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In Service - OMPT for SIS
1. T-Spine Manipulation & Manual Therapy in the Treatment of SIS Using Evidence to Expand Your Practice
2. SIS Background Primary v. Secondary Neerโs Stages: Edema & hemorrhage RC deterioration Degenerative & partial tendon rupture Massive Tear Multi-factorial Condition Neuromuscular & mechanical components Typical Presentation: RC weakness, possible acromial deformity, insidious or traumatic onset, bone spurring Special Test Cluster: H/K, Infraspinatus, Painful Arch. 3/3 = +LR 10.56, 2/3 = +LR 3.6
3. PT Management of SIS: Where Are We Now? Modalities Exercises / UMC Joint Mobilization
4. Conroy & Hayes โ JOSPT, 1998 Result: Experimental Group had a short-term (24 hr) reduction in pain, not function or mobility Take Home Message: Indicated for use in tx of pain associated with primary SIS What is your tx goal? Effect of Joint Mobilization as a Component of Comprehensive Treatment for Primary Shoulder Impingement Syndrome Design: RCT, N=14, Primary SIS Experimental Group: MT + TherEx Control Group: TherEx Outcomes: Pain, function, AROM Tx: 3x/wk for 3 weeks Oxford Level: 2B
5. PT Management of SIS:Where Are We Going? Regional Interdependence T-Spine Focus? More MT, Manipulation Thoracic CT Junction Rib Manipulation Exercise / UMC
6. Bang & Deyle โ JOSPT, 2000 Result: Both groups improved in pain and function, but MT + TherEx had significantly more improvement Only MT + TherEx improved in strength Take Home Message: We can achieve gains w/ TherEx alone โ but adding MT enhances those gains May also be helpful for increasing strength gains Comparison of Supervised Exercises With and Without Manual PT for Patients With SIS Design: RCT, N=52, SIS Experimental Group: MT + TherEx Control Group: TherEx Outcomes: Pain (VAS), Strength, Functional Questionnaire Tx: 6 Sessions over 3-4 weeks Oxford Level: 1B
7. Bergman et al. โ Annals of Internal Medicine, 2004 Result: @ 12, 26, 52 weeks: โFull Recoveryโ perceived by MT group > UMC group (43% v. 21%) Severity of main complaint and DA, MT>UMC Take Home Message: MT + UMC accelerates recovery of SIS No difference at 6 weeks, most difference at 12 weeks Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder Dysfunction and Pain Design: RCT, N=150, Shoulder pain Experimental Group: Manip + UMC Control Group: UMC Outcomes: pt. perceived recovery, severity of main complaint, sh. DA Tx: 12 Weeks, 6 tx sessions Oxford Level: 1B
8. Boyles et al. โ Manual Therapy, 2009 Result: significant results observed for pain on all provocative and resistive tests, SPADI, & GRCS Take Home Message: While significant, these results are not clinically meaningful Two different patient types? The Short-Term Effects of Thoracic Spine Thrust Manipulation on Patients with SIS Design: Exploratory Pre/Post, N=56, Dx: SIS Experimental Group: Manipulation Control Group: None Outcomes: Pain (NPRS), SPADI, GRCS Tx: Single Tx with 48 hr F/U Oxford Level: 2B
9. The evidence seems to be supporting the use of manual and manipulative therapy for the tx of SIS, but, IS IT SAFE?
10. Manip. Safety: Comparative Analysis Common Side-effects: Fatigue โ 10%, Local discomfort - 50%, Radiating discomfort โ 10%, Increase in symptoms โ 0% (?%) **Symptoms usually resolved <48 hrs (81%)** - LeBoeuf-Yde et al (J Manip Ther, 1997)
11. Contraindications Osteoporosis Recent Sx, Fx, trauma Collagenous or CT Disorders Clotting Deficiency โ concern for vascular health Mechanical/bony limitations โ fusion, scoliosis Generalized, excessive hypermobility or joint instability Not between the ages of 18 and 60 (relative)
12. Selecting Appropriate Patients Overhead Athletes and Workers Pts with poor posture Computer/IT workers Other pts suffering from SIS
13. Manipulation: Key Concepts Proper Technique Patient Position Therapist Position Cavitation Specificity High velocity, low amplitude thrust Does HVLAT = Level V mobilization? 1 2 Anatomic Limit 3 4 Barrier Available Joint Play Adapted from Maitland by Robertson
14. Thoracic Manipulation pt Position: sitting on very edge of plinth, arms crossed or behind neck PT position: behind pt, with firm grasp on ptโs lower-most elbow, can use a towel roll Thrust direction: J-style HVLAT superiorly and posteriorly Reassess motion & pain
15. CT Manipulation pt Position: sitting on very edge of plinth, arms behind neck, fingers interlocked over lower C-spine PT position: Behind pt, arms through ptโs, hands clasped over ptโs Thrust direction: HVLAT applied in a superior and posterior direction Reassess motion & pain
17. Review Articles Michener et al. Effectiveness of rehab for patients with SIS: A systematic review. J Hand Ther. 2004; 17:152-164. Take Home Message: โThe addition of MT techniques in combination with ther-ex should be favored over ther-ex alone in the tx of SISโ US, cold Laser, acupuncture are not effective in management of SIS Desmeules et al. Therapeutic exercise and orthopedic manual therapy for impingement syndrom: A systematic review. Clin J Sport Med. 2003; 13:176-182. Take Home Message: More studies are needed to confirm that PT (not just MT) is a viable option for tx of SIS Lack of uniformity in the profession for evaluating, defining, and treating SIS
18. Further Research Development of a clinical prediction rule (CPR) for patients who will benefit from manipulative therapy Adding to the current body of knowledge How does postural correction decrease symptoms experienced at peripheral joints? Scapular position as it relates to SIS? Is manipulative therapy useful for pts diagnosed with secondary SIS?
19. Take Home Messages TherEx + Manipulation/MT is proven to have better improvement on pain, strength gains, and overall function compared to TherEx alone Manipulation proven to be safe This IS the best tx for our pts! The existing evidence is strong, but limited, supporting manipulation to treat SIS โ more research is needed โWhy not go out on a limb? Isn't that where all the fruit is?โ โ Frank Scully
21. Evidence Bang MD, Deyle GD. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. J Orthop Sports Phys Ther. 2000;30(3):126-37. Bergman GJD, Winters JC, Groenier KH, 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(6):432-9. Boyles RE, Ritland BM, Miracle BM, et al. The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Man Ther. 2009. Available at: http://www.ncbi.nlm.nih.gov/pubmed/18703377 [Accessed June 20, 2009]. Conroy DE, Hayes KW. The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome. J Orthop Sports Phys Ther. 1998;28(1):3-14. Desmeules et al. Therapeutic exercise and orthopedic manual therapy for impingement syndrom: A systematic review. Clin J Sport Med. 2003; 13:176-182. Michener et al. Effectiveness of rehab for patients with SIS: A systematic review. J Hand Ther. 2004; 17:152-164.
Editor's Notes
Today we are going to be talking about thoracic spine manipulation and manual therapy in relation to the management of shoulder impingement syndrome. We will review several recent research articles and discuss their impact on how we should treat these patients in the clinic. If you have any questions as we go along, please stop and we will review. The articles that are presented in a way to give you an idea on the population and treatments used in the study, and also to give you a take home message, or a review of the most important points. But first, lets quickly review SIS.
General definition = impingement of generally the supraspinatus tendon or subacromial bursa by the humeral head in the subacromial space during elevation of the arm. Can be any structure in this area. About 15-20% of population has shoulder pain, 44 โ 60% of all shoulder pain cases are SIS, second only to LBP in occurrence in Orthopedic MD offices.Primary = mechanical restriction of RC tendons. Anatomical, often associated with older patients or degenerative changes. Can be caused by spurs, arthritic changes, capsular thickening, bony defects.Secondary = GH instability, relative rdx in Subacromial space. Often associated with younger pts and hypermobility. Can be caused by RC tear, labral tear, or multi-directional instabilityMultifactorial condition regardless of the classification or stage, it is now believed that pain, muscle recruitment, and capsular or bony restrictions are all combined in this condition.* Neers Stages of Impingement: Stages are fluid, and can overlap, also correlated with age.ย Stage 1: localized inflammation, slight bleeding, and edema of RC. Usually observed in people <25 years. Reversible tendon changes, often with rest.Stage 2: Progressive process in the deterioration of RC tissues. Usually people<40 years. Irreversible tendon damage, some partial tears.Stage 3:Microtrauma or soft tissue rupture of RC tissues. 40+ years. Degenerative changes.Stage 4: massive tear (more than one tendon).ย Special test Cluster: some tests cannot be separated from impingement and RC tears. Tests that are passive may help with impingement, active can help with RC tears. Use the test item cluster (H/K, Infraspinatus, and Painful Arc) for impingement. If all three are positive, the +LR of the pt having SIS is 10.56, if the patient is over 60, that number jumps to 28. . If 2/3 are positive, the +LR is 3.6, which is still strong. Park, H.B., Yokota, A., Gill, H.S., EI RG, McFarland, E.G. (2005). Diagnostic accuracy of clinical tests for the different degrees of subacromial impingement syndrome. J Bone Joint Surg Am, 87(7), 1446-1455.Younger Patients: abnormal stresses on normal tissue. Recreational, trauma, overuse, work etc.Older Patients: Normal stresses on abnormal tissues. Arthritic changes, repetitive stress, tendinopathy, etcโฆ
Modalities โ typical uses are pain management and inflammation control. Include US, ES, MHP, CP etcโฆ Do these really treat the target tissue? Most of these only treat to a depth of a few cm, with US being the deepest. In addition none of the tx address the multifactorial nature of SIS.Exercises โ RC Strengthening? ROM improvement? Scapular Stability exercises. All are important, but in what order? UMC: US, CSI, pt education, NSAIDSJoint Mobs: GH PROM, distraction, ant -> post mobs Grade II and III, inferior glides Grade II โ pain control, Grade III โ ROM
This study by Conroy et al is the basis upon which most MT research and practice is based in regards to SIS. This study is an RCT, with 14 patients dx with primary SIS.Ther-ex: Hot pack, AROM, stretching, strengthening, STM, pt education, postural correctionMid-range joint mobs were used, probably around grade II, III. The GH jt mobs resulted in improvements in both 24 hr and joint compression pain, but not ROM. This may have been related to a small sample size or perhaps the lack of inclusion of end-range mobilizations. <<II and III do not address ROM issues.What is your tx goal: joint mobs may not be necessary if your tx goal is mobility and function, not pain reduction. Better for acute pts who rate high on pain scales?
Regional Interdependence: simply the idea of treating a joint above or below the joint in question. For the shoulder, this means looking at the c-spine and t-spine, which in general is just good practice. This does not mean shifting the focus of tx away from the shoulder, just considering the effect other joints may have on the biomechanics of the shoulder.Manipulations used to tx SIS include thoracic, CT, and rib manipulation. Today we will talk about the thoracic and CT junction manipulationsExercise / Usual Medical Care: same as before, used to restore normal arthro- and osteo-kinematics, ROM, strength, and function
We are now going to explore a few studies that take into account the concept of regional interdependence while incorporating some degree of manual and/or manipulative therapy into treatment. First is Bang & DeyleThis RCT looked at 52 patients all dx with SIS. -TherEx for both groups consisted of stretching and 6 RC and scapular strengthening exercises. Both groups were given a HEP and were instructed to keep a HE log.The TherEx +MT group added MT which included manual stretching and ROM to the affected shoulder, as well as cervical and thoracic mobilization and manipulation as needed. Not all patients in this group received manipulation, but all received some type of manual therapy. The authors cite that manual techniques to increase upper thoracic and/or cervical extension or side bend were especially helpful. In addition, these patients received exercises on their HEP that reinforced the MT, such as postural exercises or self mobilizations.The results were measured at 1 and 2 months. Both groups improved in pain and function, but the MT+TherEx group showed significantly more improvement. In addition, only the MT+TherEx group showed an improvement in strength.The take home message from this study is that although patients benefited from TherEx, their treatment was positively influenced by the addition of a variety of manual techniques, especially strength.
This straight forward RCT looked at 150 patients with shoulder pain, and split them into 2 groups, a Manipulation +UMC group, and a UMC group. The authors considered the following to be UMC: - Education, CSI, standard PT, NSAIDS - The Manip group added neck, tx-spine/ribs, and shoulder girdle, and only included Manip in <6 sessionsMajor weakness with this study is that the main outcome measure, โFull Recoveryโ, is extremely subjective.Although the changes were not seen until the 12th week, the MT + UMC group achieved full recovery before the UMC group. After 52 weeks, both groups were equal.
This is a new study that looks at the SHORT TERM effects of two different specific manipulation techniques. This study is the best study that specifically studies the concepts of regional interdependence and manipulation. This study had 56 participants and used a pre-post test design. ((No control group, everyone received the tx)). Patients were subjected to several pain provocation tests (neers, H/K, empty can, active-resisted ER, IR, abduction)Tx consisted of a thoracic manipulation, a CT junction manipulation, and a rib manipulation (prn for rib angle tenderness). It is also important to note that the pts in this study did not do any exercise or HEP to support the manipulative therapy.Although the results were statistically significant, they are not clinically meaningful. Clinically meaningful means that the SPADI decreased by at least 10 points, 2 points needed for NPRS. Does this mean that a change did not occur?Two different patient types: those seeking tx and those not seeking tx may have resulted in a floor effect during initial measurement of the SPADI and NPRS scores.GRCS = global rating of change scale.
Here we see a comparative analysis of some common treatments, not just for SIS, but really to serve as a comparison.The important thing to consider is the balance of risk v. effectiveness for the treatments we prescribe on a daily basis. The benefit clearly outweighs the risk.Are these weak side-effects worth the strong outcomes seen in the previous studies?
Since the risk of complication is so low, it may be better to ask the question: โWhy would this patient not benefit from this treatmentโ rather than, โWould this patient benefit from this treatment?โSo, who is manipulation not safe for? Patients presenting with these contraindications should not be considered for manipulative therapy.This list rules out patients w/ shoulder symptoms due to trauma, fracture, RC rupture, or shoulder dislocation
Positioning of the patient and therapist is crucial to have successful outcomes with manipulative tx. Therapist position is important for the same reasons as it is for any other tx, to ensure that you have a long career as a PT and donโt end up as the patient. For the SIS patient it is important to position them in a way that does not cause pain. Pain should not be felt during the set up or actual manipulation.Cavitation: the cavitation, or popping, may be heard as a result of manipulative therapy, although it is not imperative to the success of the therapy. Manipulation can be effective even when a cavitation is not heard. If the therapist feels the manipulation was unsuccessful, it is often helpful to reposition the patient and try again, a general rule is to give it three chances and then move on. It is also important to let patient response determine if you were successful.Specificity: So what structures are responsible for the cavitations that are sometimes heard? In short we donโt really know, nor do we need to know. We do know that manipulation is region specific, but no more precise than that. Think of manipulation acting as CTRL-ALT-DEL for the area, resetting the neuro-muscular components surrounding the joint. Remember, SIS is a multi-factorial problem, with a proven neuromuscular component.Manipulation can be thought of as a HIGH VELOCITY LOW AMPLITUDE THRUST, so keep this in mind when practicing. There should be no โwind upโ to manipulation, and the patient generally should not be lifted off the table. The thrust technique should be quick, simple, precise, and to the point. Traits that all come from practice. It is important to note that Manipulation is more of a quick-stretch to the joint that offers some neural effects, and effects possibly extending distant to the site of application (this is why we are learning tx-spine manips for shoulder!). Whereas normal mobilizations get their effectiveness from rhythmic, repetitive, passive motion of a joint into a determined range. The effectiveness of the HVLAT comes from the velocity, not the amplitude of the thrust. Results are different!For example, manipulation has a central effect on pain pressure threshold, and pain processing, ability to reset the neuromuscular components. **SIS?Grading of Mobilizations:I. Small Amp, Out of Resistance, PAINII. Large Amp, Out of Resistance, PAINIII. Large Amp, Into Resistance, MOTIONIV. Small Amp, Into Resistance, MOTIONV. (Manipulation), pushes beyond Restrictive Barrier (HVLAT)
In addition to the previously cited articles we have already discussed, there are currently 2 review articles on the tx of SIS that consider PT tx of SIS. First is Michener, who found that the addition of MT techniques in combination with ther-ex should be favored over ther-ex alone in the tx of SIS. This review also found that US, cold laser, and acupuncture are generally not supported in the literature as being effective tx for SISSecond is Desmeules, who concluded that more studies and support is needed to confirm that PT (not just MT) is a viable option for tx of SIS, they reached this conclusion b/c there is a lack of uniformity in the profession for evaluation, defining, and treating SIS.
Secondary SIS = due to instability. Good question because of the proven increases in strength seen with MT techniques for primary SIS.What else?
The best tx for our patients may be to add a manipulative, at the least, more manual techniques in addition to traditional TherEx for proper tx of SISThere is strong, but limited evidence supporting manipulation to treat SIS โ more research is needed I included this quote by Frank Scully to remind us that it is ok to try new treatment techniques for dx that you may have treated hundreds of times, or to be ok with tx outside of our comfort zone, especially when it is proven safe and supported by evidence. After all, it may be the best tx you can provide.
