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Comparison Of Interventions With And Without Manual Physical Therapy For

Patients With Shoulder Impingement Syndrome: A Prospective, Randomized
Clinical Trial

Article  in  Medicine and Science in Sports and Exercise · May 2005

DOI: 10.1249/00005768-200505001-01033

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Knee Surg Sports Traumatol Arthrosc (2007) 15:915–921
DOI 10.1007/s00167-007-0288-x

SHOULDER

Comparison of conservative treatment with and without manual

physical therapy for patients with shoulder impingement
syndrome: a prospective, randomized clinical trial
Gamze Senbursa Æ Gul Baltacı Æ Ahmet Atay

Received: 24 September 2006 / Accepted: 9 January 2007 / Published online: 28 February 2007
Ó Springer-Verlag 2007

Abstract The aim of this prospective, randomized functional assessment questionnaire. The VAS (10 cm)
clinical study was to compare the effectiveness of two used to measure pain with functional activities and the
physical therapy treatment approaches for impinge- functional assessment questionnaire (Neer) were also
ment syndrome, either by joint and soft tissue mobili- measured 3 months after the initiation of treatment.
zation techniques or by a self-training program. Thirty Subjects in both groups experienced significant de-
patients (Group 1, n = 15; Group 2, n = 15) with creases in pain and increases in shoulder function, but
the diagnosis of an outlet impingement syndrome of there was significantly more improvement in the
the shoulder were treated either by strengthening the manual therapy group compared to the exercise group.
depressors of the humeral head with a guided self- For example, pain in the manual therapy group was
training program (Group 1, age 49.5 ± 7.9 years), or by reduced from a pre-treatment mean (±SD) of 6.7
joint and soft tissue mobilization techniques (Group 2, (±0.3) to a post-treatment mean of 2.0 (±2.0). In con-
age 48.1 ± 7.5 years). Group 1 was instructed with trast, pain in the exercise group was reduced from a
the active range of motion (ROM), stretching and pre-treatment mean of 6.6 (±1.4) to a post-treatment
strengthening exercise program including rotator cuff mean of 3.0 (±1.8). ROM at flexion, abduction and
muscles, rhomboids, levator scapulae and serratus external rotation in the manual therapy group im-
anterior with an elastic band at home at least seven proved significantly while ROM in the exercise group
times a week for 10–15 min and Group 2 received a did not. There were statistically differences among the
prescription for 12 sessions of joint and soft tissue groups in function (P > 0.05). Group 2 showed signif-
mobilization techniques, ice application, stretching and icantly greater improvements in the Neer Question-
strengthening exercise programs and patient education naire score and shoulder satisfaction score than Group
in clinic for three times per week. All patients were 1. The patients treated with manual physical therapy
tested with visual analog scale (VAS) for pain level, applied by experienced physical therapists combined
goniometric measurement for ROM and algometry for with supervised exercise in a brief clinical trial showed
the pain threshold. Function was measured with a improvement of symptoms including increasing strength,
decreasing pain and improving function earlier than
with exercise program.
This study was presented in the 52nd Annual Meeting of
American College of Sports Medicine in Nashville, USA, 2005. Keywords Manual therapy
Shoulder

Impingement Syndrome
Exercise
G. Senbursa
G. Baltacı (&)
School of Physiotherapy and Rehabilitation,
Hacettepe University, 06100 Ankara, Turkey
e-mail: ybaltaci@hacettepe.edu.tr Introduction
A. Atay
Department of Orthopaedics and Traumatology, The shoulder joint, the most mobile joint in the human
Hacettepe University, 06100 Ankara, Turkey body, is at greater risks for injuries. Shoulder pain is

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916 Knee Surg Sports Traumatol Arthrosc (2007) 15:915–921

second only to low back pain in occurrence, affecting randomized clinical trial. Short-term was defined as the
approximately 16–21% of the population [13]. More- end of the 4-week treatment period. The study was
over, approximately one-fifty of all disability payments conducted at the outpatient clinic of Physiotherapy
for musculoskeletal disorders are for patients with and Rehabilitation, Hacettepe University, Ankara,
shoulder disorders [9]. Turkey. After informed consent was obtained, 30 con-
The most frequent cause of shoulder pain is subac- secutive patients (Group 1, n = 15; Group 2, n = 15)
romial impingement syndrome, accounting for 44–60% with the diagnosis of an outlet impingement syndrome
of all complaints of shoulder pain [17]. Several factors of the shoulder were treated either by strengthening the
causing shoulder impingement syndrome include rota- depressors of the humeral head with a guided self-
tor cuff muscle weakness, acromial morphology, muscle training program (Group 1, age 49.5 ± 7.9 years), or by
imbalance, capsular laxity or tightness, dysfunctional joint and soft tissue mobilization techniques (Group 2,
glenohumeral and scapulothoracic kinematics, degen- age 48.1 ± 7.5 years).
eration and inflammation of the tendons or bursa [4].
Subacromial impingement syndrome is one of the Assessment
most common shoulder disorders which characterized
by shoulder pain that is exacerbated with arm elevation The study population consisted of 30 patients between
or overhead activities, in adults, with a high socioeco- 30 and 55 years of age. The criteria for inclusion in the
nomic impact on working ability [6, 18]. study were shoulder pain with no major shoulder
While many treatments have been employed in the trauma, taken no treatment another physiotherapy
management of shoulder impingement syndromes, clinic in the last 2 years, marked loss of active and
few have been proven to be effective in randomized passive shoulder motion or painful range of motion
controlled trials [20, 26, 31]. Corticosteroid injections (ROM), magnetic resonance imaging as a reference
into the glenohumeral joint, non-steroid anti-inflam- standard. Exclusion criteria included a history of fro-
matory drugs, physical therapy modalities, strength zen shoulder, disorders of the acromioclavicular joint,
and stretching exercises have been listed non-surgical degenerative arthritis of the glenohumeral joint, calci-
approaches to treatment in subacromial impingement fying tendonitis, shoulder instability, posttraumatic
syndrome [18, 27, 30]. One of treatment techniques in disorders, or shoulder surgery and/or elbow, hand,
shoulder impingement syndrome is manual therapy wrist and cervical spine disorders.
techniques including deep friction massage, exercise Each patient underwent a history assessment and a
and soft tissue and joint mobilization techniques [6]. The physical examination that tested the shoulder mobility,
goals of manual therapy of subacromial impingement tenderness and impingement.
are to decrease subacromial inflammation, to allow All patients were tested with visual analog scale
healing and strengthening of a dysfunctional rotator cuff (VAS) for pain level [8, 29], goniometric measurement
and to restore pain-free shoulder function [4, 21, 25]. for ROM [22] and algometry for the pain threshold
It seems reasonable to suggest that manipulation/ [23]. Function was measured with a functional assess-
mobilization techniques for joints that exhibit limited ment questionnaire. All patients were also evaluated
passive accessory motion may be helpful in the man- before and after rehabilitation. The VAS (10 cm) used
agement of shoulder problems that do no respond to to measure pain with functional activities and the
conventional management. Unfortunately, there is lit- functional assessment questionnaire (Neer) were also
tle evidence on the efficacy of these types of inter- measured 3 months after the initiation of treatment.
ventions for patients with subacromial impingement Manual muscle testing for flexion, abduction, internal
syndromes not responding to conventional manage- and external rotation strength of the shoulder was as-
ment. Thus, the purpose of this study was to compare sessed. Supraspinatus muscle trigger point tenderness
the effectiveness of two physical therapy treatment was determined by Algometry (Commander 1998
approaches for impingement syndrome, either by joint JTech Medical Industries) (Fig. 1). The Neer test was
and soft tissue mobilization techniques or by a self- applied to diagnose impingement syndrome [24]. While
training program after 4 weeks of treatment. scapular rotation was prevented with one hand, the
shoulder of the patient was passively forced to eleva-
tion at an angle between flexion and abduction by the
Materials and methods other hand. Pain in the subacromial was indicative of a
positive test. The ROM of the shoulder was measured
The short-term clinical effectiveness of manual physi- in all planes with a goniometer while the patients were
cal therapy compared with usual care was assessed in a lying supine as blind pre- and post-treatment. Shoulder

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Knee Surg Sports Traumatol Arthrosc (2007) 15:915–921 917

program was given to each patient as shoulder exercise

brochure [1].

Group 2: manual therapy

Group 2 received a prescription for 12 sessions of joint

and soft tissue mobilization techniques, ice application,
stretching and strengthening exercise programs and
patient education in clinic for three times per week.
Self-training and manipulative physiotherapy aim at
strengthening rotator cuff muscles, increase tenderness
and pain and, therefore, probably reduce subacromial
impingement. Patients were treated in physical therapy
unit three times per week (12 sessions) for 4 weeks.
The manual therapy included deep friction massage
Fig. 1 Supraspinatus muscle trigger point tenderness measured
by Algometer on supraspinatus muscle tendon (Fig. 3), radial nerve
stretching, scapular mobilization (Fig. 4a, b), glenohu-
flexion was assessed in the sagittal plane with the arm meral joint mobilization (Fig. 5a, b) [5], proprioceptive
at the side and the hand pronated, while shoulder neuromuscular facilitation techniques including rhyth-
abduction was measured in the frontal plane with mic stabilization and hold-relax [11]. The self-training
the arm at the side and shoulder externally rotated to was taught and controlled to patients under the guid-
obtain maximum abduction. Shoulder external and ance of a physiotherapist. An instruction of the exer-
internal rotation were measured in the transverse plane cise program was given as shoulder exercise brochure
while the arm was abducted to 90°, the elbow flexed to [1]. For self-training at home, an elastic band was used
90°, the hand pronated and forearm perpendicular to because this seemed more suitable then dumbbells.
floor. The measurement of spontaneous pain, at night The main advantage of the Thera-Band was the
pain, pain at rest and pain with motion was conducted availability of different levels of resistance, so it could
by means of a 100 mm VAS (Tables 1, 2; Fig. 2). be adjusted individually to the patient’s level of
The study was approved by the ethical committee of strength [11, 28]. The patients with painful disabling
the Medical Faculty at the University of Hacettepe. All impingement syndrome of the shoulder were random-
patients gave their written consent to participate. ized into two different conservative treatment groups.
Each group was treated over a period of 4 weeks. In
Treatment addition to the therapy regimen, the patients were
advised to avoid overhead sports and overhead work.
Group 1: self-training After the 16-week period, they were told to use their
shoulders normally without any limitation. All patients
Group 1 was instructed with the active ROM, agreed to conservative treatment.
stretching and strengthening exercise program includ-
ing rotator cuff muscles, rhomboids, levator scapulae Statistical analysis
and serratus anterior with an elastic band at home at
least seven times a week for 10–15 min and the exer- Statistical analysis was conducted with SPSS Version
cises were taught by physiotherapist and patients did 10 by using of the Student t-test for results. A signifi-
the exercises everyday during 4 weeks. Same exercise cant P-value was considered to be <0.05.

Table 1 Comparison of pain at night, rest and with motion before and after treatment in Group 1 and 2 according to VAS
Night pain Pain with motion Pain at rest
Before treatment After treatment P Before treatment After treatment P Before treatment After treatment P
X SD X SD X SD X SD X SD X SD

Group 1 6.1 1.9 1.2 1.6 0.01 6.3 2.7 2.5 1.5 0.01 2.0 2.0 0.9 0.2 0.07
Group 2 5.6 2.1 2.2 2.4 0.02 6.0 2.5 3.1 2.0 0.01 3.0 1.8 0.7 1.4 0.02

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918 Knee Surg Sports Traumatol Arthrosc (2007) 15:915–921

Table 2 The Neer results of patients with subacromial Results

impingement
Neer 1 Neer 2 P The statistical analysis of the two therapy groups did
not reveal any significant differences in age, duration of
0 1
disease, pain level, and initial result of the Neer score.
Group 1 Subjects in both groups experienced significant de-
0 5 0.008 creases in pain and increases in shoulder function, but
1 8 2
Group 2
there was significantly more improvement in the man-
0 1 0.002 ual therapy group compared to the exercise group. For
1 10 4 example, pain in the manual therapy group was reduced
P 0.169 0.651 from a pre-treatment mean (±SD) of 6.7 (±0.3) to a
post-treatment mean of 2.0 (±2.0). In contrast, pain in
the exercise group was reduced from a pre-treatment
90
mean of 6.6 (±1.4) to a post-treatment mean of 3.0
85
(+1.8). ROM at flexion, abduction and external rotation
80
75
in the manual therapy group improved significantly
70 while ROM in the exercise group did not. There were
65 statistically differences among the groups in function
60
Ext.Rot.Group I Ext. Rot.Group II Int. Rot. Group I Int.Rot Group II
(P > 0.05). Group 2 showed significantly greater
improvements in the Neer Questionnaire score and
Before Treatment After treatment
shoulder satisfaction score than Group 1.
Fig. 2 Comparison of external and internal rotation ROM
before and after treatments in Group 1 and 2
Discussion

Two groups with a subacromial impingement syn-

drome of the shoulder were treated with two different
conservative methods: self-training (Group 1), and
manual therapy (Group 2).
The patients were treated and followed up for a
period of 4 weeks. The main reason to limit the study
to 4 weeks was that it was impossible to keep stan-
dardized conditions over a longer period. Prescribing
physiotherapy for a longer time is not allowed by the
health insurance system. Also the treatment at hospital
might occasionally be interrupted due to problems of
time and transportation. The Cyriax method requires
fewer hospital visits enabling the patients to proceed in
their daily and sports activities. No special equipment
is needed for the method but only an experienced
Fig. 3 Deep friction massage on supraspinatus muscle physical therapist in the technique. The manipulation

Fig. 4 Scapular mobilization

techniques

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Knee Surg Sports Traumatol Arthrosc (2007) 15:915–921 919

therapy and were thus eliminated from review. In the

41 remaining studies, 18 did not utilize statistical
comparisons or report blinded assessment of outcome
measures [7].
Another systematic review examined the evidence
for the efficacy of rehabilitation interventions for
patients with subacromial impingement syndrome via
computerized bibliographic databases of Medline, the
Cumulative Index to Nursing and Allied Health Lit-
erature, and the Cochrane Database of Systematic
Reviews from 1966 to October 2003 [19]. They found
15 randomized clinical trails. The limited evidence
currently suggests that exercise and joint mobilizations
were efficacious for decreasing pain and improving
function for patients with subacromial impingement
syndrome [19].
The efficacy of the treatments for shoulder symp-
toms have rarely been evaluated in randomized com-
parative studies so far [3, 6]. In the last 10 years, many
publications have focused on functional disorders that
may result in subacromial impingement [10, 14, 28, 31].
There is one report on treating subacromial disorders
with manual therapy. Bergman et al. performed a
randomized controlled study in 250 patients with
shoulder symptoms [2]. The patients received standard
treatment and manipulative treatment. The authors
reported a reduction shoulder complaints and an
improvement in the range-of-motion after treatment.
All two methods led to a significant improvement in
function and a significant decrease in pain levels over a
period of 4 weeks. The findings of Bergmanet al. con-
Fig. 5 Glenohumeral joint mobilization techniques
firm our results with regard to reduced pain as well as
improvement in mobility and muscle strength [2]. Our
results confirm the efficacy of a manipulative therapy
used during the Cyriax approach is mild and does not described by Cyriax in the early phase of the treatment
require anesthesia. It provides a health-care advantage in subacromial impingement. Patients in the manual
during the active treatment period and this is of major therapy group demonstrated a significant reduction in
importance for both the patient and the overloaded pain and increased function compared to the control
physical therapy clinics of referral hospitals [8]. It group both immediately after treatment and at a 1-
seems reasonable to suspect that some of these indi- month follow-up. Although there are limitations in
viduals may have decreased passive accessory joint Bergman study’s methodology, the results seem to
motion that is not addressed by conventional man- support the use of manipulation in patients with per-
agement and may benefit from interventions that uti- sistent symptoms after an impingement syndrome.
lize manipulation/mobilization techniques. Soft tissue (muscle, ligaments, tendons, joint cap-
There is little published evidence on the efficacy of sules, articular surfaces, skin and fascia) injuries such
manipulation/mobilization for patients with any diag- as joint sprains or muscle damage are often treated by
nosis involving the shoulder. Although literature data manual therapy [16]. Normal tissue regeneration and
lacks a consensus on the non-operative approach for remodeling depend on mechanical stimulation during
the treatment of subacromial impingement, it is still the repair process [16]. This may help improve the
the primary intervention. The abstracts or full reports tissue’s overall mechanical and physical behaviors,
of 146 titles with appropriate key words regarding such as tensile strength and flexibility. Manipulation
manual therapy were reviewed in February 2005. Of was seen to have some effect in this study. Soft tissue
these, 105 studies were not primarily studies of manual and joint mobilization and deep friction massage

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920 Knee Surg Sports Traumatol Arthrosc (2007) 15:915–921

techniques stimulated the more superficial level of increasing strength, decreasing pain, and improving
proprioception, whereas manual techniques using joint function in patients with shoulder impingement syn-
movement, stretching or deep kneading would stimu- drome. The findings are interesting and motivate fur-
late the deep level of proprioception. Comparing the ther studies, including long-term follow-up of large
results of the different studies, there is no clear supe- groups, randomized studies and the comparison of this
riority of a particular method. After 3 months, half of treatment model with other treatment models.
the patients improved by 50% or more. A faster program with fewer hospital visits not only
The therapeutic exercise programs within the liter- enables the patients to proceed with most of their daily
ature related to impingement syndrome generally activities but also decreases the costs of the treatment.
consisted of stretching the anterior and posterior A manipulative therapy might also be an alternative to
shoulder girdle, muscle relaxation techniques, motor conventional physiotherapy in the treatment of the
learning to normalize dysfunctional patterns of motion, subacromial impingement.
and strengthening the rotator cuff and scapular muscles
[9–12]. It is unclear what the optimal exercise regime is
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