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March 2018, Volume 68, Issue 3

Research Article

Comparison of conservative exercise therapy with and without Maitland Thoracic Manipulative therapy in patients with subacromial pain: Clinical trial

Rizwan Haider  ( Department of Physiotherapy, Mayo Hospital )
Muhammad Salman Bashir  ( Associate Professor, UIPT, FAHS, UOL )
Muhammad Adeel  ( Shalamar Institute of Health Sciences )
Muhammad Junaid Ijaz  ( School of Physiotherapy, King Edward Medical University )
Azhar Ayub  ( Arthritis Care Clinic, Shadman, Lahore )


Objective: To determine the effect of conservative exercise therapy with and without Maitland thoracic manipulation in patients with subacromial pain.
Methods: The randomised controlled trial study was conducted at the Mayo Hospital, Lahore, Pakistan, from June 2015 to February 2016, and comprised patients with subacromial pain (group 1) and controls (group 2).Pre-assessment was done by using numeric pain rating scale and shoulder pain and disability index as subjective measurements, while range of motion was taken as objective measurement. SPSS version 21 was used for data analysis.
Results: Of the 40 participants, there were 20(50%) in each group. The baseline pain intensity on numeric pain rating scale for group 1 was 5.05±1.538 and for group 2 was 5.35±1.137; the values later changed to 0.70±0.923 and 2.30±0.979, respectively. The baseline functional status score according to shoulder pain and disability index for group 1 and 2 was 40.25±12.354 and 43.15±7.343 that changed to 12.30±4.714 and 22.55±5.577, respectively.
Conclusion: Maitland thoracic spinal manipulation with conservative exercise therapy was more effective than conservative exercise therapy alone.
Keywords: Shoulder impingement syndrome, Manipulation, Spinal, Physical therapy modalities. (JPMA 68: 381; 2018)


American surgeon Charles Neer described shoulder impingement as reduced structural space between the head of humerus and the acromion of spine of scapula.1 Shoulder impingement syndrome is the most common disease of the shoulder region that occurs by bony variations due to rotator cuff (RC) and scapular muscles imbalance and improper posture.2 The prevalence of shoulder impingement syndrome is highest (36%) among the people with shoulder pain.3 In Iran, the prevalence of shoulder pain was found to be 41.6% in athletic population.4 RC tendinopathy accounts for 69% to 75% of shoulder pain cases.5
To describe the occurrence of subacromial pain, the term "regional interdependence\\\'\\\' has been used in literature to explain that impairments in far anatomic region can associate patient\\\'s symptoms of shoulder pathology.6 The aetiology of RC tendinopathy has been portrayed as multifactorial and can be related to a blend of both intrinsic and extrinsic causes. Intrinsic causes that add to RC tendon degeneration are identified as adjustments in its structure, mechanical properties, morphology and vascularity. Extrinsic factors that can add to the advancement of RC tendinopathy by diminishing the subacromial space incorporate anatomic variations of the acromion, modifications in scapular or humeral kinematics, postural anomalies, deficiencies in the execution of rotator cuff and scapular muscles or diminished flexibility of pectoralis minor or posterior shoulder.7
Initial treatment of subacromial impingement syndrome (SIS) and related shoulder issues is prevalently non-surgical, including rest, non-steroidal inflammatory drugs, corticosteroid infusions, and diverse modalities of physical therapy, specifically exercises. In the instance of symptoms not diminishing for over three months, referral to orthopaedic assessment is required.8 Numerous rehabilitation modalities exist to treat RC tendinopathy, for example, physiotherapeutic exercises include open chain, closed chain, and a range of motion (ROM) exercises,9 manual therapy, and electrotherapy. For
practical concerns, multiple strategies for treating shoulder pain disorders are used in clinics but no one is more effective.10
Maitland postero-anterior mobilisation is frequently used to treat spinal pain. The technique comprises rhythmic, passive and gentle oscillations of the spine, and force and amplitude are applied permitting tissue responses and the individual\\\'s condition.11 Thoracic spinal manipulation results in pain reduction and physical function improvement in subacromial impingement syndrome patients.12-14
The results of one systematic review has shown the impact of physiotherapy with activities in regard to decreasing pain and enhancing functional capacity in patients with SIS.15 In physical therapy, neck and shoulder pathologies are commonly managed by thoracic spinal manipulation.16 Physiotherapy interventions for subacromial pain are stretching and strengthening exercises, joint mobilisation and manipulation, scapular and proprioceptive training, taping, acupuncture and physical modalities.17 The current study was planned to determine the effect of therapeutic exercises with and without Maitland thoracic manipulation in patients with subacromial pain.

Patients and Methods

This randomised controlled trial was conducted in the outpatient physiotherapy department of Mayo Hospital, Lahore, Pakistan, from June 2015 to February 2016, and comprised patients with subacromial pain and controls. Simple random sampling technique was used. Patients were divided into two groups (group 1: experimental, and group 2: control) by even and odd randomisation in which both groups have equal number of participants with a ratio of 1:1. By computer-generated random number table, each participant was assigned a random number. The sample size was measured by using G power priori analysis 3.1 software by assuming power 0.80 with 95%confidence interval (CI) on the difference. The mean difference between groups and effect size were calculated for the pain and function/disability outcomes using the equation:

In the equation, d = effect size; X1 and X2 are the group means, and S1 and S2 are the group standard deviations.
The effect sizes for studies that showed added benefit from manual therapy intervention ranged from 0.34 to 1.29 for pain measures and 0.34 to 1.66 for function/disability outcomes.18
The inclusion criteria were: shoulder impingement syndrome with positive physical test, shoulder pain for two to three months, shoulder pain score of at least 3 on the 10-point numeric pain rating scale, age 25-60 years, available documentation of patient consent. In contrast, patients with systemic rheumatic disease, operative interventions on shoulder, spine and thorax, shoulder arthrosis, concomitant shoulder pathology, cognitive impairments and pregnancy were excluded.
In group 1, patients received thoracic manipulative therapy included 1 non-thrust mobilisation and 3 different thrust manipulation techniques directed at thoracic spine and exercise therapy including hot or cold pack, mobility exercises (flexion and extension exercises with arms in front of the wall, shoulder flexion 90°, and exercises with shoulder circles)and strengthening exercises (resistance exercise with elbow flexion 90° and an elastic band, shoulder flexion with elbow extension holding bar (1-4 kg), body lift from a seated position with elbows extended, and resistance exercises for external rotation).19 In group 2, patients received conservative exercise therapy including hot or cold pack, mobility exercises and strengthening exercises. Each patient\\\'s first assessment was done before the first treatment session and terminal assessment after the sixth treatment session. Patients were treated for two weeks with three sessions per week. Patients were followed for another week for any change in signs and symptoms (Figure).

The patient came to physical therapist either after being referred by an orthopaedic surgeon or by themselves. The therapist assessed patients using Neer impingement test (specificity=30.5, sensitivity=88.7) and Hawkins Kennedy impingement test (specificity=25%, sensitivity=92%).(20) The physical therapist completed the assessment after obtaining consent from the patient and then used numeric pain rating scale (NPRS) to measure pain intensity, range of motion for mobility and shoulder pain and disability index (SPADI) for functional status. The study was approved by the institutional ethics committee.
The data were analysed using SPSS version 21. Data was presented in the form of mean ± standard deviation (SD) along with its range, frequency tables, percentages and appropriate graphs. P<0.05 was considered significant. Pre- and post-assessed parameters for pain intensity, ROM and functional status were compared by mean difference. The comparison between pain intensity and functional status for experimental and control groups was done by repeated measures analysis of variance (ANOVA).


Of the 45 patients, 40(88.9%) were included. Of them, there were 20(50%) in each group. The overall mean age was 49.55±9.706 years. Moreover, 22(55%) participants were females and 18(45%) males. Besides, 19(47.5%) participants had right shoulder impingement, 17(42.5%) left and 4(10%) bilateral shoulder involvement. The duration of symptoms was two months in 13(32.5%) cases, one month in 11(27.5%) cases and four months in 9(22.5%) cases (Table-1).

The baseline pain intensity on NPRS for group 1 was 5.05±1.538 and for group 2 it was 5.35±1.137 that was changed to 0.70±0.923 and 2.30±0.979, respectively. The baseline functional status score according to SPADI for group 1 and group 2 was 40.25±12.354 and 43.157.343 that was changed to 12.30±4.714 and 22.55±5.577, respectively (Table-2).

Repeated measures ANOVA for pain intensity and functional status score within subjects\\\' comparison and between the subjects\\\' comparison was carried out. The pain intensity and functional status scores after treatment were significant (p<0.05) (Tables 3-4).

Mean values for active ROM of shoulder flexion, extension, abduction, external rotation and internal rotation ranged between 33.25±12.698 and 161±5.525 (Table-5).


Our study findings suggest that subacromial pain was more common in females as compared to males. Moreover, the patients of subacromial pain belonged to the age group of 49-50 years because we collected data from a public hospital where the ratio of old population with shoulder pain was high. In a previous study, the mean age was 31.15±12.2 years.21 The duration of onset of shoulder pain symptoms in the current study was 4 to 8 weeks as compared to >12 weeks in a previous study.21 The difference can be explained by the fact that about 50% patients in the present study had one- to two-month history of onset of shoulder pain and that the age group differed between the two studies.
Impingement syndrome is the most common cause of shoulder or subacromial pain.2> The main findings of this study suggest that thoracic spinal manipulative therapy (SMT) with conservative physical therapy have greater effect on pain reduction and shoulder functional status improvement in subacromial impingement syndrome than conservative physical therapy alone.
Pain intensity scores in comparison to the control group changed 4.3 points on the numeric pain rating scale from pre- to post-treatment in the experimental group. The difference of change in the NPRS score was more significant in the experimental group. The previous study reported 0.9-point change in score on NPRS by applying thoracic spinal manipulative therapy and 1.5-point change for the sham spinal manipulative therapy group.21
The functional status score on the SPADI scale changed by 27.95 points in the experimental group and 20.6 points in the control group. The more improvement was noted in the experimental group in terms of functional status. But in comparison, Penn scale was used that showed a change of 9.2 points in the thoracic SMT group and 11 points in the sham SMT group.21 The results of a previous study for functional status showed more improvement in the sham SMT group than in the thoracic SMT group, but the difference was very small and also different scale was used, therefore its results can be compared to our study.
The active ROM for shoulder flexion, extension and external rotation consistently increased from pre- to post-treatment in both groups except left-side abduction (mean difference =31.75) and internal rotation (mean difference =16.25) for the experimental group.
The current study had a few limitations as well. The data was collected from a single department of the hospital; therefore, the results and conclusions had limited applicability. Due to shortage of time, the data was obtained from fewer
patients. Moreover, some illiterate and hesitant patients did not give appropriate answers and were less responsive.
Future research is necessary to know the mechanism of thoracic SMT in patients with shoulder pain. There should be a long-term follow-up to check the relation of thoracic manipulation with shoulder impingement syndromes. Besides, future research should examine changes in kinematics or neurophysiologic variables in groups of patients with shoulder pain who respond to thoracic SMT compared to the control group.


The Maitland mobilisation and manipulation with conservative physical therapy for subacromial pain was better and yielded improved outcome than conservative physical therapy.

Disclaimer: None.
Conflict of Interest: One of the authors was also Incharge of the ethics committee during that tenure. That article has been retrieved from thesis work.
Source of Funding: None.


1.  Neer CS. Anterior acromioplasty for the chronic impingement syndrome in the shoulder. J Bone Joint Surg Am. 2005; 87:1399.
2.  Morton S, Chan O, Ghozlan A, Price J, Perry J, Morrissey D. High volume image guided injections and structured rehabilitation in shoulder impingement syndrome: a retrospective study. Muscles Ligaments Tendons J. 2015; 5:195-9.
3.  Juel NG, Natvig B. Shoulder diagnoses in secondary care, a one year cohort. BMC Musculoskelet Disord. 2014; 15:89.
4.  Mohseni-Bandpei MA, Keshavarz R, Minoonejhad H, Mohsenifar H, Shakeri H. Shoulder Pain in Iranian Elite Athletes: The Prevalence and Risk Factors. J Manipulative Physiol Ther. 2012; 35:541-8.
5.  Tekavec E, Jöud A, Rittner R, Mikoczy Z, Nordander C, Petersson IF, et al. Population-based consultation patterns in patients with shoulder pain diagnoses. BMC Musculoskelet Disord. 2012; 13:238.
6.  Wainner RS, Whitman JM, Cleland JA, Flynn TW. Regional interdependence: a musculoskeletal examination model whose time has come. J Orthop Sports Phys Ther. 2007; 37:658-60.
7.  Seitz AL, McClure PW, Finucane S, Boardman ND, Michener LA. Mechanisms of rotator cuff tendinopathy: intrinsic, extrinsic, or both? Clin Biomech (Bristol, Avon). 2011; 26:1-12.
8.  Chaudhury S, Gwilym SE, Moser J, Carr AJ. Surgical options for patients with shoulder pain. Nat Rev Rheumatol. 2010; 6:217-26.
9.  Heron SR, Woby SR, Thompson DP. Comparison of three types of exercise in the treatment of rotator cuff tendinopathy/shoulder impingement syndrome: A randomized controlled trial. Physiotherapy. 2017; 103:167-73.
10.  Green S, Buchbinder R, Glazier R, Forbes A. WITHDRAWN: Interventions for shoulder pain. Cochrane Database Syst Rev. 2007; 4:CD001156.
11.  Maitland GD. Maitland\\\'s vertebral manipulation: Butterworth-Heinemann; London 2005.
12.  Boyles RE, Ritland BM, Miracle BM, Barclay DM, Faul MS, Moore JH, et al. The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Man Ther. 2009; 14:375-80.
13.  Muth S, Barbe MF, Lauer R, McClure P. The effects of thoracic spine manipulation in subjects with signs of rotator cuff tendinopathy. J Orthop Sports Phys Ther. 2012; 42:1005-16.
14.  Strunce JB, Walker MJ, Boyles RE, Young BA. The immediate effects of thoracic spine and rib manipulation on subjects with primary complaints of shoulder pain. J Man Manip Ther. 2009; 17:230-6.
15.  Hanratty CE, McVeigh JG, Kerr DP, Basford JR, Finch MB, Pendleton A, et al. editors. The effectiveness of physiotherapy exercises in subacromial impingement syndrome: a systematic review and meta-analysis. Semin Arthritis Rheum. 2012; 42:297-316.
16.  McDevitt A, Young J, Mintken P, Cleland J. Regional interdependence and manual therapy directed at the thoracic spine. J Man Manip Ther. 2015; 23:139-46.
17.  Haik M, Alburquerque-Sendín F, Moreira R, Pires E, Camargo P. Effectiveness of physical therapy treatment of clearly defined subacromial pain: a systematic review of randomised controlled trials. Br J Sports Med. 2016; 50:1124-34.
18.  Kardouni JR. Effects of Thoracic Spinal Manipulative Therapy on Thoracic Spine and Shoulder Kinematics, Thoracic Spine Flexion/Extension Excursion, and Pressure Pain Sensitivity in Patients with Subacromial Pain Syndrome: [Online] 2013 [Cited 2014 February 21]. Available from: URL:
19.  Vinuesa-Montoya S, Aguilar-Ferrándiz ME, Matarán-Peñarrocha GA, Fernández-Sánchez M, Fernández-Espinar EM, Castro-Sánchez AM. A Preliminary Randomized Clinical Trial on the Effect of Cervicothoracic Manipulation Plus Supervised Exercises vs a Home Exercise Program for the Treatment of Shoulder Impingement. J Chiropr Med. 2017;16:85-93.
20.  White R, Paull D, Fleming K. Rotator cuff tendinitis: comparison of subacromial injection of a long acting corticosteroid versus oral indomethacin therapy. J Rheumatol. 1986; 13:608-13.
21.  Kardouni J. Effects of Thoracic Spinal Manipulative Therapy on Thoracic Spine and Shoulder Kinematics, Thoracic Spine Flexion/Extension Excursion, and Pressure Pain Sensitivity in Patients with Subacromial Pain Syndrome. [Online] 2013 [Cited 2014 February 11]. Available from URL:

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