Short-Term Effects of Thoracic Spine Manipulation on Shoulder Impingement Syndrome

A Randomized Controlled Trial
Published:March 01, 2017DOI:



      To investigate the short-term effects of thoracic spine manipulation (TSM) on pain, function, scapular kinematics, and scapular muscle activity in individuals with shoulder impingement syndrome.


      Randomized controlled trial with blinded assessor and patient.




      Patients with shoulder impingement syndrome (N=61).


      Participants were randomly allocated to TSM group (n=30) or sham-TSM group (n=31) and attended 2 intervention sessions over a 1-week period.

      Main Outcome Measures

      Scapular kinematics and muscle activity were measured at day 1 (baseline, before the first intervention), day 2 preintervention (before second intervention), day 2 postintervention (after the second intervention), and day 3 (follow-up). Shoulder pain and function were assessed by the Disability of the Arm, Shoulder and Hand questionnaire and Western Ontario Rotator Cuff Index at baseline, day 2 preintervention, and follow-up. An assessor blinded to group assignment measured all outcomes.


      Pain decreased by 0.7 points (95% confidence interval, 1.3–0.1 points) at day 2 preintervention and 0.9 points (95% confidence interval, 1.5–0.3 points) at day 2 postintervention in the TSM group. The Disability of the Arm, Shoulder and Hand questionnaire (P=.01) and Western Ontario Rotator Cuff Index (P=.02) scores improved in both groups. Scapular upward rotation increased during arm lowering (P<.01) at day 2 postintervention (5.3°) and follow-up (3.5°) in the TSM group. Upper trapezius activity increased (P<.05) in the sham-TSM group. Middle trapezius, lower trapezius, and serratus anterior decreased activities in both groups during elevation and lowering of the arm.


      TSM may increase scapular upward rotation during arm lowering. TSM does not seem to influence activity of the scapular muscles. The results concerning shoulder pain, function, scapular tilt, and internal rotation are not conclusive.


      List of abbreviations:

      DASH (Disability of the Arm, Shoulder and Hand), LT (lower trapezius), MCID (minimal clinically important difference), MT (middle trapezius), SA (serratus anterior), SIS (shoulder impingement syndrome), TSM (thoracic spine manipulation), UT (upper trapezius), WORC (Western Ontario Rotator Cuff Index)
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        • van der Windt D.A.
        • Koes B.W.
        • de Jong B.A.
        • Bouter L.M.
        Shoulder disorders in general practice: incidence, patient characteristics, and management.
        Ann Rheum Dis. 1995; 54: 959-964
        • Ludewig P.M.
        • Reynolds J.F.
        The association of scapular kinematics and glenohumeral joint pathologies.
        J Orthop Sports Phys Ther. 2009; 39: 90-104
        • Phadke V.
        • Camargo P.R.
        • Ludewig P.M.
        Scapular and rotator cuff muscle activity during arm elevation: a review of normal function and alterations with shoulder impingement.
        Rev Bras Fisiot. 2009; 13: 1-9
        • Marzetti E.
        • Rabini A.
        • Piccinini G.
        • et al.
        Neurocognitive therapeutic exercise improves pain and function in patients with shoulder impingement syndrome: a single-blind randomized controlled clinical trial.
        Eur J Phys Rehabil Med. 2014; 50: 255-264
        • Camargo P.R.
        • Avila M.A.
        • Alburquerque-Sendín F.
        • Asso N.A.
        • Hashimoto L.H.
        • Salvini T.F.
        Eccentric training for shoulder abductors improves pain, function and isokinetic performance in subjects with shoulder impingement syndrome: a case series.
        Braz J Phys Ther. 2012; 16: 74-83
        • Beaudreuil J.
        • Lasbleiz S.
        • Aout M.
        • et al.
        Effect of dynamic humeral centring (DHC) treatment on painful active elevation of the arm in subacromial impingement syndrome: secondary analysis of data from an RCT.
        Br J Sports Med. 2015; 49: 343-346
        • Ludewig P.M.
        • Borstad J.D.
        Effects of a home exercise programme on shoulder pain and functional status in construction workers.
        Occup Environ Med. 2003; 60: 841-849
        • McClure P.W.
        • Bialker J.
        • Neff N.
        • Williams G.
        • Karduna A.
        Shoulder function and 3-dimensional kinematics in people with shoulder impingement syndrome before and after a 6-week exercise program.
        Phys Ther. 2004; 84: 832-848
        • Camargo P.R.
        • Haik M.N.
        • Ludewig P.M.
        • Filho R.B.
        • Mattiello-Rosa S.M.
        • Salvini T.F.
        Effects of strengthening and stretching exercises applied during working hours on pain and physical impairment in workers with subacromial impingement syndrome.
        Physiother Theory Pract. 2009; 25: 463-475
        • Bang M.D.
        • Deyle G.D.
        Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome.
        J Orthop Sports Phys Ther. 2000; 30: 126-137
        • Bergman G.J.
        • Winters J.C.
        • Groenier K.H.
        • et al.
        Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and pain: a randomized controlled trial.
        Ann Intern Med. 2004; 141: 432-440
        • Tate A.R.
        • Mcclure P.W.
        • Young I.A.
        • Salvatori R.
        • Michener L.A.
        Comprehensive impairment-based exercise and manual therapy intervention for patients with subacromial impingement syndrome: a case series.
        J Orthop Sports Phys Ther. 2010; 40: 474-493
        • Winters J.C.
        • Sobel J.S.
        • Groenier K.H.
        • Arendzen H.J.
        • Meyboom-de Jong B.
        Comparison of physiotherapy, manipulation, and corticosteroid injection for treating shoulder complaints in general practice: randomised, single blind study.
        BMJ. 1997; 314: 1320-1325
        • Meurer A.
        • Grober J.
        • Betz U.
        • Decking J.
        • Rompe J.D.
        Thoracic spine mobility in patients with an impingement syndrome compared to healthy subjects—an inclinometer study.
        Z Orthop. 2004; 142: 415-420
        • Theisen C.
        • van Wagensveld A.
        • Timmesfeld N.
        • et al.
        Co-occurrence of outlet impingement syndrome of the shoulder and restricted range of motion in the thoracic spine—a prospective study with ultrasound-based motion analysis.
        BMC Musculoskelet Disord. 2010; 11: 135
        • Mintken P.E.
        • McDevitt A.W.
        • Cleland J.A.
        • et al.
        Cervicothoracic manual therapy plus exercise therapy versus exercise therapy alone in the management of individuals with shoulder pain: a multicenter randomized controlled trial.
        J Orthop Sports Phys Ther. 2016; 46: 617-628
        • McDevitt A.
        • Young J.
        • Mintken P.
        • Cleland J.
        Regional interdependence and manual therapy directed at the thoracic spine.
        J Man Manip Ther. 2015; 23: 139-146
        • Muth S.
        • Barbe M.F.
        • Lauer R.
        • McClure P.W.
        The effects of thoracic spine manipulation in subjects with signs of rotator cuff tendinopathy.
        J Orthop Sports Phys Ther. 2012; 42: 1005-1016
        • Boyles R.E.
        • Ritland B.M.
        • Miracle B.M.
        • et al.
        The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome.
        Man Ther. 2009; 14: 375-380
        • Strunce J.B.
        • Walker M.J.
        • Boyles R.E.
        • Young B.A.
        The immediate effects of thoracic spine and rib manipulation on subjects with primary complaints of shoulder pain.
        J Man Manip Ther. 2009; 17: 230-236
        • Haik M.N.
        • Alburquerque-Sendín F.
        • Silva C.Z.
        • Siqueira-Junior A.L.
        • Ribeiro I.L.
        • Camargo P.R.
        Scapular kinematics pre- and post-thoracic thrust manipulation in invidividuals with and without shoulder impingement symptoms: a randomized controlled study.
        J Orthop Sports Phys Ther. 2014; 44: 475-487
        • Kardouni J.R.
        • Shaffer S.W.
        • Pidcoe P.E.
        • Finucane S.D.
        • Cheatham S.
        • Michener L.
        Immediate changes in pressure pain sensitivity after thoracic spinal manipulative therapy in patients with subacromial impingement syndrome: a randomized controlled study.
        Man Ther. 2015; 20: 540-546
        • Haik M.N.
        • Alburquerque-Sendín F.
        • Moreira R.F.
        • Pires E.D.
        • Camargo P.R.
        Effectiveness of physical therapy treatment of clearly defined subacromial pain: a systematic review of randomised controlled trials.
        Br J Sports Med. 2016; 50: 1124-1134
        • Neer II, C.S.
        Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report.
        J Bone Joint Surg Am. 1972; 54: 41-50
        • Hawkins R.J.
        • Kennedy J.C.
        Impingement syndrome in athletes.
        Am J Sports Med. 1979; 8: 151-158
        • Jobe F.W.
        • Moynes D.R.
        Delineation of diagnostic criteria and a rehabilitation program for rotator cuff injuries.
        Am J Sports Med. 1982; 10: 336-339
        • Michener L.A.
        • Walsworth M.K.
        • Doukas W.C.
        • Murphy K.P.
        Reliability and diagnostic accuracy of 5 physical examination tests and combination of tests for subacromial impingement.
        Arch Phys Med Rehabil. 2009; 90: 1898-1903
        • Hegedus E.J.
        Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests.
        Br J Sports Med. 2012; 46: 964-978
        • Bishop P.B.
        • Quon J.A.
        • Fisher C.G.
        • Dvorak M.F.
        The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) study: a randomized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical low back pain.
        Spine J. 2010; 10: 1055-1064
        • McClure P.W.
        • Michener L.A.
        • Karduna A.R.
        Shoulder function and 3-dimensional scapular kinematics in people with and without shoulder impingement syndrome.
        Phys Ther. 2006; 86: 1075-1090
        • Mintken P.E.
        • Cleland J.A.
        • Carpenter K.J.
        • Bieniek M.L.
        • Keirns M.
        • Whitman J.M.
        Some factors predict successful short-term outcomes in individuals with shoulder pain receiving cervicothoracic manipulation: a single-arm trial.
        Phys Ther. 2010; 90: 26-42
        • Michener L.A.
        • Kardouni J.R.
        • Sousa C.O.
        • Ely J.M.
        Validation of a sham comparator for thoracic spinal manipulation in patients with shoulder pain.
        Man Ther. 2015; 20: 171-175
        • Mintken P.E.
        • Glynn P.
        • Cleland J.A.
        Psychometric properties of the shortened Disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) and Numeric Pain Rating Scale in patients with shoulder pain.
        J Shoulder Elbow Surg. 2009; 18: 920-926
        • Farrar J.T.
        • Young J.P.
        • LaMoreaux L.
        • Werth J.L.
        • Poole R.M.
        Clinical importance of changes in chronic pain intensity measured on an 11-point numerical rating scale.
        Pain. 2001; 94: 149-158
        • Dworkin R.H.
        • Turk D.C.
        • McDermott M.P.
        • et al.
        Interpreting the clinical importance of group differences in chronic pain clinical trials: IMMPACT recommendations.
        Pain. 2009; 146: 238-244
        • Orfale A.G.
        • Araújo P.M.
        • Ferraz M.B.
        • Natour J.
        Translation into Brazilian Portuguese, cultural adaptation and evaluation of the reliability of the Disabilities of the Arm, Shoulder and Hand Questionnaire.
        Braz J Med Biol Res. 2005; 38: 293-302
        • Lopes A.D.
        • Stadniky S.P.
        • Masiero D.
        • Carrera E.F.
        • Ciconelli R.M.
        • Griffin S.
        [Translation and cultural adaptation of WORC: a quality-of-life questionnaire for rotator cuff disorders] [Portuguese].
        Braz J Phys Ther. 2006; 10: 309-315
        • Franchignoni F.
        • Vercelli S.
        • Giordano A.
        • Sartorio F.
        • Bravini E.
        • Ferriero G.
        Minimal clinically important difference of the Disabilities of the Arm, Shoulder and Hand outcome measure (DASH) and its shortened version (QuickDASH).
        J Orthop Sports Phys Ther. 2014; 44: 30-39
        • Camargo P.R.
        • Alburquerque-Sendín F.
        • Avila M.A.
        • Haik M.N.
        • Vieira A.
        • Salvini T.F.
        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.
        J Orthop Sports Phys Ther. 2015; 45: 984-997
        • Ekeberg O.M.
        • Bautz-Holter E.
        • Keller A.
        • Tveitå E.K.
        • Juel N.G.
        • Brox J.I.
        A questionnaire found disease-specific WORC index is not more responsive than SPADI and OSS in rotator cuff disease.
        J Clin Epidemiol. 2010; 63: 575-584
        • Haik M.N.
        • Alburquerque-Sendín F.
        • Camargo P.R.
        Reliability and minimal detectable change of 3-dimensional scapular orientation in individuals with and without shoulder impingement.
        J Orthop Sports Phys Ther. 2014; 44: 341-349
        • Michener L.A.
        • Elmore K.A.
        • Darter B.J.
        • Timmons M.K.
        Biomechanical measures in participants with shoulder pain: intra-rater reliability.
        Man Ther. 2016; 22: 86-93
        • Sousa Cde O.
        • Michener L.A.
        • Ribeiro I.L.
        • Reiff R.B.
        • Camargo P.R.
        • Salvini T.F.
        Motion of the shoulder complex in individuals with isolated acromioclavicular osteoarthritis and associated with rotator cuff dysfunction. Part 2: muscle activity.
        J Electromyogr Kinesiol. 2015; 25: 77-83
        • Ekstrom R.A.
        • Soderberg G.L.
        • Donatelli R.A.
        Normalization procedures using maximum voluntary isometric contractions for the serratus anterior and trapezius muscles during surface EMG analysis.
        J Electromyogr Kinesiol. 2005; 15: 418-428
        • Seitz A.L.
        • Uhl T.L.
        Reliability and minimal detectable change in scapulothoracic neuromuscular activity.
        J Electromyogr Kinesiol. 2012; 22: 968-974
        • Barzi F.
        • Woodward M.
        Imputations of missing values in practice: results from imputations of serum cholesterol in 28 cohort studies.
        Am J Epidemiol. 2004; 160: 34-45
        • Cohen J.
        The concepts of power analysis.
        in: Statistical power analysis for the behavioral sciences. Academic Pr, New Jersey1988: 1-17
        • Kardouni J.R.
        • Pidcoe P.E.
        • Shaffer S.W.
        • et al.
        Thoracic spine manipulation in individuals with subacromial impingement syndrome does not immediately alter thoracic spine kinematics, thoracic excursion, or scapular kinematics: a randomized controlled trial.
        J Orthop Sports Phys Ther. 2015; 45: 1-34
        • Bialosky J.E.
        • Bishop M.D.
        • Price D.D.
        • Robinson M.E.
        • George S.Z.
        The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model.
        Man Ther. 2009; 14: 531-538
        • Coronado R.A.
        • Simon C.B.
        • Valencia C.
        • George S.Z.
        Experimental pain responses support peripheral and central sensitization in patients with unilateral shoulder pain.
        Clin J Pain. 2014; 30: 143-151
        • Borstad J.
        • Woeste C.
        The role of sensitization in musculoskeletal shoulder pain.
        Braz J Phys Ther. 2015; 19: 251-256
        • Sanchis M.N.
        • Lluch E.
        • Nijs J.
        • Struyf F.
        • Kangasperko M.
        The role of central sensitization in shoulder pain: a systematic literature review.
        Semin Arthritis Rheum. 2015; 44: 710-716
        • Alburquerque-Sendín F.
        • Camargo P.
        • Vieira A.
        • Salvini T.
        Bilateral myofascial trigger points and pressure pain thresholds in the shoulder muscles in patients with unilateral shoulder impingement syndrome: a blinded, controlled study.
        Clin J Pain. 2013; 29: 478-486
        • Ludewig P.M.
        • Cook T.M.
        Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement.
        Phys Ther. 2000; 80: 276-291
        • Lin J.J.
        • Hanten W.P.
        • Olson S.L.
        • et al.
        Functional activity characteristics of individuals with shoulder dysfunctions.
        J Electromyogr Kinesiol. 2005; 15: 576-586