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February 2023, Volume 73, Issue 2

Systematic Review

Effects of thoracic spinal thrust manipulation for the management of shoulder impingement syndrome: Systematic review

Bazal Bukhari  ( University Institute of Physical Therapy, University of Lahore, Lahore, Pakistan )
Ashfaq Ahmad  ( University Institute of Physical Therapy, University of Lahore, Lahore, Pakistan. )
Arooj Fatima  ( University Institute of Physical Therapy, The University of Lahore, Lahore, Pakistan )
Sarwat Ali  ( University Institute of Physical Therapy, University of Lahore Teaching Hospital, Lahore, Pakistan. )

Abstract

Objective: To determine the effectiveness of thoracic spinal thrust manipulation for shoulder impingement syndrome in the improvement of pain, range of motion and functional outcomes.

 

Method: The systematic review was conducted by 2 researchers independently using search strategy developed for different databases, including Cochrane Central register of control trials, PubMed, Pedro and MEDLINE, for relevant articles published between 2008 and 2020. The search strategy was designed for each database by combining the key terms and Boolean operators related to the review’s objective.

 

Results: Of the 312 studies identified, 14(4.5%) were included. Of them, 4(28.6%) were in favour of thoracic thrust manipulation, 8(57.2%) did not support thoracic thrust manipulation as the sole treatment and 2(14.3%) favoured thoracic thrust manipulation along with exercises.

 

Conclusion: Studies indicated immediate improvement in range of motion as well as pain after thrust manipulation, but others reported no such clinical difference. Manipulation should be combined with other exercise therapy to ensure some clinical improvement.

 

Keywords: Rotator cuff impingement, Rotator cuff impingement syndrome, Shoulder impingement, Shoulder impingement syndrome, Spinal manipulation.  (JPMA 73: 338; 2023) 

 

DOI: https://doi.org/10.47391/JPMA.5151

 

Submission completion date: 28-10-2021 -Acceptance date: 26-05-2022

 

Introduction

 

The scapula, clavicle, and proximal humerus work together as a single biomechanical unit to form the shoulder girdle. Three joints – the glenohumeral (GH), acromioclavicular and sternoclavicular joints – and two gliding planes – the subacromial and the scapulothoracic – allow the shoulder a greater range of motion (ROM) than any other joint in the body, reaching nearly 180 degrees in almost all directions of movement. It's evident that such a large range of shoulder mobility relies on these joints and gliding planes working in harmony to allow the arm and the hand to be positioned as needed in space around the body.1

The GH joint, a synovial ball and socket joint, is formed when the humeral head articulates with the glenoid fossa of the scapula.2 Internal and external rotation, abduction and adduction, flexion and extension are all achievable with this joint, which is chiefly controlled by the rotator cuff muscles (teres minor, subscapularis, supraspinatus, infraspinatus), pectoralis major, and deltoid. The subacromial, subdeltoid, subcoracoid, and coracobrachial bursae were amongst the synovial bursae that allow frictionless motion in the GH joint.3 The GH joint is stabilised by the coracoacromial and acromioclavicular ligaments, which restrict proximal humerus migration.4,5

For more than 2000 years, spinal manipulation has been practiced. The physiology of the varied impacts of spinal manipulation has been explained numerous times, especially of the high-velocity, low-amplitude thrusts (HVLATs) or high-velocity thrusts (HVTs). This type of manipulation, as the name implies, involves a high-velocity "impulse" or "thrust" administered to a diarthrodial synovial joint with a very small amplitude. This form of manipulation is generally accompanied by an audible "crack," which is often seen as a sign of successful manipulation.6 The cracking sound is created by a phenomenon known as "cavitation," which occurs within the joint's synovial fluid (SF).

Cavitation describes the production and activity of bubbles (or cavities) within a fluid as a result of a local pressure reduction.7 Acute and chronic low back pain (LBP) have both been benefited by the spinal manipulative therapy. While previously examined for effectiveness, spinal HVLAT manipulation and mobilisation (a light, often oscillatory, passive movement) were grouped together as one intervention due to a lack of basic information.8 Peculiar outcomes associated with spinal HVLAT manipulation, especially those that appear to occur only in conjunction with the cavitation event, have the potential to give sufficient theoretical justification for evaluating mobilisation and manipulation as distinct clinical entities.9

The third most frequently reported musculoskeletal condition is shoulder pain, with incidence rates up to 2.5% and prevalence ranging from 6.9% to 26% for point prevalence, which increases to 65.7% for the general population lifetime prevalence.10,11 About half of all patients with shoulder discomfort heal entirely within Six months of the injury and another 10% recover over a 6-month period.12 The major proportion of patients, however, report chronic shoulder ache with increase in the frequency of sick leaves which contributes over 80% of the whole cost of shoulder pain.13 The health, personal and socio-economic impacts of shoulder discomfort are widely observed, but the contributors to chronicity are little known. Rotator cuff disorders, adhesive capsulitis of the shoulder, and GH osteoarthritis are perhaps the most commonly reported clinical pathologies associated with chronic shoulder pain, comprising the majority of all shoulder pain pathologies. Furthermore, one of most frequent causes of chronic shoulder discomfort is rotator cuff disorders, particularly supraspinatus tendinopathies.14 The rotator cuff is the primary dynamic stabiliser of the shoulder joint, allowing the humeral head to be centered in the glenoid.  A trauma or weakening of the rotator cuff can thus produce further instability, causing other muscles to co-activate and stabilise the GH joint, such as the long head of the biceps. Not surprisingly, the effects of the long head of the biceps are often linked to supraspinatus tendinopathies. Furthermore, shoulder adhesive capsulitis is a high prevalence pathology (up to 5.3% in general populations) which is characterised by long-term symptoms, therefore accounting for a substantial number of individuals with chronic shoulder discomfort.15

Exercise has been seen to be useful for both short-term recovery in rotator cuff disease and long-term benefits in terms of function. When compared with exercise alone, combination of mobilisation and exercise provided extra benefits for rotator cuff disease. For adhesive capsulitis, laser therapy was found to be more efficacious than placebo, but not for supraspinatus tendonitis. In comparison with placebo, both ultrasound and pulsed electromagnetic field therapy relieved pain in calcific tendonitis. Ultrasound did not appear to have any impact on shoulder pain, adhesive capsulitis, or rotator cuff tendonitis. Compared to workout alone, ultrasound provides no substantial benefit. For rotator cuff dysfunction, there were some reports that corticosteroid injections are favourable to physiotherapy (PT), but no proof that PT alone is beneficial for adhesive capsulitis.16

Bursitis, tendinitis, rotator cuff injury, adhesive capsulitis, impingement syndrome, avascular necrosis, GH osteoarthritis (OA), and other forms of degenerative joint diseases, as well as traumatic damage, can all cause persistent shoulder pain, either together or separately. Rotator cuff dysfunction, adhesive capsulitis, and GHOA all seems to be likely reasons of persistent shoulder pain, accounting for around 10%, 6% and 2-5% of all shoulder discomfort, respectively. Although the aetiologies of all three disorders are complicated, the majority of patients can be diagnosed based on their medical history, thorough physical examination, and plain film radiographs.17

Heavy workload, stiff postures, repeated movements, quivering and number of years in service are the consequence associated with physical load. Repetitive movements, vibration, and duration of work show consistent results in trials.

Studies obtaining a method score of 60% or higher reported odds ratios (ORs) ranging from 1.3 to 4.0. The statistical pooling of results is hampered by significant variation in the methodologies utilised for exposure assessment and data processing.18

Age, excessive physical strain and arm abduction are all interconnected with shoulder pain and rotator cuff syndrome in men. Shoulder pain is strongly associated with an automated work pace and a lack of supervisor assistance, while the rotator cuff syndrome is linked with a high psychological demand and a lack of skill discernment. Age, repetitive nature of jobs, and inadequate supervisor assistance are all interconnected with shoulder pain and rotator cuff syndrome in women. Shoulder pain is linked with perceived increase in physical activity and exposure to cold temperature.19

Thrust manipulation is a therapy for shoulder pain commonly used by physiotherapists. In the peer-reviewed literature, spinal or extremity-directed thrust manipulations are known as Grade V mobilisations or HVLA manipulation. Spinal manipulative therapy (SMT) refers to thrust manipulation of the spine. SMT may have a therapeutic effect through a variety of mechanisms, some of which overlap. SMT affects sensory processing in the brain and spinal cord, and is associated with decreased pain sensitivity in the extremities. Fibrous adhesions resulting from disuse, injury, or degenerative diseases are considered to be disrupted by thrust manipulation of the spine, extremities and joints.20

A numerical rating scale (NRS) requires the patient to rate their pain on a defined scale. For example, 0–10 where 0 is no pain and 10 is the worst pain imaginable. The commonly used NRSs have 11 points (0-10), 21 points (0-20) and 101 points (0-100).21,22

A physical therapist can test ROM. This may begin with a simple physical exam, but can also include the use of a goniometer, an instrument that tests the angle of joints, such as elbow or knee. It measures the degree of movement at a joint with various flexing exercises.

Global rating of change (GRC) scales are very commonly used in clinical research, particularly in the musculoskeletal area. These scales are designed to quantify a patient's improvement or deterioration over time, usually either to determine the effect of an intervention or to chart the clinical course of a condition. GRC scales ask that subjects assess their current health status, recall that status at a previous time-point, and then calculate the difference between the two.23

The current systematic review was planned to analyse the efficacy of thoracic thrust manipulation (TTM) on patients with shoulder impingement syndrome.

 

Materials and Methods

 

The systematic review was conducted after aapproval from the institutional ethics review board of The University of Lahore, and comprised randomised controlled trials (RCTs) and controlled clinical trials (CCTs) published from 2008 to 2020. The review followed preferred reporting item for systematic review and meta-analysis (PRISMA) guidelines as outlined by EQUATOR network.24 The review protocol was registered with PROSPERO (CRD 42021272608) or (272608). A detailed search was conducted by 2 authors independently, using a search strategy developed for different databases, including Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Pedro and MEDLINE. Hand searching was also conducted on different databases to ensure the inclusion of all relavent articles. Search strategy was designed for each database by combining key terms and Boolean operators i.e. ‘and’, ‘or’ and ‘not’. Full text articles were retrieved for eligibilty. In case of conflict of opinion, the matter was decided with discussion. Indexing terms, synonyms and population, intervention, control and outcome (PICO)25 format terms were used and filtered applied. These included ‘full text’, ‘clinical trials’, ‘RCT’, ‘humans’ and ‘English’.

Study eligibilty were based on PICO format. Relevant information from the included studies was extracted and reviewed by the authors. Peer-reviewed RCTs and CCTs published in English language were included in which thrust manipulation treatment directed to thoracic spine had been tested on impingement syndrome patients of both genders aged 19-44 years. Studies were excluded if the treatment was other than thrust manpulation or if the manipulation was done under anaesthesia. Also excluded were studies that did not include a detailed description of the methodology, those investigating main diagnoses not related to the shoulder or that resulted in referred shoulder pain. Studies involving people who needed to be evaluated for surgery or those recovering from surgery were also excluded, and so were all forms of editorials, commentaries and case series.

Search records were saved in EndNote X8 software. Duplicate records were removed, followed by screening of the articles on the basis of abstracts and full text articles. In the end final text articles which were included from different databases were used to create tables describing different variables, like methdology, sample size, demographic data, etc. Studies were assessed thoroughly to calculate standard mean difference and effect between intervention and control groups.

Differences between the groups were noted to divide outcome measures and quality scores.

Methdological quality of all studies were assessed using the 11-point Pedro scale.26 which is a tool for assessing the quality of RCTs. A high score on the scale indicates better quality of the study. The scale does not measure studies' external validity or the treatments’ effect size. As a result, although item 1 (eligibility criteria) was assessed, it was not included in the score computation. This explains why a maximum score of 10 points is achieved with 11 components.

Risk of bias was assessed by two independent reserachers using the Risk of bias tool in accordance with Cochrane handbook for systematic review of interventions.27 Selection bias was assessed by allocation concealment and random sequence generation, and detection bias by blinding of outcome assessment and marked as unclear (?), low risk (+) and high risk (-).

 

Results

 

Of the 312 studies found, 14(4.5%) were included (Figure).

 

 

Demographic characteristics of the studies reviewed were noted (Table 1).22-35 Methodology adopted by each study (Table 2), methodological quality of the studies (Table 3) and the risk of bias of each study reviewed were noted separately (Table 4).

 

 

 

 

 

 

In 2(14.3%) studies, TTM along with exercise resulted in the reduction of symptoms of impingement syndrome and pain, and improved ROM.22,23

Also, in 2(14.3%) studies, the TTM alone was not sufficient for improving symptoms like pain, ROM and quality of life (QOL).24,25

TTM along with exercise was effective in 1(7.1%) study,26 cervico-thoracic thrust had no pain reduction or function in patients in 1(7.1%)study,27 ROM and pain improved by manipulative therapy,28 thoracic spinal manipulation did not seem to influence the activity of scapular muscles,29 and sham SMT and SMT had the same beneficial effects.30

Further, 1(7.1%) study demonstrated that there was no difference in patients receiving TTM and those who do not receive this treatment.31 There was no apparent improvement in pain sensations or overall ROM in 1(7.1%) study,32 while another study showed no improvement in clinical symptoms.33 In 1(7.1%) study, there was immediate improvement in pain after thoracic spinal manipulation,34 and 1(7.1%) study manipulation with movement and exercise resulted in decreased pain and improved functions.35

Discussion

The review included 14 studies. In some studies there was immediate improvement in ROM and pain after thrust manipulation, but more than half the studies reported no such clinical difference. Treatment with manipulation alone is not much effective, and it should be combined with exercise therapy to attain clinical improvement.

A systematic review conducted in 2017 by Amy L. Minkalis20 showed results that had strong resemblance with the current findings.

The limitation of this study is that no time-filter was applied which resulted in the usage of old references as in the past very few researches has been done on this topic.

Further extensive work should be done in terms of meta-analysis by including RCTs published in languages other than English alone.

 

Conclusion

 

There is no long-term improvement in ROM and in pain after thrust manipulation in shoulder impingement syndrome patients and there is no such clinical difference seen in the quality of functional activities in such patients. The sole treatment of manipulation is not much effective rather it should be combined with other exercise therapy to show some clinical improvement.

 

Disclaimer: The text is part of an academic project.

 

Conflict of Interest: None.

 

Source of Funding: None.

 

References

 

1.      Bianchi S, Martinoli C. Shoulder. In: Ultrasound of the Musculoskeletal System, 1st ed. Berlin, Germany: Springer Berlin, Heidelberg, 2007; pp 189-331. Doi: 10.1007/978-3-540-28163-4

2.      Prescher A. Anatomical basics, variations, and degenerative changes of the shoulder joint and shoulder girdle. Eur J Radiol 2000;35:88-102. doi: 10.1016/s0720-048x(00)00225-4.

3.      Wilk KE, Arrigo CA, Andrews JR. Current concepts: the stabilizing structures of the glenohumeral joint. J Orthop Sports Phys Ther 1997;25:364-79. doi: 10.2519/jospt.1997.25.6.364.

4.      Kong AC, Varacallo M. Anatomy, Shoulder and Upper Limb, Hand Volar Arch Arteries. Treasure Island, FL: StatPearls Publishing; 2022.

5.      Kanatli U, Bölükbaşi S, Ekin A, Ozkan M, Simşek A. Anatomy, biomechanics, and pathophysiology of instability of the glenohumeral joint. Acta Orthop Traumatol Turc 2005;39:4-13.

6.      Sandoz R. The significance of the manipulative crack and of other articular noises. Ann Swiss Chiropract Assoc 1969;4:47-68.

7.      Unsworth A, Dowson D, Wright V. 'Cracking joints'. A bioengineering study of cavitation in the metacarpophalangeal joint. Ann Rheum Dis 1971;30:348-58. doi: 10.1136/ard.30.4.348.

8.      Koes BW, Assendelft WJ, van der Heijden GJ, Bouter LM. Spinal manipulation for low back pain. An updated systematic review of randomized clinical trials. Spine 1996;21:2860-71. doi: 10.1097/00007632-199612150-00013.

9.      Evans DW. Mechanisms and effects of spinal high-velocity, low-amplitude thrust manipulation: previous theories. J Manipulative Physiol Ther 2002;25:251-62. doi: 10.1067/mmt.2002.123166.

10.    Luime JJ, Koes BW, Hendriksen IJ, Burdorf A, Verhagen AP, Miedema HS, et al. Prevalence and incidence of shoulder pain in the general population; a systematic review. Scand J Rheumatol 2004;33:73-81. doi: 10.1080/03009740310004667.

11.    Ryall C, Coggon D, Peveler R, Reading I, Palmer KT. A case-control study of risk factors for arm pain presenting to primary care services. Occup Med 2006;56:137-43. doi: 10.1093/occmed/kqj024.

12.    Kuijpers T, van der Windt DAWM, Boeke JPA, Twisk JWR, Vergouwe Y, Bouter LM, et al. Clinical prediction rules for the prognosis of shoulder pain in general practice. Pain 2006;120:276-85. doi: 10.1016/j.pain.2005.11.004.

13.    Kuijpers T, van Tulder MW, van der Heijden GJ, Bouter LM, van der Windt DA. Costs of shoulder pain in primary care consulters: a prospective cohort study in The Netherlands. BMC Musculoskelet Disord 2006;7:83. doi: 10.1186/1471-2474-7-83.

14.    Redondo-Alonso L, Chamorro-Moriana G, Jiménez-Rejano JJ, López-Tarrida P, Ridao-Fernández C. Relationship between chronic pathologies of the supraspinatus tendon and the long head of the biceps tendon: systematic review. BMC Musculoskelet Disord 2014;15:377. doi: 10.1186/1471-2474-15-377.

15.    Struyf F, Meeus M. Current evidence on physical therapy in patients with adhesive capsulitis: what are we missing? Clin Rheumatol 2014;33:593-600. doi: 10.1007/s10067-013-2464-3.

16.    Green S, Buchbinder R, Hetrick S. Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev 2003;2003:CD004258. doi: 10.1002/14651858.CD004258.

17.    Meislin RJ, Sperling JW, Stitik TP. Persistent shoulder pain: epidemiology, pathophysiology, and diagnosis. Am J Orthop (Belle Mead NJ). 2005;34(12 Suppl):5.

18.    van der Windt DA, Thomas E, Pope DP, de Winter AF, Macfarlane GJ, Bouter LM, et al. Occupational risk factors for shoulder pain: a systematic review. Occup Environ Med 2000;57:433-42. doi: 10.1136/oem.57.7.433.

19.    Bodin J, Ha C, Chastang JF, Descatha A, Leclerc A, Goldberg M, et al. Comparison of risk factors for shoulder pain and rotator cuff syndrome in the working population. Am J Ind Med 2012;55:605-15. doi: 10.1002/ajim.22002.

20.    Minkalis AL, Vining RD, Long CR, Hawk C, de Luca K. A systematic review of thrust manipulation for non-surgical shoulder conditions. Chiropr Man Therap 2017;25:e1. doi: 10.1186/s12998-016-0133-8.

21.    Williamson A, Hoggart B. Pain: a review of three commonly used pain rating scales. J Clin Nurs 2005;14:798-804. doi: 10.1111/j.1365-2702.2005.01121.x.

22.    Chiarotto A, Maxwell LJ, Ostelo RW, Boers M, Tugwell P, Terwee CB. Measurement Properties of Visual Analogue Scale, Numeric Rating Scale, and Pain Severity Subscale of the Brief Pain Inventory in Patients With Low Back Pain: A Systematic Review. J Pain 2019;20:245-63. doi: 10.1016/j.jpain.2018.07.009.

23.    Wang YC, Sindhu BS, Kapellusch J, Yen SC, Lehman L. Global rating of change: perspectives of patients with lumbar impairments and of their physical therapists. Physiother Theory Pract 2019;35:851-9. doi: 10.1080/09593985.2018.1458930.

24.    Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/ bmj.n71.

25.    Aslam S, Emmanuel P. Formulating a researchable question: A critical step for facilitating good clinical research. Indian J Sex Transm Dis AIDS 2010;31:47-50. doi: 10.4103/0253-7184.69003.

26.    Matos AP, Pegorari MS. How to Classify Clinical Trials Using the PEDro Scale? J Lasers Med Sci 2020;11:1-2. doi: 10.15171/jlms.2020.01.

27.    Higgins JP, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, et al. Cochrane Bias Methods Group; Cochrane Statistical Methods Group. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ 2011;343:d5928. doi: 10.1136/bmj.d5928.

28.    Park SJ, Kim SH, Kim SH. Effects of Thoracic Mobilization and Extension Exercise on Thoracic Alignment and Shoulder Function in Patients with Subacromial Impingement Syndrome: A Randomized Controlled Pilot Study. Healthcare 2020;8:316. doi: 10.3390/ healthcare8030316.

29.    Land H, Gordon S, Watt K. Effect of manual physiotherapy in homogeneous individuals with subacromial shoulder impingement: A randomized controlled trial. Physiother Res Int 2019;24:e1768. doi: 10.1002/pri.1768

30.    Grimes JK, Puentedura EJ, Cheng MS, Seitz AL. The Comparative Effects of Upper Thoracic Spine Thrust Manipulation Techniques in Individuals With Subacromial Pain Syndrome: A Randomized Clinical Trial. J Orthop Sports Phys Ther 2019;49:716-24. doi: 10.2519/jospt. 2019.8484.

31.    Silva ACD, Santos GM, Marques CMG, Marques JLB. Immediate Effects of Spinal Manipulation on Shoulder Motion Range and Pain in Individuals With Shoulder Pain: A Randomized Trial. J Chiropr Med 2019;18:19-26. French. doi: 10.1016/j.jcm.2018.10.001.

32.    Haider R, Bashir MS, Adeel M, Ijaz MJ, Ayub A. Comparison of conservative exercise therapy with and without Maitland Thoracic Manipulative therapy in patients with subacromial pain: Clinical trial. J Pak Med Assoc 2018;68:381-7.

33.    Wright AA, Donaldson M, Wassinger CA, Emerson-Kavchak AJ. Subacute effects of cervicothoracic spinal thrust/non-thrust in addition to shoulder manual therapy plus exercise intervention in individuals with subacromial impingement syndrome: a prospective, randomized controlled clinical trial pilot study. J Man Manip Ther 2017;25:190-200. doi: 10.1080/10669817.2016.1251377..

34.    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. doi: 10.1016/j.jcm.2016.10.002.

35.    Haik MN, Alburquerque-Sendín F, Camargo PR. Short-Term Effects of Thoracic Spine Manipulation on Shoulder Impingement Syndrome: A Randomized Controlled Trial. Arch Phys Med Rehabil 2017;98:1594-1605. doi: 10.1016/j.apmr.2017.02.003.

36.    Michener LA, Kardouni JR, Sousa CO, Ely JM. Validation of a sham comparator for thoracic spinal manipulation in patients with shoulder pain. Man Ther 2015;20:171-5. doi: 10.1016/j.math. 2014.08.008.

37.    Kardouni JR, Shaffer SW, Pidcoe PE, Finucane SD, Cheatham SA, Michener LA. Immediate changes in pressure pain sensitivity after thoracic spinal manipulative therapy in patients with subacromial impingement syndrome: A randomized controlled study. Man Ther 2015;20:540-6. doi: 10.1016/j.math.2014.12.003

38.    Kardouni JR, Pidcoe PE, Shaffer SW, Finucane SD, Cheatham SA, Sousa CO, 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;45:527-38. doi: 10.2519/jospt.2015.5647.

39.    Coronado RA, Bialosky JE, Bishop MD, Riley JL, Robinson ME, Michener LA, et al. The comparative effects of spinal and peripheral thrust manipulation and exercise on pain sensitivity and the relation to clinical outcome: a mechanistic trial using a shoulder pain model. J Orthop Sports Phys Ther 2015;45:252-64. doi: 10.2519/jospt. 2015.5745.

40.    Haik MN, Alburquerque-Sendín F, Silva CZ, Siqueira-Junior AL, Ribeiro IL, Camargo PR. Scapular kinematics pre- and post-thoracic thrust manipulation in individuals with and without shoulder impingement symptoms: a randomized controlled study. J Orthop Sports Phys Ther 2014;44:475-87. doi: 10.2519/jospt.2014.4760.

41.    Kachingwe AF, Phillips B, Sletten E, Plunkett SW. Comparison of manual therapy techniques with therapeutic exercise in the treatment of shoulder impingement: a randomized controlled pilot clinical trial. J Man Manip Ther 2008;16:238-47. doi:10.1179/106698108790818314

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