Subacromial impingement has got to be at the top of the list of umbrella term diagnoses. It’s right up there next to patellofemoral pain syndrome. The PTs in this research highlight even think so. Subacromial shoulder pain is one of the most common shoulder diagnoses, so it’s a pretty great topic to look at for research! Michener and colleagues studied the effects of treating this condition with both manual therapy and exercise. Keep reading this research highlight to see what they found.
Lori A.Michener,PT,ATC,FAPTA, Philip W.McClure, PT, PhD,FAPTA, Angela R. Tate,PT,PhD, Lane B. Bailey,PT,PhD , Amee L.Seitz,PT,DPT,PhD, Rachel K.Straub,PhD, Charles A.Thigpen,PTATC,PhD
The Rundown
The authors took 93 participants and divided them into 2 groups. A therex plus manual therapy group and a therex only group. All the treating therapists went through a training program in order to standardize manual therapy and exercise treatment. It’s important to note the therex portion was the SAME for both groups. It was a progressive 3-phase standardized plan.
The manual therapy portion was also very detailed with very specific instructions on what techniques PTs had to use with patients. Manual therapy focused on three areas: the glenohumeral joint, the posterior shoulder, and the thoracic spine. The authors have both the exercise and manual therapy really well laid out in Table 2 if you want to look at the specifics.
Patients completed treatment for a maximum of 10 visits at 2 times a week for 6 weeks. Sounds familiar right? The primary outcome measure was the DASH (Disabilities of the Arm, Shoulder, and Hand Questionnaire) which I’m sure a lot of us are pretty familiar with. The authors also measured satisfaction with shoulder use and healthcare use. These measurements were taken at 2, 4, 6, 26, and 52 weeks. So we get to see how the groups did both during treatment and looong after it ended.
The Results
In my opinion the results were pretty interesting and not at all what I was expecting. The therex plus manual therapy group had better DASH and shoulder satisfaction scores at 26 weeks and 52 weeks. If you’d asked me to guess what I thought the results of this study would have been, I would have guessed therex plus manual therapy to have higher scores in the earlier weeks of testing. I honestly was a little perplexed at these results. However, the authors do provide some explanations for them and great points that I want to discuss.
The Takeaways
The first thing I like about this study is that it took previous research and made it better. The authors clearly point out the flaws other similar studies had and how their study addressed those flaws. In the intro, the authors explain previous studies looking at manual therapy or exercise were not very standardized. Which honestly makes results inconsistent and hard to repeat in practice.
The researchers fixed this by having very clear, standardized and detailed treatments for both groups. I was impressed just how in depth their protocols were for both the exercise and manual therapy treatments. This makes it easy to implement into practice which I always say is super important.
If the larger PT population can’t implement the treatment, then it’s like what’s the point of it ya know? Let’s say the researchers didn’t have the techniques used clearly listed. What if it just said “manual therapy” and “rotator cuff exercises” or “scapular exercises”. As a PT reading this I’d be okay cool, this a great I’m gonna try to do this with my shoulder patients. But I’d be doing a lot of guessing. I’d maybe end up just doing only glenohumeral mobilizations or only rotator cuff exercises when the researchers actually did a lot more than that. I’m not gonna get the same results they got. This is why I love when authors give these detailed outlines of treatments and protocols.
The other thing I loved about this article is the authors gave great explanations on the TRUE benefits of manual therapy. I’ve actually written about this in another blog post so I was definitely excited when I saw it in the article. Definitely no perpetuating old, false rhetoric on what manual therapy actually does or doesn’t do. If you want to learn more about that you should for sure check out that other blog post.
I was really impressed with the thorough training the therapists completed. When I first started reading the article I was ready to say “Well how do we know people were doing techniques the correct way and consistently?” Halfway through I no longer had that argument. All therapists went through training and even testing over the techniques. They even assessed treatment compliance with random check-ins to make sure the therapists were sticking to the treatment plan. Pretty honest system if you ask me.
Now time to get to the good stuff. The results. Not gonna lie, at first the results REALLY confused me. I could not wrap my head around why the manual therapy plus exercise group had better results at 26 and 52 weeks. I would’ve guessed that if there had been a difference between groups, if at all, it would’ve been in that 2-6 week range. Manual therapy benefits tend to only be short term right? I couldn’t come up with a good explanation for the results. Thankfully the researchers did.
Before they tell us their theory though they again rule out any false beliefs about manual therapy. They clearly state the effects of manual therapy were likely NOT due to biomechanical mechanisms. The researchers acknowledge manual therapy has more effect on pain processing in the central nervous system than the biomechanics of the shoulder.
They attributed this to some of their findings. Again, the study found long term effects only. Manual therapy benefits tend to work more in the short term. The researchers hypothesize the manual therapy decreased pain, which helped patients with their HEP, making it more effective.
They also think the manual therapy created a stronger therapuetic alliance between the patient and the therapist. Which they believed increased the patient’s adherence to the HEP and any lifestyle recommendations made by the PT. Kinda wish we had numbers on those right? Well, so do the authors, but on the bright side this leaves a door open for future research.
I think the results bring up an interesting point about manual therapy in general. Again, it doesn’t do what we used to think it did. It doesn’t put joints back in place or release adhesions. However, it can modulate pain through other mechanisms and possibly build a stronger patient rapport and buy-in. So it’s definitely still something we should at least consider using as a part of our treatment – especially when it comes to subacromial pain according to this study’s results! If the use of manual therapy is something you want to discuss further I highly recommend you check out that other blog post I mentioned earlier!
Overall what do you think of the results or the study in general? If you read the entire article what did you find good, bad, or at least interesting about the study? I’d love to hear your thoughts so share them in the comments section! If you enjoyed this research highlight and want to make sure you don’t miss the next one or any other PT Page content hit the subscribe button and follow on Instagram @the_pt_page so you can stay up to date on all things PT!
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