Immediate changes in pressure pain sensitivity after thoracic spinal manipulative therapy in patients with subacromial impingement syndrome: A randomized controlled study

doi:10.1016/j.math.2014.12.003

Manual Therapy

Volume 20, Issue 4, August 2015, Pages 540-546

https://doi.org/10.1016/j.math.2014.12.003 Get rights and content

Abstract

Background

Thoracic SMT can improve symptoms in patients with subacromial impingement syndrome. However, at this time the mechanisms of SMT are not well established. It is possible that changes in pain sensitivity may occur following SMT.

Objectives

To assess the immediate pain response in patients with shoulder pain following thoracic spinal manipulative therapy (SMT) using pressure pain threshold (PPT), and to assess the relationship of change in pain sensitivity to patient-rated outcomes of pain and function following treatment.

Design

Randomized Controlled Study.

Methods

Subjects with unilateral subacromial impingement syndrome (n = 45) were randomly assigned to receive treatment with thoracic SMT or sham thoracic SMT. PPT was measured at the painful shoulder (deltoid) and unaffected regions (contralateral deltoid and bilateral lower trapezius areas) immediately pre- and post-treatment. Patient-rated outcomes were pain (numeric pain rating scale – NPRS), function (Pennsylvania Shoulder Score – Penn), and global rating of change (GROC).

Results

There were no significant differences between groups in pre-to post-treatment changes in PPT (p ≥ 0.583) nor were there significant changes in PPT within either group (p ≥ 0.372) following treatment. NPRS, Penn and GROC improved across both groups (p < 0.001), but there were no differences between the groups (p ≥ 0.574).

Conclusion

There were no differences in pressure pain sensitivity between participants receiving thoracic SMT versus sham thoracic SMT. Both groups had improved patient-rated pain and function within 24–48 h of treatment, but there was no difference in outcomes between the groups.

Introduction

Shoulder pain is one of the most common musculoskeletal pain complaints in general medical practice, with a prevalence ranging from 16 to 48% (Pope et al., 1997, Broadhurst et al., 2006). Treatment of shoulder pain with manual therapy techniques that include thoracic spinal manipulative therapy (SMT) is reported to produce positive clinical outcomes (Winters et al., 1997, Bang and Deyle, 2000, Bergman et al., 2004, Boyles et al., 2009, Strunce et al., 2009, Mintken et al., 2010a). Although clinical efficacy is reported with thoracic SMT for the treatment of shoulder pain, the mechanisms underlying the clinical improvements have not been well established. Recent studies have found improvements in patient-rated pain and function after a single treatment of thoracic SMT in patients with subacromial impingement syndrome (SIS), but did not find mechanical changes in thoracic spine or shoulder mobility (Muth et al., 2012, Haik et al., 2014).

Pain relief after thoracic SMT may be due to neurophysiologic changes in pain sensitivity at the peripheral and/or central nervous system (Bialosky et al., 2009). Decreased sensitivity to pressure pain (increase in PPT) has been reported after SMT in patients with musculoskeletal pain (Vernon et al., 1990, Fernandez-Carnero et al., 2008, Mansilla-Ferragut et al., 2009, de Camargo et al., 2011, Martinez-Segura et al., 2012). To date, no studies have characterized the neurophysiologic effects of pain sensitivity after thoracic SMT in patients with SIS.

The primary purpose of this study was to assess the effects of thoracic SMT on central and peripheral pain sensitivity measured with PPT in patients with SIS. The secondary purpose of this study was to examine the relationship between change in the pain sensitivity following thoracic SMT and patient-rated outcomes of pain and function. It is hypothesized that patients receiving thoracic SMT compared to sham thoracic SMT will show: 1) increased PPT (decreased sensitivity to pressure pain) at the affected shoulder, indicating a decreased peripheral and/or central sensitivity to pain, 2) increased PPT at regions away from the affected shoulder (unaffected shoulder and over the lower trapezius muscle bilaterally) indicating decreased central sensitivity to pain, and 3) decreased pressure pain sensitivity will be related to improved patient-rated pain and function.

Section snippets

Participants

Participants (n = 48) with SIS were recruited from local physical and occupational therapy offices, physicians' clinics, as well as by advertisement at a university gym during the period from November 2012 to April 2013. This study took place in a research laboratory in the Physical Therapy Department at Virginia Commonwealth University, and the study protocol was approved by the university's Institutional Review Board. Inclusion criteria for patients with SIS were: 1) pain for ≥6 weeks, 2)

Results

Forty-eight (n = 48) individuals with SIS were randomly assigned to receive thoracic SMT (n = 24) or sham thoracic SMT (n = 24). Three participants were excluded from the final analysis (all in the sham thoracic SMT group) because it was discovered after testing that they had pain in both shoulders, leaving n = 45 for final analysis (Table 1). PPT measurements for both groups are shown in Table 2, and patient-rated outcomes are shown in Table 3. The mixed-model ANCOVA (Table 4) showed no

Discussion

Thoracic SMT did not have any greater effect than the sham thoracic SMT on measures of pain sensitivity or patient-rated outcomes. While there was no pre-to post-treatment change in pain sensitivity, patient-rated outcomes improved across both groups. When we examined the relationship between mechanism (PPT) and outcome in the thoracic SMT group, a higher level of function (higher Penn score) at baseline was related to increased pain threshold at the unaffected lower trapezius following

Conclusion

Thoracic SMT did not alter sensitivity to pressure pain at the affected shoulder or remote regions compared to sham thoracic SMT. There was also no difference in patient-rated outcomes between the groups. Interestingly, both groups had improved patient-rated outcomes following treatment. Clinically, thoracic SMT leads to improvements in pain and function in patients with SIS, but since effects were similar to sham thoracic SMT they may be related to factors such as manual contact, positioning

Acknowledgements

This research was funded through Clinical and Translational Science Award No. UL1TR000058 from the National Center for Advancing Translational Sciences and the AD Williams' Fund of the Virginia Commonwealth University. The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in this study.

Disclaimer

The opinions or assertions contained herein are the private views of the author(s) and are not to be construed as official or reflecting the views of the National Institutes of Health, the Department of the Army or the Department of Defense.

Any citations of commercial organizations and trade names in this report do not constitute an official Department of the Army endorsement or approval of the products or services of these organizations.

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Cited by (32)

A systematic review of the measurement properties of the Pennsylvania Shoulder Score
2024, Journal of Hand Therapy
Pennsylvania Shoulder Score (PSS) is a patient-reported outcome measure (PROM) that is gaining use when examining shoulder-specific outcomes. To date, a systematic review of the PSS measurement properties has not been published.
To systematically locate, appraise, and synthesize the evidence concerning the measurement properties of the PSS.
Systematic literature review.
A pair of raters conducted a literature search using pre-defined keywords from 5 databases (PubMed, CINAHL, SPORTdiscus, PsychINFO, Scopus) during the week of October 23, 2022. Critical appraisal of study design for psychometric articles was used to assess methodological quality and risk of bias. Measurement property data were synthesized with pooled estimates for the indices of test-retest reliability (ICC), standard error of measurement (SEM), minimal detectable change (MDC), Cronbach α (CA), effect size (ES), and standardized response means (SRM) calculated from applicable studies.
A total of 13 articles met the inclusion criteria for this review. Methodological quality was agreed upon between the 2 raters with a weighted kappa of 0.77, and 9/13 of the articles were rated above 70%. Test-retest reliability of the PSS total score ranged between 0.90 and 0.94, and construct validity was high when compared to other shoulder-specific PROMs (0.75 < r > 0.96). Responsiveness of the PSS was large across all studies with few PSS subscales dropping to moderate. Pooled MDC90 of the total PSS was 12.13 points, and the pooled ES of the total PSS was 0.85.
The scope of this review demonstrates positive measurement properties of the PSS as a reliable, valid, and responsive measurement of shoulder-specific PROM. However, there are few studies examining the measurement properties of the PSS and more research is needed to assess cross-cultural appropriateness and factor analysis of the questions contained in the PSS.
Thoracic Manual Therapy Improves Pain and Disability in Individuals With Shoulder Impingement Syndrome Compared With Placebo: A Randomized Controlled Trial With 1-Year Follow-up
2022, Archives of Physical Medicine and Rehabilitation
Citation Excerpt :
Thoracic posture and ROM were not measured at any follow-up time points; hence, it is unknown if they would have changed over time. No identified study previously reported the effects of thoracic MET on SIS; however, 3 randomized controlled trials19,21,22 investigated the effects of a different manual therapy technique, thoracic spine HVLA manipulation, on SIS symptoms. All 3 studies found no difference between manipulation intervention and a sham intervention, described as a “hands-on” sham, where participants were placed in the same position as the intervention (but with no thrust given).
To investigate whether muscle energy technique (MET) to the thoracic spine decreases the pain and disability associated with shoulder impingement syndrome (SIS).
Single-center, 3-arm, randomized controlled trial, single-blind, placebo control with concealed allocation and a 12-month follow-up.
Private osteopathic practice.
Three groups of 25 participants (N=75) 40 years or older with SIS received allocated intervention once a week for 15 minutes, 4 consecutive weeks.
Participants were randomly allocated to MET to the thoracic spine (MET-only), MET plus soft tissue massage (MET+STM), or placebo.
Primary outcome measure: Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Secondary outcome measures: Shoulder Pain and Disability Index (SPADI) questionnaire; visual analog scale (VAS) (mm/100): current, 7-day average, and 4-week average; Patient-Specific Functional Scale (PSFS); and Global Rating of Change (GROC). Measures recorded at baseline, discharge, 4-week follow-up, 6 months, and 12 months. Also baseline and discharge thoracic posture and range of motion (ROM) measured using an inclinometer. Statistical analysis included mixed-effects linear regression model for DASH, SPADI, VAS, PSFS, GROC, and thoracic posture and ROM.
MET-only group demonstrated significantly greater improvement in pain and disability (DASH, SPADI, VAS 7-day average) than placebo at discharge (mean difference, DASH=−8.4; 95% CI, −14.0 to −2.8; SPADI=−14.7; 95% CI, −23.0 to −6.3; VAS=−15.5; 95% CI, −24.5 to −6.5), 6 months (−11.1; 95% CI, −18.6 to −3.7; −14.9; 95% CI, −26.3 to −3.5; −14.1; 95% CI, −26.0 to −2.2), and 12 months (−13.4; 95% CI, −23.9 to−2.9; −19.0; 95% CI, −32.4 to −5.7; −17.3; 95% CI, −30.9 to −3.8). MET+STM group also demonstrated greater improvement in disability but not pain compared with placebo at discharge (DASH=−8.2; 95% CI, −14.0 to −2.3; SPADI=−13.5; 95% CI, −22.3 to −4.8) and 6 months (−9.0; 95% CI, −16.9 to −1.2; −12.4; 95% CI, −24.3 to −0.5). For the PSFS, MET-only group improved compared with placebo at discharge (1.3; 95% CI, 0.1-2.5) and 12 months (1.8; 95% CI, 0.5-3.2); MET+STM at 12 months (1.7; 95% CI, 0.3-3.0). GROC: MET-only group improved compared with placebo at discharge (1.5; 95% CI, 0.9-2.2) and 4 weeks (1.0; 95% CI, 0.1-1.9); MET+STM at discharge (1.2; 95% CI, 0.5-1.9) and 6 months (1.2; 95% CI, 0.1-1.3). There were no differences between MET-only group and MET+STM, and no between-group differences in thoracic posture or ROM.
MET of the thoracic spine with or without STM improved the pain and disability in individuals 40 years or older with SIS and may be recommended as a treatment approach for SIS.
Evidence for increased neuromuscular drive following spinal manipulation in individuals with subacromial pain syndrome
2021, Clinical Biomechanics
Thoracic spinal manipulation can improve pain and function in individuals with shoulder pain; however, the mechanisms underlying these benefits remain unclear. Here, we evaluated the effects of thoracic spinal manipulation on muscle activity, as alteration in muscle activity is a key impairment for those with shoulder pain. We also evaluated the relationship between changes in muscle activity and clinical outcomes, to characterize the meaningful context of a change in neuromuscular drive.
Participants with shoulder pain related to subacromial pain syndrome (n = 28) received thoracic manipulation of low amplitude high velocity thrusts to the lower, middle and upper thoracic spine. Electromyographic muscle activity (trapezius-upper, middle, lower; serratus anterior; deltoid; infraspinatus) and shoulder pain (11-point scale) was collected pre and post-manipulation during arm elevation, and normalized to a reference contraction. Clinical benefits were assessed using the Pennsylvania Shoulder Score (Penn) at baseline and 2–3 days post-intervention.
A significant increase in muscle activity was observed during arm ascent (p = 0.002). Using backward stepwise regression analysis, a specific increase in the serratus anterior muscle activity during arm elevation explained improved Penn scores following post-manipulation (p < 0.05).
Thoracic spinal manipulation immediately increases neuromuscular drive. In addition, increased serratus anterior muscle activity, a key muscle for scapular motion, is associated with short-term improvements in shoulder clinical outcomes.
Changes in pressure pain threshold and temporal summation in rapid responders and non-rapid responders after lumbar spinal manipulation and sham: A secondary analysis in adults with low back pain
2020, Musculoskeletal Science and Practice
Citation Excerpt :
The clinical relevance of changes in QST after SMT is unknown, in part because the vast majority of studies only measure before and immediately after the intervention (Aspinall et al., 2019; Honoré et al., 2018). Only two studies appear to have investigated the association between short-term changes in PPT and changes in pain or disability, both finding no significant associations in shoulder pain populations (Coronado et al., 2015; Kardouni et al., 2015). Whether hypoalgesia after SMT differs based on symptomatic change does not appear to have been investigated.
People with LBP who experience rapid improvement in symptoms after spinal manipulative therapy (SMT) are more likely to experience better longer-term outcomes compared to those who don't improve rapidly. It is unknown if short-term hypoalgesia after SMT could be a relevant finding in rapid responders.
We aimed to explore whether rapid responders had different short-term pressure pain threshold (PPT) and temporal summation (TS) outcomes after SMT and sham compared to non-rapid responders.
This was a planned secondary analysis of a randomised controlled trial that recruited 80 adults with LBP (42 females, mean age 37 yrs). PPT at the calf, lumbar spine, and shoulder and TS at the hands and feet were measured before and three times over 30 min after a lumbar SMT or sham manipulation. Participants were classified as rapid responders or non-rapid responders based on self-reported change in LBP over the following 24 h.
Shoulder PPT transiently increased more in the rapid responders than non-rapid responders immediately post-intervention only (between-group difference in change from baseline = 0.29 kg/cm², 95% CI 0.02–0.56, p = .0497). There were no differences in calf PPT, lumbar PPT, hand TS, or foot TS based on responder status.
Hypoalgesia in shoulder PPT occurred transiently in the rapid responders compared to the non-rapid responders. This may or may not contribute to symptomatic improvement after SMT or sham in adults with LBP, and may be a spurious finding. Short-term changes in TS do not appear to be related to changes in LBP.
Immediate effects of spinal manipulation on shoulder motion range and pain in individuals with shoulder pain: A randomized trial
2019, Journal of Chiropractic Medicine
The purpose of this study was to investigate the influence of thoracic spinal manipulation (SM) on shoulder pain and ranges of motion in individuals with shoulder pain.
The sample was composed of 60 individuals, randomly allocated into the manipulation group (n = 30), who received the SM, and the placebo group (n = 30) who received a placebo manipulation. Pain evaluation was performed using the visual analog scale, and evaluation of shoulder flexion and abduction ranges of motion was assessed using a goniometer pre- and post-intervention. The intervention was performed by either upper thoracic SM or a placebo manipulation.
The manipulation group demonstrated increased flexion and abduction of the painful shoulder (P < .01) and increased abduction of the nonpainful shoulder (P = .03), but only the abduction of the painful shoulder reached the minimal detectable change. The placebo group showed a post-intervention increase in the flexion (P = .03) and abduction (P < .01) movement of the painful shoulder. Both groups presented a statistically significant reduction in post-intervention pain (P < .01), but not clinically significant.
Although the SM demonstrated a statistically significant difference for shoulder pain, this was not over the clinically meaningful change. Only the abduction of the painful shoulder reached the minimal detectable change.
Immediate Effects of Thoracic Spine Manipulation Upon Shoulder Functionality in Patients With Sutured Rotator Cuff Repair: A Prospective Study
2018, Journal of Manipulative and Physiological Therapeutics
The purpose of this study was to evaluate the immediate effect of thoracic spine manipulation upon active flexion and abduction mobility of the shoulder, spine temperature, and the size of the subacromial space as measured by ultrasound in 3 positions (internal, neutral, and external rotation) of the glenohumeral joint in patients who have undergone surgery because of subacromial impingement.
Quasi-experimental, prospective, short-term effect study with consecutively sampled participants. Thirty-two patients had undergone subacromial decompression together with supraspinatus tendon suture. The following variables were studied: age, sex, dominant shoulder, presurgery evolution time, working status, surface temperature of dorsal segment with limited mobility, premanipulation functional assessment using the Spanish version of the Upper Limb Functional Index Scale, goniometric range of motion measurement at glenohumeral joint before and after manipulation, and ultrasound measurement of subacromial space before and after manipulation.
Significant differences and small effect size were found in measurements for flexion and abduction movements after thoracic spine manipulation (P > .001; ES > 0.2) and subacromial space measurements in neutral rotation and external rotation (P > .001), but without clinical relevance effect size (<0.2).
Active shoulder flexion and abduction mobility increase after manipulation of thoracic spine in patients who have undergone surgery for rotator cuff suture. Subacromial space increases significantly with shoulder in neutral and external rotation position after manipulation. No differences were found regarding surface temperature of manipulated area.

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Original articleImmediate changes in pressure pain sensitivity after thoracic spinal manipulative therapy in patients with subacromial impingement syndrome: A randomized controlled study

Abstract

Background

Objectives

Design

Methods

Results

Conclusion

Introduction

Section snippets

Participants

Results

Discussion

Conclusion

Acknowledgements

Disclaimer

Man Ther

Man Ther

Pain

J Manip physiological Ther

Control Clin trials

J Manip Physiological Ther

Arch Phys Med Rehabil

Arch Phys Med Rehabil

J Shoulder Elbow Surg

Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome

J Orthop Sports Phys Ther

Placebo, nocebo, and expectations: leveraging positive outcomes

J Orthop Sports Phys Ther

Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and pain: a randomized, controlled trial

Ann Intern Med

The influence of expectation on spinal manipulation induced hypoalgesia: an experimental study in normal subjects

BMC Musculoskelet Disord

Pressure pain sensitivity maps of the neck-shoulder and the low back regions in men and women

BMC Musculoskelet Disord

Patient expectations of benefit from interventions for neck pain and resulting influence on outcomes

J Orthop Sports Phys Ther

Original article
Immediate changes in pressure pain sensitivity after thoracic spinal manipulative therapy in patients with subacromial impingement syndrome: A randomized controlled study