary outcomes are presented in Table 2. The comparison of 3 groups across 5 specific time points for outcome measures of function, pain at rest, pain at night, pain with activity and shoulder flexion, and internal and external range of motion revealed the exact same responses of no group-by-time interaction (Table 3). There was a main effect for time in all variables studied, indicating that over the course of treatment, regardless of the treatment group, patients improved, and there were no significant differences found between groups (Table 3). All the results for the post hoc analysis for pain, function, and range of motion are located in Tables 4 and 5 and Figure 14. The results from all outcome variables behave similarly. Scores typically improve during treatment period and then plateau at follow-up assessments. This demonstrates that treatment effects appear to be maintained during follow-up periods of this study. The level of patient satisfaction determined at the end of the 3 weeks of treatment was compared between groups and resulted in no significant difference between groups (Table 6).
Table 1 Demographic Comparison of Age, Height, and Weight Scapular mobilization
Sham scapular mobilization
Supervised exercise
Total
P
Age, y, mean ± SD
52 ± 3
52 ± 4
51 ± 4
52 ± 4
.64
Height, cm, mean ± SD
161 ± 7
164 ± 8
163 ± 8
163 ± 8
.58
Weight, kg, mean ± SD
74 ± 13
77 ± 17
71 ± 12
74 ± 14
.36
female
18 (81.8)
14 (63.6)
19 (86.4)
51 (77.3)
male
4 (18.2)
8 (36.4)
3 (13.6)
15 (22.7)
right
16 (72.7)
10 (45.5)
8 (36.4)
34 (51.5)
left
6 (27.3)
12 (54.5)
14 (63.6)
32 (48.5)
right
22 (100)
22 (100)
22 (100)
66 (100)
left
0 (0)
0 (0)
0 (0)
Sex, n (%)
Affected side, n (%)
Dominant side, n (%)
Note: Each variable was compared across the 3 groups with an ANOVA. The resulting probability statistic is reported.
JSR Vol. 24, No. 2, 2015
Table 2 Descriptive Data for the Primary and Secondary Outcome Variables Presented for Each Group at Each Assessment Time SM Outcome measure
SSM
Supervised Exercise
Wk
Mean
SD
Mean
SD
Mean
SD
0
41.4
16.9
41.7
17.0
37.5
15.1
2
32.1
17.2
31.0
17.9
29.6
15.7
3
29.7
18.6
25.6
17.1
27.2
15.2
7
19.5
14.0
18.8
13.5
23.4
18.9
11
28.7
23.4
24.3
19.0
20.5
17.1
0
3.8
3.2
2.7
2.4
4.0
2.9
2
3.5
2.6
2.1
2.3
3.0
2.4
3
2.2
2.7
1.6
2.3
2.1
2.3
7
0.7
1.3
0.9
1.4
1.3
2.2
11
0.8
1.0
1.3
2.3
1.5
2.3
Disability of Arm, Shoulder, and Hand score
.83
Pain at rest
Downloaded by Univ of Florida on 09/16/16, Volume 24, Article Number 2
P
.28
Pain at night
.47 0
6.5
2.4
6.1
2.7
6.1
3.0
2
3.8
3.3
4.8
3.0
3.6
3.1
3
3.5
2.9
2.8
2.7
2.5
2.4
7
2.8
2.9
2.6
3.3
2.5
2.7
11
2.3
2.6
2.5
2.8
2.1
3.1
0
7.0
2.5
7.3
2.3
7.1
2.3
2
5.0
3.1
5.6
2.3
5.1
2.6
3
3.8
2.8
4.8
2.3
4.0
2.2
7
3.0
2.8
3.8
2.4
3.6
2.2
11
2.3
2.5
3.7
3.1
2.9
2.7
Pain with activity
.77
Shoulder flexion (°)
.41 0
160
10
159
15
155
15
2
169
11
166
8
166
12
3
173
10
171
9
171
8
7
173
8
171
8
174
9
11
173
7
170
14
175
7
0
72
18
71
17
72
15
2
78
17
74
18
79
16
3
82
17
81
12
84
12
7
85
13
79
14
86
7
11
89
4
80
14
85
9
Shoulder external rotation (°)
.55
Shoulder internal rotation (°)
.19 0
75
13
68
18
75
15
2
77
13
73
18
76
16
3
81
14
81
14
84
9
7
82
10
77
16
86
8
11
78
12
80
12
85
8
Abbreviations: SM, scapular mobilization; SSM, sham scapular mobilization. Note: Baseline variables were compared across the 3 groups with an ANOVA, The resulting probability statistic is reported.
JSR Vol. 24, No. 2, 2015
123
Table 3 Group-by-Visit Interaction Results From the Mixed-Model ANOVA and the Main Effects for Each Variable Outcome measure Disability of Arm, Shoulder, and Hand
Pain at rest
Downloaded by Univ of Florida on 09/16/16, Volume 24, Article Number 2
Pain with activity
Pain at night
Shoulder flexion
Shoulder external rotation
Shoulder internal rotation
df numerator
df denominator
F
P
group × visit
8
201.4
0.88
.53
group
2
74.9
0.42
.66
visit
4
201.5
14.3
Original Research Report
The Effects of Scapular Mobilization in Patients With Subacromial Impingement Syndrome: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial Aydan Aytar, Gul Baltaci, Tim Uhl, Handan Tuzun, Pinar Oztop, and Metin Karatas Objective: To determine the effects of scapular mobilization on function, pain, range of motion, and satisfaction in patients with subacromial impingement syndrome (SAIS). Design: Randomized, double-blind, placebocontrolled clinical trial. Setting: University hospital clinics in Turkey. Participants: 66 participants (mean ± SD age 52.06 ± 3.71 y) with SAIS. Interventions: Participants were randomized into 3 groups: scapular mobilization, sham scapular mobilization, and supervised exercise. Before the interventions transcutaneous electrical stimulation and hot pack were applied to all groups. Total intervention duration for all groups was 3 wk with a total of 9 treatment sessions. Main Outcome Measures: Shoulder function and pain intensity were primary outcome measures; range of motion and participant satisfaction were secondary outcome measures. Shoulder function was assessed with the short form of the Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH). A visual analog scale was used to evaluate pain severity. Active range of motion was measured with a universal goniometer. A 7-point Likert scale was used to evaluate satisfaction. Outcome measurements were performed at baseline, before visits 5 and 10, 4 wk after visit 9, and 8 wk after visit 9. Results: There was no group difference for DASH score (P = .75), pain at rest (P = .41), pain with activity (P = .45), pain at night (P = .74), and shoulder flexion (P = .65), external rotation (P = .63), and internal rotation (P = .19). There was a significant increase in shoulder motion and function and a significant decrease in pain across time when all groups were combined (P < .001). The level of satisfaction was not significantly different for any of the questions about participant satisfaction between all groups (P > .05). Conclusion: There was not a significant advantage of scapular mobilization for shoulder function, pain, range of motion, and satisfaction compared with sham or supervised-exercise groups in patients with SAIS. Keywords: shoulder, rehabilitation, pain, function, satisfaction Shoulder pain is a common problem in both sporting and working populations.1,2 Approximately 1% of adults consult a general medical practitioner with an episode of shoulder pain each year.1,2 The most frequent cause of shoulder pain is subacromial impingement syndrome (SAIS), accounting for 44% to 65% of all complaints of shoulder pain.3,4 There are many treatment methods prescribed for SAIS, incorporating 4 primary areas: modalities,5–10 manual therapy,11–13 therapeutic strengthening,14–17 and flexibility exercises.11,16 Physiotherapy agents such as Aytar is with the Dept of Physiotherapy and Rehabilitation, and Oztop and Karatas, the Dept of Physical Medicine and Rehabilitation, Baskent University School of Medicine, Ankara, Turkey. Baltaci is with the School of Physiotherapy, Hacettepe University, Ankara, Turkey. Uhl is with the Div of Athletic Training, University of Kentucky, Lexington, KY. Tuzun is with the Dept of Physiotherapy and Rehabilitation, Kirikkale University, Ankara, Turkey. Address author correspondence to Aydan Aytar at [email protected].
116
transcutaneous electrical stimulation (TENS) and hot packs are generally used in physiotherapy clinics.5–10 The application of heat and TENS could help reduce pain, soreness, and stiffness and so help improve function; in addition to these effects they enhance plasticity of connective tissue.18,19 These modalities could help relax and prepare patients for interventions before exercising or using manual techniques in rehabilitation. Different physiotherapy applications such as manual therapy are used with other interventions to regain motion and improve function.2,20 Physiotherapists usually use mobilization in association with other physiotherapy interventions to regain normal shoulder and scapular function.5,21–24 Manual therapy often is a combination of joint mobilization to a specific joint and various forms of massage. There is limited but supporting evidence that indicates that manual therapy is beneficial in this patient population when integrated with other interventions.11–13,20 Shoulder-impingement disorders are classified as primary or secondary. Primary shoulder impingement occurs when the rotator-cuff tendons, long head of the biceps tendon, glenohumeral (GH) joint capsule, and/
Downloaded by Univ of Florida on 09/16/16, Volume 24, Article Number 2
The Effects of Scapular Mobilization 117
or subacromial bursa becomes impinged between the humeral head and anterior acromion. Primary impingement may be due to intrinsic factors: rotator-cuff weakness, chronic inflammation of the rotator-cuff tendons and/or subacromial bursa, rotator-cuff degenerative tendinopathy, and posterior-capsule tightness leading to abnormal anterosuperior translation of the humeral head. It may also be due to extrinsic factors: possession of a curved or hooked acromion, acromial spurs, or postural dysfunction. Secondary shoulder impingement is defined as a relative decrease in the subacromial space due to GH-joint instability or abnormal scapulothoracic kinematics.25 The anatomy and function of the shoulder girdle depend on the function of 3 synovial joints (GH, acromioclavicular, and sternoclavicular) and 1 pseudo-joint (scapulothoracic).26 The relationship of scapular motion to GH motion is termed scapulohumeral rhythm. During normal shoulder abduction (or flexion), a natural 2:1 ratio or rhythm exists between the GH and scapulothoracic joints.21 This means that for every 2° of GH abduction, the scapula must simultaneously upwardly rotate roughly 1°. Based on this rhythm, a full arc of 180° of shoulder abduction is the result of a simultaneous 120° of GH abduction and 60° of scapulothoracic upward rotation.27 Therefore, scapular-movement abilities in many directions are important for shoulder range of motion, and it is important to remember the overall relationship between humeral and scapular motion when considering the full 180° of shoulder abduction. There is substantial evidence of scapular kinematic abnormalities in persons with shoulder pain.21 Alteration of scapular kinematics can be a key component in the production of the symptoms associated with impingement.28 However, the manual-therapy techniques have primarily focused on mobilization of the GH joint in patients with SAIS.11–13 To date, limited studies have examined the effectiveness of scapular mobilization.20,29 Therefore, the purpose of this study was to determine the immediate and lasting effects of scapular mobilization in patients with SAIS.
following findings: a positive Neer impingement test, a positive Hawkins impingement test, a positive painfularc sign (60–120° of elevation), pain with palpation of the rotator-cuff tendons, pain with isometric resisted abduction, and pain at the shoulder region.23,30,31 On confirmation of these findings, participants were further screened for participation in this study by meeting the following criteria: score of the Disabilities of the Arm, Shoulder and Hand Questionnaire (Quick DASH) >20, pain for ≥6 months, and pain with activity between 2 and 8 on a 10-cm visual analog scale. Participants were excluded from this study if they demonstrated any of the following symptoms: signs of a rotator-cuff tear or rupture (a positive lag sign such as a drop-arm or lift-off sign); positive shoulder anterior, posterior, and inferior instability tests (a positive anterior and posterior apprehension test, relocation and sulcus sign, drawer test, load and shift test); cervical neurologic symptoms (symptom reproduction from a Spurling test, light touch deficits in a particular dermatome); current trauma such as fractures or dislocations; or previous history of surgery in the affected shoulder. This study was carried out at the Baskent University Physical Medicine and Rehabilitation Outpatient Clinic. All participants provided written informed consent before this study, which was approved by an ethics board (University of Baskent).
Materials and Methods
Before the study began randomization procedure was performed using an online random-allocation software program32 by the treating physical therapist with 69 participants in case of dropout. Participants were randomized into 1 of 3 groups: scapular mobilization (SM) (n = 23), sham SM (SSM) (n = 23), or supervised exercise (SE) (n = 23), but 3 participants did not receive interventions, so 66 participants were divided into 1 of 3 groups: SM (n = 22), SSM (n = 22), and SE (n = 22) (Figure 1).
Participants Before the study began, 69 participants were screened in case of dropout. Three participants did not receive interventions. Sixty-six (15 male, 51 female) participants (mean ± SD = 52.06 ± 3.71 y) enrolled for this study at baseline (0 wk) and before the fifth visit (2 wk) and the tenth visit (3 wk). Some participants were lost to follow-up. Sixty participants were enrolled at 4 weeks after the ninth visit (7 wk), and 31 participants were enrolled at 8 weeks after ninth visit (11 wk). Statistical analyses were done considering this dropout. A flow diagram is provided to show how participants progressed through this study (Figure 1). Study participants were referred from a physician with the diagnosis of SAIS. To confirm this evaluation, potential participants demonstrated at least 3 of the
Sample Size The sample size required to detect significant differences was determined using statistical software (N-Query Advisor, Statistical Solutions, Saugus, MA). Effect size was based on change scores from clinical data of 20 subjects with signs of impingement using the quick DASH, which is highly correlated with the DASH. The sample size was determined as 18 patients in each group with the alpha level set at .05 to achieve 90% power.
Randomization Procedures
Interventions and Blinding Procedures Before the interventions 1 physical therapist (PT) was designated as Evaluator PT. Evaluator PT performed all measurements for this study. A second PT was designated as Treating PT. Treating PT performed all treatments for this study. Evaluator PT and patients were blinded to the group allocations during the course of treatment.
JSR Vol. 24, No. 2, 2015
Downloaded by Univ of Florida on 09/16/16, Volume 24, Article Number 2
118 Aytar et al
Figure 1 — A flow diagram of the study. Abbreviations: SM, scapular mobilization; SSM, sham scapular mobilization; SE, supervised exercise.
Evaluator PT filled out a questionnaire at the beginning of study. This questionnaire included physical characteristics of participants, contact numbers, and mail addresses. Also, primary and secondary outcome measurements were taken before the interventions by Evaluator PT. Before the interventions, Treating PT applied hot pack and TENS for all study participants. The aim of this
application was to relax and prepare participants for interventions. Hot pack and conventional TENS (frequency = 100 Hz, pulse duration = 60 μs) were applied to all study participants (SM, SSM, and SE groups) for 20 minutes per treatment session. TENS electrodes and a hot pack were placed on shoulder joint. Interventions were designated into 3 groups: SM, SSM, and SE. Participants
JSR Vol. 24, No. 2, 2015
The Effects of Scapular Mobilization 119
were placed in only 1 of these 3 groups according to the randomization by Treating PT. Frequencies of all these interventions were approximately 12 minutes and 3 times per week for all groups. In addition to all interventions, some recommendations were made (sleeping position, load carrying, and daily living) were given to all groups for education at baseline and during all the intervention sessions.24,33,34 Total intervention duration for all groups was 3 weeks with a total of 9 treatment sessions. At the tenth visit all participants were retested with all measures and given the same home-exercise brochure.
Downloaded by Univ of Florida on 09/16/16, Volume 24, Article Number 2
SM Group
Figure 4 — Position for the distraction.
SM consisted of the application of superior and inferior gliding, rotations, and distraction to the scapula of affected shoulder.6,20,29 All interventions were applied in side-lying position with the involved extremity accessible to the PT. The PT grasped the superior and inferior angle of scapula and moved the scapula superiorly and inferiorly for superior and inferior glide (Figure 2) and then rotated it upward and downward for scapular rotation (Figure 3). Second, the PT grasped the inferior angle and vertebral border of the scapula and with both hands tilted the scapula away from the thoracic wall along with distraction of the scapula (Figures 4 and 5). Each application was applied 3 times for 10 repetitions and a rate of 1 cycle per 6 seconds, with a 30-second interval between sets.
Figure 5 — Application of scapular distraction.
SSM Group SSM replicated the treatment condition except for the hand positions and pressure. Borders of scapula were not grasped. Hands were randomly put on the scapula, and then just skin was moved in the superoinferior, mediolateral, and rotation directions with minimal pressure to make a sham application.29 Each application was applied 3 times for 10 repetitions and a rate of 1 cycle per 6 seconds with 30-second intervals between sets.
SE Group Figure 2 — Application of superior and inferior glide mobilization.
Figure 3 — Application of scapular upward and downward rotation.
Stretching (posterior capsule, external rotation, flexion and abduction stretch, pectoral stretch) and strengthening (serratus anterior, external rotation, and inferior glide) exercises were performed in front of the mirror with supervision of the PT. Participants performed stretching exercises 4 times for 30 seconds. They performed 2 sets of 10 repetitions of strengthening exercises, holding for 5 seconds at the end of each repetition. Between stretching and strengthening exercises, a 30-second interval was given. According to participants’ strength, suitable Thera-Band and weight were chosen by PT at the beginning of the treatment. Suitable Thera-Band and weight were determined by participants’ performing 10 repetitions of exercises with proper form and without pain or fatigue. Thera-Band or weight was progressed weekly. Stretching exercises were as follows: • The posterior-capsule stretch was performed by participants’ standing and holding the affected elbow with the opposite hand in front of the body
JSR Vol. 24, No. 2, 2015
120 Aytar et al
Downloaded by Univ of Florida on 09/16/16, Volume 24, Article Number 2
and slowly pulling the elbow across the body until they felt a comfortable stretch (Figure 6). • The external-rotation stretch was performed by participants’ placing the affected hand with elbow in 90° flexion on a cornered wall and turning their body until they felt a stretch (Figure 7). • The flexion and abduction stretch was performed by participants’ placing the affected hand with the elbow extended onto a table and reaching forward until stretch was felt (Figures 8 and 9).
• The pectoralis minor stretch was performed by participants’ placing each hand at shoulder height on adjacent walls of a corner and leaning into the corner (Figure 10). Strengthening exercises were as follows: • Strengthening for the serratus anterior muscle was performed participants ling supine and performing a scapular punch with scapular protraction against resistance of a handheld weight (Figure 11). • Strengthening for external rotation was performed by participants standing with both elbows bent by their sides. Holding a Thera-Band with both hands for resistance, they then retracted both scapulae while performing external rotation (Figure 12).
Figure 6 — Posterior-capsule stretch exercise.
Figure 9 — Abduction stretch exercise.
Figure 7 — External-rotation stretch exercise.
Figure 8 — Flexion stretch exercise.
Figure 10 — Pectoralis minor stretch exercise.
JSR Vol. 24, No. 2, 2015
The Effects of Scapular Mobilization 121
• Inferior glide was performed with the shoulder in scaption. Participants adducted into an inflated ball placed on a table with force applied through the hand while retracting the scapula (Figure 13).
Home Exercise For home exercise, the same exercises as done in the SE group were prescribed at the end of the 3 weeks for all groups (SM, SSM, and SE) to be performed at home.
Outcome Measures In this study, shoulder function and pain intensity at rest, at night, and during activity were used as a primary outcome measures. Range of motion and participant satisfaction were used as secondary outcome measures. Primary and secondary outcome measurements were taken at baseline (0 wk), before the fifth visit (2 wk) and tenth visit (3 wk), 4 weeks after the ninth visit (7 wk), and 8 weeks after the ninth visit (11 wk).
Downloaded by Univ of Florida on 09/16/16, Volume 24, Article Number 2
Primary Outcome Measures
Figure 11 — Serratus anterior strengthening exercise.
Figure 12 — External-rotation strengthening exercise.
Function. Shoulder function was assessed with the Turkish version of the Quick DASH.35 The Quick DASH is a shortened version of the DASH outcome measure. Instead of 30 items, the Quick DASH uses 11 items to measure physical function and symptoms in people with any of multiple musculoskeletal disorders of the upper limb during the preceding week. Each item has 5 response scores, and the scores for all items are used to calculate a scale score ranging from 0 (no disability) to 100 (most-severe disability).36–38 Pain. Pain intensity at rest, at night, and during activity was evaluated by using a visual analog scale. Participants were asked to indicate intensity by marking a 10-cm-long horizontal line that was labeled with the anchors on one end no pain and worst pain possible at the other end. This required participants to be able to equate the length of the line (as measured from the left-hand side to the point marked) with the amount of pain they were experiencing.39
Secondary Outcome Measures
Figure 13 — Inferior glide exercise.
Range of Motion. A universal goniometer was used to measure active shoulder range of motion while subjects were in supine position. Participants moved the affected extremity (thumb pointing upward) to the end of active range of shoulder flexion. The flexion angle was formed by aligning the goniometer with the lateral epicondyle of the humerus, the middle of the glenoid fossa, and a vertical line in the coronal plane. The external- and internal-rotation (90° GH-joint abduction, 90° elbow flexion, neutral forearm position) angle was formed by aligning the goniometer with the ulnar styloid process; the olecranon process of the ulna was the center of rotation, with a horizontal line in the transverse plane. This measurements have interrater and intrarater reliability. Hayes et al40 determined that for flexion, abduction, and external rotation, fair to good reliability was demonstrated for the goniometer (interrater rho = .64–.69, intrarater rho = .53–.65).
JSR Vol. 24, No. 2, 2015
122 Aytar et al
Participant Satisfaction. A 7-point point Likert scale was used to evaluate participants’ satisfaction with the physical therapy interventions. The scale included the anchors completely dissatisfied on the left equaling 0 and the right anchor completely satisfied equaling 7. Questions about participant satisfaction were satisfaction with the amount of pain relief from therapy, satisfaction with the amount of increase in function from therapy, overall satisfaction with therapy, and overall satisfaction with the therapist. To avoid bias, the questionnaire was administered by an independent staff member from the physical therapy department at the tenth visit.41
Downloaded by Univ of Florida on 09/16/16, Volume 24, Article Number 2
Statistical Analysis Comparison of demographics between the 3 groups for age, height, and weight were performed using 1-way ANOVA for each variable to demonstrate homogeneity of 3 groups and that the randomization procedure evenly distributed the subjects. Comparison of outcome variables at baseline was performed to confirm equality between groups using ANOVA as the data were normally distributed as determined by a Levene test. A linear mixed model was used to evaluate the change of the 3 groups across the 5 assessment time points for each dependent measure separately. A mixed model was used, as we had most but not all data points at each time point from all participants (Figure 1). The factors of interest were group (SM, SSM, and SE) and time (baseline and 2, 3, 7, 11 wk after initiation of the intervention). Patient satisfaction was evaluated at the end of therapeutic interventions at week 3. The 4 constructs of satisfaction were compared with ANOVA. All statistical analysis was set a priori at an alpha level of P < .05. If significance was found, post hoc analysis with a Bonferroni correction for multiple comparisons was used to determine differences between specific factors.
All analysis was performed using SPSS version 18 (IBM, Armonk, NY, USA).
Results Demographic and clinical characteristics of study participants are presented in Table 1. There were no significant differences between groups for demographic characteristics (Table 1). Comparison of baseline outcome variables for function, pain, and range of motion revealed no significant differences, indicating that patients were basically at the same level of dysfunction at the outset of the intervention (Table 2). The descriptive data that were normally distributed (P < .05) for the primary and secondary outcomes are presented in Table 2. The comparison of 3 groups across 5 specific time points for outcome measures of function, pain at rest, pain at night, pain with activity and shoulder flexion, and internal and external range of motion revealed the exact same responses of no group-by-time interaction (Table 3). There was a main effect for time in all variables studied, indicating that over the course of treatment, regardless of the treatment group, patients improved, and there were no significant differences found between groups (Table 3). All the results for the post hoc analysis for pain, function, and range of motion are located in Tables 4 and 5 and Figure 14. The results from all outcome variables behave similarly. Scores typically improve during treatment period and then plateau at follow-up assessments. This demonstrates that treatment effects appear to be maintained during follow-up periods of this study. The level of patient satisfaction determined at the end of the 3 weeks of treatment was compared between groups and resulted in no significant difference between groups (Table 6).
Table 1 Demographic Comparison of Age, Height, and Weight Scapular mobilization
Sham scapular mobilization
Supervised exercise
Total
P
Age, y, mean ± SD
52 ± 3
52 ± 4
51 ± 4
52 ± 4
.64
Height, cm, mean ± SD
161 ± 7
164 ± 8
163 ± 8
163 ± 8
.58
Weight, kg, mean ± SD
74 ± 13
77 ± 17
71 ± 12
74 ± 14
.36
female
18 (81.8)
14 (63.6)
19 (86.4)
51 (77.3)
male
4 (18.2)
8 (36.4)
3 (13.6)
15 (22.7)
right
16 (72.7)
10 (45.5)
8 (36.4)
34 (51.5)
left
6 (27.3)
12 (54.5)
14 (63.6)
32 (48.5)
right
22 (100)
22 (100)
22 (100)
66 (100)
left
0 (0)
0 (0)
0 (0)
Sex, n (%)
Affected side, n (%)
Dominant side, n (%)
Note: Each variable was compared across the 3 groups with an ANOVA. The resulting probability statistic is reported.
JSR Vol. 24, No. 2, 2015
Table 2 Descriptive Data for the Primary and Secondary Outcome Variables Presented for Each Group at Each Assessment Time SM Outcome measure
SSM
Supervised Exercise
Wk
Mean
SD
Mean
SD
Mean
SD
0
41.4
16.9
41.7
17.0
37.5
15.1
2
32.1
17.2
31.0
17.9
29.6
15.7
3
29.7
18.6
25.6
17.1
27.2
15.2
7
19.5
14.0
18.8
13.5
23.4
18.9
11
28.7
23.4
24.3
19.0
20.5
17.1
0
3.8
3.2
2.7
2.4
4.0
2.9
2
3.5
2.6
2.1
2.3
3.0
2.4
3
2.2
2.7
1.6
2.3
2.1
2.3
7
0.7
1.3
0.9
1.4
1.3
2.2
11
0.8
1.0
1.3
2.3
1.5
2.3
Disability of Arm, Shoulder, and Hand score
.83
Pain at rest
Downloaded by Univ of Florida on 09/16/16, Volume 24, Article Number 2
P
.28
Pain at night
.47 0
6.5
2.4
6.1
2.7
6.1
3.0
2
3.8
3.3
4.8
3.0
3.6
3.1
3
3.5
2.9
2.8
2.7
2.5
2.4
7
2.8
2.9
2.6
3.3
2.5
2.7
11
2.3
2.6
2.5
2.8
2.1
3.1
0
7.0
2.5
7.3
2.3
7.1
2.3
2
5.0
3.1
5.6
2.3
5.1
2.6
3
3.8
2.8
4.8
2.3
4.0
2.2
7
3.0
2.8
3.8
2.4
3.6
2.2
11
2.3
2.5
3.7
3.1
2.9
2.7
Pain with activity
.77
Shoulder flexion (°)
.41 0
160
10
159
15
155
15
2
169
11
166
8
166
12
3
173
10
171
9
171
8
7
173
8
171
8
174
9
11
173
7
170
14
175
7
0
72
18
71
17
72
15
2
78
17
74
18
79
16
3
82
17
81
12
84
12
7
85
13
79
14
86
7
11
89
4
80
14
85
9
Shoulder external rotation (°)
.55
Shoulder internal rotation (°)
.19 0
75
13
68
18
75
15
2
77
13
73
18
76
16
3
81
14
81
14
84
9
7
82
10
77
16
86
8
11
78
12
80
12
85
8
Abbreviations: SM, scapular mobilization; SSM, sham scapular mobilization. Note: Baseline variables were compared across the 3 groups with an ANOVA, The resulting probability statistic is reported.
JSR Vol. 24, No. 2, 2015
123
Table 3 Group-by-Visit Interaction Results From the Mixed-Model ANOVA and the Main Effects for Each Variable Outcome measure Disability of Arm, Shoulder, and Hand
Pain at rest
Downloaded by Univ of Florida on 09/16/16, Volume 24, Article Number 2
Pain with activity
Pain at night
Shoulder flexion
Shoulder external rotation
Shoulder internal rotation
df numerator
df denominator
F
P
group × visit
8
201.4
0.88
.53
group
2
74.9
0.42
.66
visit
4
201.5
14.3
