The Effect of Biomechanical Scapular Mobilization With Movement and Motor Learning in Shoulder Impingement Patients
Phase: NA
Conditions: Shoulder Impingement Syndrome
Sponsor: Pharos University in Alexandria

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The effect of biomechanical scapular mobilization with movement and motor learning in 
shoulder impingement patients 
 
 
NCT: 04701814 
 
Ethical committee approval: 
The study was approved by research ethical committee in Pharos University in Alexandria 
(PUA 201901013).  
Document date: 13-10-2019 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Introduction 
The shoulder pain is one of most compliance among the musculoskeletal problem, which consider the third 
most common musculoskeletal compliance in general practice. (VanDerWindt 1995) 1 In which incidence is 
14.7\1000 per year, that present 7-14% among population (Medicina 2017) 2. It’s common among female than 
male (Linsell 2006). 3 On the other hand, shoulder impingement syndrome is the most common disorder of 
shoulder pain compline (DeWitte 2011, Rizzo 2017) 4,5. That present 44 – 65% of all shoulder complain of 
shoulder pain (Rizzo 2017) 5. The shoulder impingement is disorder in which the long head of biceps and 
rotor cuff muscles of shoulder especially tendon of supraspinatus with bursa all are compressed against the 
anterior edge of acromion processes of scapula and the coracoacromial ligament in subacromial space this 
occur especially when the patient elevate his arm (Rizzo 2017, Gold 1993, Almekinders 2001 ) 5,7,9. The etiology 
of shoulder impingement is summarized as narrowing of subacromial space or \ and enlargement of 
subacromial structure (bursa and tendon) (Dabholkar 2017) 8. The abnormal mechanics can cause joint 
dysfunction (Almekinders 2001 ) 9. 
Treatment options  
The aim of treatment in shoulder impingement is to decrease the pain and restore the normal function of 
the shoulder (Garving 2017) 11. There are two option to treat the shoulder impingement: first one is non-
surgical treatment which is the first choice in treatment unless there is no major structure damage, while 
the second option is surgical procedure (Garving 2017, Diercks 2014)11,12. The conservative treatment including 
non-steroidal anti-inflammatory drugs, physical therapy intervention, tapping, active modification and 
corticosteroids injection (Garving 2017, Akgu 2004) 11,13. However, there is no evidence tell us that the surgical 
intervention has the upper hand in treatment of shoulder impingement (Diercks 2014) 12. 
Statement of the problem 
What is the effect of biomechanical scapular mobilization with movement and motor learning in shoulder 
impingement patients? 
 

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Purpose of the study 
 
This study was conducted to detect the effect of biomechanical scapular mobilization with movement and 
motor learning in decreasing the pain, and increasing the ROM in shoulder impingement. 
The significance of shoulder impingement: 
Shoulder impingement can lead to disability (Neumann 2010) 15, which reduces the personal functionallevel 
and activity so the patientcouldn’t do ADLs and work properly, especially in athletic persons who play 
sports that needed overhead activities. 
Limitation 
The limitation that face me during the study is the physical status of patients and psychosocial factors and 
socioeconomic level in each person, while the delimitation is age, BMI, simple, gender and instrument. 
The hypothesis 
The hypothesis is biomechanical scapular mobilization with movement and motor learning is effective in 
decrease the pain and increase the ROM and functional level in shoulder impingement syndrome. 
Methods 
Thirty participants with shoulder impingement syndrome were diagnosed by physiotherapist selected from, 
Pharos University in Alexandria, outpatient clinic. Their ages were ranged from 25 to 50 years old. The 
including criteria: Patients with unilateral shoulder pain compatible with shoulder impingement syndrome 
who hadn’t any pervious experiment of physical therapy session in affected shoulder. Also, patients were 
included if they had: 
 

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1. History of shoulder pain when they elevated their arm. 
2. Limited range of motion due to the pain. 
3. Pain localized at the painful point at proximal anterolateral shoulder region or medical diagnosis 
of shoulder impingement syndrome with at least 2 positive impingement tests including Neer, 
Hawkins or Jobe test. 
The researches revealed that the pooled sensitivity and specificity for the Neer test were 79% and 53%, 
respectively, and for the Hawkins test were 79% and 59%, respectively. Because no single test had shown 
high specificity, a cluster of 2 or more tests is recommended to properly identify patients with Shoulder 
impingement syndrome (Delgado-Gil 2015)14. 
The excluding criteria included: patients were diagnosed by fibromyalgia, fracture or dislocation or 
subluxation of shoulder, history of trauma that causing shoulder pain, rupture of tendons,  shoulder surgery, 
numbness or tingling in upper limb, corticosteroids injection within 1 year, ligamentous laxity and systemic 
illness. Patientsprovided written informed consent to participate in this study. The design of the study was 
two groups pre and post experimental study. 
Patients will divide randomly in two equal groups (A and B): Group A (controlled group):  
They will receive traditional physical therapy program including: passive range of motion (PROM)/ 
active assisted range of motion (AAROM)/ active range of motion (AROM), strengthen of rotator cuff, 
biceps, shoulder and scapular muscles,  ultrasound (5 min. – 1.5 W/c.m2 - 1 MHZ), electrical stimulation ( 
interferential bipolar technique for 20 min. on shoulder joint). Group B (study group): they were received 
the same physical therapy program as in group A, in addition to Biomechanical scapular mobilization 
with movement and motor learning. 
Assessment tools 
All information including: Name, age, address, gender, height, weight, previous history of shoulder pain, 
location and duration of pain. 

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Visual analogue scale (VAS) Visual Analogue Scale: was used to evaluate the intensity of pain, which 
The pain VAS is a continuous scale comprised of a horizontal (HVAS) or vertical (VVAS) line, usually, 
10 centimetres (100 mm) in length, anchored by 2 verbal descriptors, one for each symptom extreme. For 
pain intensity, the scale is most commonly anchored by “no pain” (score of 0) and “pain as bad as it could 
be” or “worst imaginable pain” (score of 10 centimetres [100‐mm scale]). 
Universal goniometer: was used to measure the available range of motion at a joint. Where used to 
measure an available range of motion of abduction and flexion of the shoulder joint. 
In Abduction: the patient supine with his/ her shoulder in external rotation and her/ his elbow in 
extension. The fulcrum of goniometer was placed over the acromion process of scapula and the fixed arm 
parallel to midline of sternum, while movable arm aligned with longitudinal line of the humerus, using 
the epicondyle as a reference, then ask a patient to abduct his arm as possible as can (Delgado-Gil 2015)14 
In Flexion: The assessment done with patient supine with 0 abduction and adduction and no rotation. 
While the elbow in extension and forearm in neutral position (midrange between supination and 
pronation). The fulcrum of goniometer was located laterally on center of humerus head near to acromion 
process and the fixed arm parallel to axillary line or midline of trunk, while the moveable arm aligned 
with longitudinal midline of humerus where lateral epicondyle is used as reference. Then ask a patient to 
flex the shoulder as possible as can (Delgado-Gil 2015) 14. 
Treatment method 
All patients in the two groups (A&B) will receive passive range of motion (PROM)/ active assisted range 
of motion (AAROM)/ active range of motion (AROM) exercises, strengthen of rotator cuff, biceps, 
shoulder and scapular muscles,  ultrasound (5 min. – 1.5 W/c.m2 - 1 MHZ), electrical stimulation ( 
interferential bipolar technique for 20 min. on shoulder joint). This treatment will repeate three times per 
weeks with 24 hours rest for 3 weeks. 

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All patients in group B will receive biomechanical scapular mobilization with movement and motor 
learning and traditional methods. 
Biomechanical scapular mobilization with movement and motor learning will be applied on the patient 
seated at edge of the chair and his feet on the ground while his trunk was unsupported and his arm in external 
rotation. The therapist standing on lateral side of at affected shoulder with one hand on superior and 
anterolateral side of acromion. Where the thenar eminence of the hand applied mobilization to scapula in 
posterio-medial and inferior direction to position the scapula in posterior tilt and external rotation. While 
the index of the other hand on the inferior medial border of scapula while the thumb on the lateral border 
of scapula to mobilize the scapula upward rotated and external rotated of scapula ( the external rotation of 
scapula applied by thumb note that I applied technique by the pad of thumb to be not painful). Then the 
patient was asked to elevate his arm with maintain the external rotation of his arm and the therapist 
mobilized it with movement. Where the therapist maintained the force direction of mobilization during the 
movement. This technique was done 3 times then we added belt around the head of humerus or near to joint 
line and the other end of the belt supported by therapist’s foot. The aim of using the belt was to apply 
inferior and posterior glide of shoulder during elevation of arm (you can also use the belt to apply inferior 
and anterior glide during the shoulder elevation).  
1. Normal mechanics of shoulder elevation: During the elevation of arm there is ratio between the 
scapula and glenohumeral called scapulohumeral rhythm. This ratio is 2:1 where GH joint abducted 
120° and 60° upward rotation occur in scapulothoracic this cause 180° abduction. The 60 degree 
of scapula during shoulder abduction cause elevation in sterno-clavicular (SC) joint with upward 
rotation in acromio-clavicular (AC) joint. Also, the SC joint is retracted and scapula posterior tilted 
and externally rotated (Neumann 2010, Teece 2008),  15,16. On the other hand, there was relation of 
thoracic and shoulder elevation. When the shoulder elevated, the upper thoracic spine extend, side 
bend and rotate to same side of shoulder elevation. Also, the first and second ribs  descend while 
the fourth to sixth ribs was ascended and third ribs act as an axis 17. (table 2.1) 

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2. The mobilization of scapula is effective in increasing the range of motion and decreasing the pain 
in shoulder impingement syndrome (Surenkok 2009)18. 
3. The mulligan technique or mobilization with movement is effective in increasing the subacromial 
space (Dabholkar 2017) 8, and also effective in decreasing the pain and increasing of shoulder range 
of motion (Dabholkar 2017, Delgado-Gil 2015, Guimaraes 2016) 8,14,19. 
4. The inferior glide to the Glenohumeral joint increase the abduction of shoulder while the posterior 
glide increase the flexion of shoulder (Carolyn 2013, Maricar 2009, Chad 2012)20,21,22. 
5. Also the anterior glide and posterior glide have significant effect in increasing the abduction of arm 
(Chad 2012, Hsu 2002) 22,23.  
From the previous evidence I want mix between the results of MWM with passive mobilization of 
glenohumeral joint and scapular mobilization in one technique. When I done this I see myself applied the 
mechanics of joint, therefore I create the biomechanics scapular mobilization with movement and motor 
learning technique, which adding biomechanics of shoulder complex to mobilization with movement 
technique. 
Muscles and function failure is stimulus the motor control center in brain in order to learn new skills. For 
example when the baby learns to walk in the first time he takes some steps and then he falls, the every 
unsuccessful step there is aspect of success that is programmed in motor control center to create probable 
pattern for walking. From this point of view motor control center can achieve new successful routines 
(Weinstock 2010) 24. 
So that I added motor learning technique in my technique to create new successful routines in the brain to 
increase the effect of mobilization and modulate the abnormal pattern. Motor learning technique wasn’t the 
first time applied in shoulder impingement and it is effective in increasing ROM and decreasing pain 
(Worsley2013) 25. Before I did my technique, I had teach all patients the normal mechanics of shoulder and 
what was done when he elevated his arm. Secondly, I did my technique with variable description of 
mobilization (told the patient that I pull your scapula back, down and medially) and used this in front of 

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mirror to add a visual feedback about mobilization. At the end of session I asked the patient to elevate the 
arm actively and I evaluated the movement either by observing the movements of  the scapula or by putting 
my hand on the scapula to assess the movements of the scapula and gave the patient feedback if the 
kinematic of the shoulder is right or wrong At the end. The patient received verbal instructions about his/her 
performance and how to improve this next time. When the patient did it successfully and scapular 
movements were done properly during the motion I added functional training to shoulder elevation such as 
reaching high object. This technique will done 3 times per week with 24 hours rest between each session 
in which it repeated 30 times in every session for 3 weeks. 
Statistical method:  
Data into the computer was done followed by tabulation and analysis. 
Analysis was done using SPSS-20 (Statistical package for Social Sciences version 
21).  
Quantitative data were described using mean and standard deviation for 
normally distributed data while abnormally distributed data was expressed using 
median, minimum and maximum. 
For normally distributed data, comparison between two independent population 
were done using independent t-test  

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Student (Unpaired-sample) “t” test: 
It is used during comparison between the means of different sample groups. 
The “t” is calculated as follows: 
t = 
 
Where  
X1 = Mean of first group. 
X2  = Mean of second group. 
S1  = Standard deviation of the first group. 
S2  = Standard deviation of the second group. 
n1  = Sample size of the first group. 
n2  = Sample size of the second group. 
Chi-Square test: 
It tests the association between qualitative nominal variables, it is performed mainly on 
frequencies. It determines whether the observed frequencies differ significantly from expected 
frequencies.  
 
 
Where E = expected frequency 
            O =  observed frequency 
 
 
Statistical analysis were done at level of significance of P < 0.05 
1
2
2
2
1
2
1
2
X  - X
S
S
 
 
n
n




i
2
i
i
2
E
)
E
(O
Χ
Computed
   total
Grand
otal
   
Column   t
  x 
   total
Raw
 
E 

10 
 
Table (1): Comparison between the Group A and Group B 
 
Group A 
Group B 
t 
p 
Age (years) 
Range  
Mean 
S.D. 
25-50 
35.1 
8.123 
27-50 
35.3 
7.943 
 
 
0.210 
0.852 
Sex 
Male 
Female 
No 
% 
No 
% 
X2 
P 
5 
10 
33.3 
66.7 
5 
10 
33.3 
66.7 
 
0.0 
1.0 N.S.  
t = student t-test  
X2 = Chi square test  
P = p value and considered significant if < 0.05 
N.S. Not significant difference between the two groups.  

11 
 
 
Fig.(1): Comparison between the Group A and Group B 
 
 
0
5
10
15
20
25
30
35
40
Group A
Group B
Mean
Age (years)
0
10
20
30
40
50
60
70
Male
Female
Mean
Sex
Group A
Group B

12 
 
Table (2): Comparison between VAS, abduction and flexion ROM Pre and Post-
treatment in group A 
Group A 
Pre-
treatment 
Post-
treatment 
t-test 
P value  
VAS 
Range  
Mean 
S.D. 
3-8 
5.7 
1.543 
2-6 
4.2 
1.474 
 
 
1.92 
 
 
0.043* 
Abduction 
Range  
Mean 
S.D. 
63-88 
75.7 
9.445 
73-97 
85.7 
9.083 
 
 
2.01 
 
 
0.025* 
Flexion ROM 
Range  
Mean 
S.D. 
101-134 
119.3 
10.166 
112-147 
131.7 
10.761 
 
 
2.11 
 
 
0.013* 
t = student t-test  
P = p value and considered significant if < 0.05 
* Significant difference from the before therapy.  

13 
 
 
Fig.(2): Comparison between VAS, abduction and flexion ROM Pre and Post-
treatment in group A 
0
1
2
3
4
5
6
Pre-treatment
Post-treatment
Mean
VAS
0
10
20
30
40
50
60
70
80
90
Pre-treatment
Post-treatment
Mean
Abduction
0
20
40
60
80
100
120
140
Pre-treatment
Post-treatment
Mean
Flexion ROM

14 
 
Table (3): Comparison between VAS, abduction and flexion ROM Pre and Post-
treatment in group B 
Group B 
Pre-
treatment 
Post-
treatment 
t-test 
P value  
VAS 
Range  
Mean 
S.D. 
4-8 
6.0 
1.254 
0-4 
0.9 
1.280 
 
 
12.25 
 
 
0.0001* 
Abduction 
Range  
Mean 
S.D. 
60-85 
72.8 
9.533 
118-142 
130.9 
8.302 
 
 
8.25 
 
 
0.001* 
Flexion ROM 
Range  
Mean 
S.D. 
100-131 
116.6 
10.568 
162-180 
173.4 
6.544 
 
 
5.89 
 
 
0.001* 
t = student t-test  
P = p value and considered significant if < 0.05 
* Significant difference from the before therapy.  

15 
 
 
Fig.(3): Comparison between VAS, abduction and flexion ROM Pre and Post-
treatment in group B 
0
1
2
3
4
5
6
Pre-treatment
Post-treatment
Mean
VAS
0
20
40
60
80
100
120
140
Pre-treatment
Post-treatment
Mean
Abduction
0
20
40
60
80
100
120
140
160
180
Pre-treatment
Post-treatment
Mean
Flexion ROM

16 
 
Table (4): Comparison between VAS, abduction and flexion ROM Pre treatment in 
the two studied groups  
Pre treatment 
Group A 
Group B 
t-test 
 
P value  
VAS 
Range  
Mean 
S.D. 
3-8 
5.7 
1.543 
4-8 
6.0 
1.254 
 
 
0.82 
 
 
 
0.425 N.S 
Abduction 
Range  
Mean 
S.D. 
63-88 
75.7 
9.445 
60-85 
72.8 
9.533 
 
 
0.93 
 
 
0.341 N.S 
Flexion ROM 
Range  
Mean 
S.D. 
101-134 
119.3 
10.166 
100-131 
116.6 
10.568 
 
 
0.28 
 
 
0.701 N.S 
t = student t-test  
P = p value and considered significant if < 0.05 
N.S = No Significant difference.  
 
 
 
 

17 
 
 
Fig.(4): Comparison between VAS, abduction and flexion ROM Pre treatment in 
the two studied groups 
0
1
2
3
4
5
6
Group A
Group B
Mean
VAS
0
10
20
30
40
50
60
70
80
Group A
Group B
Mean
Abduction
0
20
40
60
80
100
120
Group A
Group B
Mean
Flexion ROM

18 
 
 
Table (5): Comparison between VAS, abduction and flexion ROM Post treatment 
in the two studied groups  
Post treatment  
Group A 
Group B 
t-test 
 
P value  
VAS 
Range  
Mean 
S.D. 
2-6 
4.2 
1.474 
0-4 
0.9 
1.280 
 
 
6.89 
 
 
0.001* 
Abduction 
Range  
Mean 
S.D. 
73-97 
85.7 
9.083 
118-142 
130.9 
8.302 
 
 
7.25 
 
 
0.001* 
Flexion ROM 
Range  
Mean 
S.D. 
112-147 
131.7 
10.761 
162-180 
173.4 
6.544 
 
 
5.01 
 
 
0.001* 
t = student t-test  
P = p value and considered significant if < 0.05 
* Significant difference between the two groups.  

19 
 
 
Fig. (5): Comparison between VAS, abduction and flexion ROM Post treatment in 
the two studied groups 
0
1
2
3
4
5
Group A
Group B
Mean
VAS
0
20
40
60
80
100
120
140
Group A
Group B
Mean
Abduction
0
50
100
150
200
Group A
Group B
Mean
Flexion ROM

20 
 
 
Informed consent form 
Recognition: I am miss or mr/                                freely and voluntarily consent to 
participate in research study under the direction of researcher / M.A . A through 
description of procedure has been explained and I understand that I may withdraw 
my consent and discontinue participation in this research at any time without 
prejudice to me. 
  
                                                                               Participant :                                   date: 
        ………………………..           ………………………… 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Table of Contents 
Cover Page  ................................................................................................................................................... 1 
Ethical ID  ...................................................................................................................................................... 1 
NCT ID ........................................................................................................................................................... 1 
Introduction .................................................................................................................................................. 2 
Treatment options ........................................................................................................................................ 2 
Statement of the problem ............................................................................................................................ 2 
Purpose of the study ………………………………………………………………………………………………………………………………3 
The significance of shoulder impingement …………………………………………………………………………………………3 
Limitation ……………………………………………………………………………………………………………………………………..3 
The hypothesis ………………………………………………………………………………………………………………………………………3 
Methods ……………………………………………………………………………………………………………………………………………..3 
Assessment tools ……………………………………………………………………………………………………………………………4 
Treatment method……………………………………………………………………………………………………………………………..5 
Statistical method……………………………………………………………………………………………………………………………….7 
Comparison between the Group A and Group B ……………………………………………………………………………..10-11 
Comparison between VAS, abduction and flexion ROM Pre and Post-treatment in group A ………12-13 
Comparison between VAS, abduction and flexion ROM Pre and Post-treatment in group B…………..14-15 
Comparison between VAS, abduction and flexion ROM Pre treatment in the two studied groups…..16-17 
Comparison between VAS, abduction and flexion ROM Post treatment in the two studied groups18-19 
Informed consent form ……………………….……………………………………………………………………………………………….20