Effects of Thoracic Orthopedic Manual Therapy and Biopsychosocial Variables on Signs of Shoulder Impingement

Shoulder impingement has been identified as the most common cause of shoulder pain in the
adult general population. High-Velocity, Low-Amplitude Thrust Manipulations (HVLATM) of the
thoracic spine and ribs result in increased shoulder ROM, as well as decreased pain and
disability in patients suffering shoulder impingement. The quality of the sparse
publications is low and lacking control or comparison groups regarding the use of HVLATM in
the management of shoulder impingement. Further higher quality randomized clinical trials
are needed. Moreover, no research has investigated the effects of the patients beliefs and
different types of verbal messages conveyed by the clinician to the subjects in regard to
the effects of HVLATM of the thoracic spine on shoulder pain and function. The purpose of
this study is to evaluate, in subjects with signs and symptoms of shoulder impingement: (1)
the effects of a series of the prone thoracic spine High Velocity Low Amplitude Thrust
Manipulation (HVLATM) as compared to the HVLATM directed at the scapula, on shoulder pain,
impingement symptoms, and functional outcomes; (2) the effect of the type of message and
language used by the clinician in regard to thoracic HVLATM on shoulder pain, impingement
symptoms, and functional outcomes; (3) the effect of subject's expectation of outcome of
thoracic and scapula HVLATM on shoulder pain, impingement symptoms, and functional outcomes;
(4) if these potential immediate improvements will be sustained at 6 to 9-day follow up.

Inclusion Criteria:

- A consecutive convenience sampling of patients with complaints of shoulder pain that
are not post-surgical will be screened at their initial evaluation. Subjects between
the ages of 18 and 69 years will be included if they present with a painful arc of
shoulder active ROM. Additional requirements for inclusion will be (1) shoulder pain
greater than 1/10 but less than 9/10 at time of testing; (2) shoulder active ROM
above horizontal; (3) the ability to lie prone with arms at their side; and (4) at
least one of the following signs or symptoms: (1) a positive Hawkins-Kennedy Sign;
(2) a positive Neer Impingement Sign; (3) painful resisted abduction; (4) painful
resisted external rotation at 0°of abduction with the elbows bent to 90°

Exclusion Criteria:

- Subjects will be excluded from the study if they have any of the following: (1) A
history of unstable thoracic spine joints or fractures; (2) A history of spinal bone
tumors; (3) A bleeding disorder or the use of anticoagulant therapy (not to include a
baby aspirin); (4) Acute rheumatoid arthritis or ankylosing spondylitis; (5) Signs
and symptoms of myelopathy or cauda equina syndrome; (6) A systemic infection that
may involve the spinal column, ribs, or shoulder girdle; (7) A history of
osteoporosis or fracture of shoulder girdle bones; (8) Presence of radiculopathy with
progressive signs; (9) Primary complaints of neck or thoracic pain; (10) A positive
cervical distraction test; (11) A positive Spurling's test; (12) A large
three-dimensional limitation of arm motion of greater than 20 degrees with any
passive motion of the shoulder as compared to the contralateral side, to rule out
adhesive capsulitis.; (13) A previous history of shoulder surgery such as a rotator
cuff repair; (14) Physical therapy treatment to the shoulder or thoracic spine within
the 3 months prior to participation in the study; (15) A cortisone or other fluid
injection into the shoulder joint within 30 days of participation in the study; (16)
A history of multiple sclerosis, or neuropathy; (17) Pregnancy; (18) Inability to
attend a 6 to 9-day follow-up; and (19) Spinal fusion.