Effects of Stretching and Strengthening Exercises, With and Without Manual Therapy, on Scapular Kinematics, Function, and Pain in Individuals With Shoulder Impingement: A Randomized Controlled Trial

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Abstract
Study Design: Randomized controlled trial. Objective: To evaluate the effects of an exercise protocol, with and without manual therapy, on scapular kinematics, function, pain, and mechanical sensitivity in individuals with shoulder impingement syndrome. Background: Stretching and strengthening exercises have been shown to effectively decrease pain and disability in individuals with shoulder impingement syndrome. There is still conflicting evidence regarding the efficacy of adding manual therapy to an exercise therapy regimen. Methods: Forty-six patients were assigned to 1 of 2 groups, one of which received a 4-week intervention of stretching and strengthening exercises (exercise alone) and the other the same intervention, supplemented by manual therapy targeting the shoulder and cervical spine (exercise plus manual therapy). All outcomes were measured preintervention and postintervention at 4 weeks. Outcome measures were scapular kinematics in the scapular and sagittal planes during arm elevation, function as determined through the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, pain as assessed with a visual analog scale, and mechanical sensitivity as assessed with pressure pain threshold. Results: Independent of the intervention group, small, clinically irrelevant changes in scapular kinematics were observed postintervention. A significant group-by-time interaction effect (P = .001) was found for scapular anterior tilt during elevation in the sagittal plane, with a 3.0° increase (95% confidence interval [CI]: −1.5°, 7.5°) relative to baseline in the exercise-plus–manual therapy group compared to a decrease of 0.3° (95% CI: −4.2°, 4.8°) in the exercise-alone group. Pain, mechanical sensitivity, and the DASH score improved similarly for both groups by the end of the intervention period. Conclusion: Adding manual therapy to an exercise protocol did not enhance improvements in scapular kinematics, function, and pain in individuals with shoulder impingement syndrome. The noted improvements in pain and function are not likely explained by changes in scapular kinematics. The study is registered at www.clinicaltrials.gov (NCT02035618). Level of Evidence: Therapy, level 1b-. J Orthop Sports Phys Ther 2015;45(12):984–997. Epub 15 Oct 2015. doi:10.2519/jospt.2015.5939

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