Mobilization With Movement as an Additional Treatment to Conventional Physical Therapy in Individuals With Shoulder Impingement Syndrome
Phase: NA
Conditions: Shoulder Impingement Syndrome, Subacromial Impingement, Subacromial Impingement Syndrome, Subacromial Pain Syndrome, Impingement Syndrome, Shoulder
Sponsor: Mahidol University

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1. Title of Project: Mobilization with movement as an additional treatment to conventional physical therapy in individuals 
with shoulder impingement syndrome. 
2. Principal Investigator: Ferian Nugraha, MSc, student, PT  
     
Contact address 
: Faculty of Physical Therapy, Mahidol University 999 
 
 
 
 Phuttamonthon Sai 4 Rd, Salaya, Phutthamonthon,  
 
 
 
Nakhon Pathom 73170 
Telephone number 
: (+62) 81220355498 / (+66) 802684910 
E-mail address  
: feypqbd@yahoo.co.id / feypqbdnew@gmail.com  
2.1 Experience and Training in Human Research ethics 
corporate in post-graduate curriculum  
3. Co-investigator  
Lect. Dr. Wunpen Chansirinukor 
 
Faculty of Physical Therapy, Mahidol University 999 
 
Phuttamonthon Sai 4 Rd, Salaya, Phutthamonthon,  
 
Nakhon Pathom 73170 
 
E-mail  
: wunpen.cha@mahidol.ac.th / wunpen.cha@mahidol.edu 
 
 
 
Assoc. Prof. Dr. Roongtiwa Vachalathiti 
 
Faculty of Physical Therapy, Mahidol University 999 
 
Phuttamonthon Sai 4 Rd, Salaya, Phutthamonthon,  
 
Nakhon Pathom 73170 
 
E-mail  
: roongtiwa.vac@mahidol.ac.th / roongtiwa.vac@mahidol.edu 
4. Background & Rationale 
There was high incidence of shoulder pain in population with occupationally related to repetitive overhead 
position or work in the awkward position. This was evident especially when involving with sustained shoulder rotation 
position, lifting heavy loads or using vibratory tools. The shoulder pain was reported to be the third most common problem 
reported on musculoskeletal disorder after back and knee pain, approximately 16% to 21% of the population. Its 
prevalence in persons 60 years and older is 34%. 

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Based on the literature review, shoulder function is related to the postural problem and scapulo-humeral kinematics. 
The main mechanism of shoulder impingement syndrome is related to the narrowing of subacromial space which leads to 
a compressive and shear forces to the structures below that space.  
The common intervention of the shoulder impingement syndrome is conventional physical therapy that consists of 
stretching, modality, education and passive mobilization. Manual therapy and exercises are necessary to treat the patient 
with the shoulder impingement syndrome. Specific exercises focus on the biomechanical aspect such as postural 
correction exercise. 
The current manual therapy technique, the mobilization with movement which is posterolateral glide using the 
treatment belt, might help the physical therapist give more stable pull action, while the other hand on the scapula to assist 
the movement and give a direction of proper biomechanics. Some studies showed different results and limitation of the 
method of applying the mobilization with movement technique. Previous studies investigated the effects of mobilization 
with movement in the patients with shoulder dysfunction and/or shoulder impingement syndrome. A case report conducted 
by DeSantis and Hasson applied the mobilization with movement, other manual therapy, modalities, and therapeutic 
exercise to a male patient with shoulder impingement syndrome. The results showed that the mobilization with movement 
may be an effective treatment intervention for the patient.  
Another study conducted by Tey et al evaluated the immediate effects of mobilization with on shoulder range of motion 
and pressure pain threshold in people with painful limitation of shoulder movement. The results showed that the 
mobilization with movement reduced pain and improved range of motion. 
Moreover, a randomized controlled trial conducted by Delgado et al showed that the short-term effects of 
mobilization with movement was effective to decrease pain intensity and increase shoulder range of motion. However, 
Guimarães et al compared the immediate effects of mobilization with movement with sham technique on shoulder range 
of motion, muscle strength and function in the patients with shoulder impingement syndrome. The results showed that the 
mobilization with movement was no more effective than sham technique in improving shoulder external rotation and 
abduction, pain and function. These different results lead this study to compare the effects of adding mobilization with 
movement on the conventional treatment. 
Several outcomes have been commonly investigated in the shoulder impingement syndrome-related previous research, 
for example, pain intensity, shoulder range of motion, muscle strength, and shoulder function. The pain intensity was usually 
assessed using the visual analogue scale. The shoulder range of motion was assessed using a bubble inclinometer, the 
shoulder muscle strength, and function were investigated using hand held dynamometer (HHD) and a self-reported 
questionnaire e.g. shoulder pain and disability index, respectively.  

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Since the postural correction exercise is commonly applied in the conventional physical therapy, neck and shoulder 
posture can be assessed using photogrammetry measurement. The neck and shoulder posture can be generally assessed by 
measuring the craniovertebral angle and shoulder angles, respectively. 
5. Objective of the Study 
5.1 General Objective  
To compare the effects of 4-week conventional physical therapy treatment (conventional group) with the conventional 
program and the addition of the mobilization with movement (mobilization with movement group) on pain intensity, 
shoulder , cervical and shoulder postures, shoulder muscle strength, and shoulder function in the patients with shoulder 
impingement syndrome. 
5.2 Specific Objective  
1) To compare the pain intensity between the conventional and the mobilization with movement groups at baseline, 
after intervention at week 1, week 2, week 3, and week 4. 
2) To compare the shoulder range of motion between the conventional and the mobilization with movement groups 
at baseline, after intervention at week 1, week 2, week 3, and week 4. 
3) To compare the craniovertebral angle and shoulder angles between the conventional and the mobilization with 
movement groups at baseline, after intervention at week 2, and week 4. 
4) To compare the shoulder muscle strength between the conventional and the mobilization with movement groups 
at baseline, after intervention at week 2, and week 4. 
5) To compare the shoulder pain and disability index scores between the conventional and the mobilization with 
movement groups at baseline, after intervention at week 2, and week 4.  
6. Research Plan 
6.1 Type of Research 
 
Biomedical / Clinical Research 
 
 Procedural / intervention 
 
___Conventional physical therapy,_Postural correction_exercise,_&_Mobilization_with_movement_____ 
6.2 Subject selection and allocation 
6.2.1 Inclusion criteria  
1) Age 20-60 years old  
2) Anterior and/or lateral shoulder pain (between acromion and glenoid) 
3) Score 4-7 cm on the 0-10 visual analogue scale (VAS)  

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4) Experienced shoulder pain at least 3 months 
5) Positive combination 2 of 3 impingement tests (Painful arc, Empty can, and External rotation test) 
6) Negative at least one of rotator cuff tear test (Isometric infraspinatus and subscapularis muscle tests) 
There is no different between dominant hand and non-dominant in case of functional assessment, because some 
of the SPADI question ask the function that required both hand activity and the severity of the involved hand). 
If the patient has bilateral shoulder impingement syndrome they will be excluded because if the patient had 
bilateral impingement syndrome, it will affect the scapular motion and scapulothoracal joint on the both sides. 
6.2.2 Exclusion criteria  
1) History of shoulder, cervical, or thoracic surgery 
2)  History of neurological conditions (stroke, brachial plexus injury) 
3) Postural deformity and musculoskeletal condition that affect the shoulder movement 
4) History of shoulder major trauma on the affected side (fracture, dislocation, tendon rupture and/or labral 
torn) 
5) Having bilateral shoulder impingement syndrome 
6) Recently using muscle relaxants, pain killer, or corticosteroid injection 
7) Ligamentous laxity based on positive sulcus sign 
8) Numbness or tingling in upper extremity 
9) Systemic illness or widespread pain 
10) Rheumatic disease 
11) Having malfunction of rotator cuff muscle (e.g. cannot perform at all) 
12) Having a passive limitation due to adhesive capsulitis 
13) Positive of scapular retraction test 
6.2.3 Withdrawal criteria (for individual participant) 
1) Unwilling to follow the procedure 
2) Unwilling to participate in this study 
3) Unable to participate until the process complete  
4) Participants with any uncomfortable condition can quit in any session 
6.2.4 Termination criteria (for the whole research project) 
1) The methodology is harmful to the participants more than 20 % of participants 
2) Researcher cannot find the patients to meet the criteria in this research  

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6.2.5 Subject allocation (for more than 1 arm study) 
 
The participants will be allocated into 2 groups according to age allocation and will be randomized by sealed 
envelopes. 
6.3 Sample size 
Sample size calculation will be performed using formula for the test of different between 2 independent means. 
 
According to the G*power 3.1.9.2 program calculation, the total of this study equal 20 subjects. Based on the 
previous study using the shoulder pain and disability index to measure the shoulder function, in the study of comparing 
the immediate effects of mobilization with movement and sham techniques. The mean (standard deviation) between 
group post-intervention for the mobilization with movement group was 4.6 (5.0) and that for the sham group was 0.4 
(1.1)   (12). In this proposed study, we need equal number of participants per group; therefore, the drop out calculation 
of 20% from the total participants (n = 1/1-20%). Therefore, after the ethical approval, the researcher will collect data 
from 24 shoulder impingement syndrome patients (12 subjects on the conventional group and 12 subjects on the 
mobilization with movement group). 
6.4 Replacement procedure if subject withdraw from the study 
not necessary because the number of subjects calculated already include drop out number   
7. Study procedures 
 
Assessment 
1. Scapulohumeral rhythm on shoulder abduction: there should be no reverse scapulohumeral rhythm, scapular 
tracking will be assessed for defining the scapular motion abnormalities and glenoid rotation on the scapular 
abduction. If there is a presence of scapular abnormalities the patients will be assessed on the point 2 and 3.  

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2. Scapular dyskinesis test of McClure: active shoulder flexion and abduction using 1 kg dumbbells on both hand 
flexion and abduction while the therapist will assess the scapular motion from behind, the result of scapular 
winging, shrugging or tipping will define the conventional treatment for each patient. 
3. Scapula assistance test: during shoulder abduction - elevation the therapist will assist the scapular movement at 
the inferior angle of the shoulder blade to see which stabilizer muscles have weakness.  
4. Painful arc: the pain is occurring during 60-120 degrees of shoulder abduction – elevation. 
5. External rotation test: known as Infraspinatus test, the patient will perform isometric contraction of shoulder 
external rotation in neutral shoulder abduction. 
6. Empty can test: during 90 degrees of shoulder abduction and maximally internal rotation, the test is isometric 
abduction while the therapist hand will resist the patient’s hand. 
7. Drop arm test: during 90 degrees of shoulder abduction, the therapist hand will support the patient’s elbow. Next, 
the therapist will move the support and ask the patient to lowering the hand slowly to test the eccentric 
performance. 
8. Lift off test: known as Subscapularis test, the patients will place their hand resting in middle lumbar region and 
perform the extension or lift the hand and reach to the back as far as they can. 
9. Scapular retraction test: the therapist will support the scapula to retract while the will patient performs the empty 
can test. If the pain is reduced while performing the test, it means that the source of the pain is from the weakness 
of scapular stabilizer muscle only. 
10. Capsulitis adhesive: the pain characteristic is stiff and painful. The patient has external rotation deficit in zero 
position at least 50% reduced or less than 30 degrees and loss of range of motion greater than 25% in at least 2 
planes (reverse humeroscapular rhythm at shoulder abduction and flexion).  
Positive of the test from the points 7 to 10 will be excluded because of the pain may occur from others region or 
not only from the subacromial region. 
The therapist (AH) and (FN) will examine all the participants. Both of them are professional physical therapy 
practitioners at Esa Unggul physical therapy clinic with more than 4 years working experience. The therapist (AH) is 
certified upper and lower orthopedic manual physical therapy (physical therapy advancement seminars APTA) and 
the therapist (FN) is certified A and B Mulligan practitioner. 
 
 
 

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Research Equipment  
1. Visual analogue scale  
 
 
 
2. Bubble inclinometer (Baseline. USA) 
 
3. Canon EOS M 10 (Canon. Japan) and tripod 
 
 
4. Postural assessment software (SAPO ver. 0.69 BMC Brazil) 
  
 
During Full Abduction 
The pain will be measured during the shoulder 
abduction because the provocation of the impinged 
structure is high on the range of 60 to 120 degrees. 
The therapist will ask the patient to rate the pain on the 
VAS scale from 0 to 10. 
The therapist will put the inclinometer on the upper arm 
and set the marker to the edge of the bubble. The 
patient will perform shoulder abduction on standing 
position, internal rotation and external rotation on the 
supine position with 90 degrees shoulder abduction and 
elbow flexion. 
The camera and tripod will be set up on the postural 
assessment room, the range of the tripod and camera 
will be set on maximum zoom and 4 meters from the 
patient. The height of the tripod will be adjusted 
depending on the patient’s height ranging from 130 to 
150 cm. 
The therapist will ask the patient to stand beside the 
grid line and face the marker on the wall. The results of 
the photograph will be inputted to the software and the 
examiner will mark the degree of cervical angle and 
sagittal shoulder posture. 

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5. Hand held dynamometer (Micro FET2, Hoggan. USA) 
 
 
6. Shoulder pain and disability index (SPADI) questionnaire 
 
Intervention 
1. Conventional physical therapy 
In the conventional physical therapy, the procedure of intervention depends on the patient’s condition (tailor 
made). After the physical examination every patient will be assessed based on the assessment list and will be 
treated based on the intervention that they needed. The conventional physical therapy includes muscle stretching, 
passive mobilization, postural correction exercise, home based exercise and education. 
No Exercise Purpose 
Type of exercise 
Dose 
 1 
Proprioception and joint 
sense recognition 
Scapular 
Retraction 
Frequency: 3x/week, Intensity: 3 
sets, Time: 6' contraction, 6' rest, 
Repetition: 10x 
2 
Middle trapezius, lower 
trapezius & serratus anterior 
Y to I Exercise 
Frequency: 3x/week, Intensity: 2 
sets, Time: 20' contraction, 10' rest, 
Repetition: 8x 
The therapist will place the dynamometer on the arm 
and ask the patient to push against the therapist’s hand to 
test the isometric contraction prior to each muscle. The 
test is performed to measure abductor and external 
rotator muscles. 
The therapist will ask the patient to rate the pain and 
shoulder disability on the SPADI questioner, the 
therapist will explain how to rate and measure the 
score. If the patient does not understand the question, 
the examiner will help until the patient can understand. 

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3 
Co-contraction of shoulder 
muscle 
Shoulder retraction 
pull back with 
elastic resistant 
Frequency: 3x/week, Intensity: 2 
sets, Time: 20' contraction, 10' rest, 
Repetition: 8x 
4 
Supraspinatus 
Seated full can 
Frequency: 3x/week, Intensity: 2 
sets, Weight: 60-80% 10RM, 1:1 rest 
interval, Repetition: 8x 
5 
Teres 
minor 
and 
infraspinatus 
Side lying external 
rotation 
Frequency: 3x/week, Intensity: 2 
sets, Weight: 60-80% 10RM, 1:1 rest 
interval, Repetition: 8x 
6 
Upper trapezius stretch 
Sitting stretch 
Frequency: 3x/day, Intensity: 2 sets, 
Time: 30’stretch, Repetition: 3x 
7 
Pectoralis minor stretch 
Wall corner stretch Frequency: 3x/day, Intensity: 2 sets, 
Time: 30’stretch, Repetition: 3x 
8 
Posterior capsule stretch 
Arm 
adducted 
across body 
Frequency: 3x/day, Intensity: 2 sets, 
Time: 30’stretch, Repetition: 3x 
Each patient will exercise based on the number in the aforementioned Table which is programmed based on the 
examination.   
The therapist (E) who will give the conventional physical therapy is a professional practitioner at Esa unggul 
physical therapy clinic Jakarta with more than 5 years working experience. He is certified level 1 sport physical 
therapist (APA) and a former official physical therapist for Indonesia national team (basketball 3x3, mini soccer, 
football and wheelchair basketball Paralympic). 
2. Mobilization with movement 
 
 
 
 
The physical therapist put the treatment belt on the anterior boarder of glenohumeral joint while the other hand is 
on the scapula. Mobilization with movement direction is posterolateral glide with active shoulder abduction in the 
pain free range of motion. The direction is changing simultaneously with the glenoid and scapular movement to 
make sure the glide of the glenoid close to the normal movement, and the therapist hand will assist the scapular 

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motion. Every patient will have the same amount of glide because the therapist will use the treatment belt to 
perform the glide. Therefore, the force will be adjusted by the body weight and performed by the same therapist. 
The place of treatment will be used in only one manual therapy room with the same bed and position. 
The therapist (S) who will give the mobilization with movement is a professional practitioner at Esa unggul 
physical therapy clinic Jakarta with more than 40 years working experience. He is certified A and B Mulligan 
practitioner, (spine, upper, and lower extremity) certified orthopedic manual physical therapy (APTA) and has 
specialist of orthopedic musculoskeletal title from Indonesian Physical Therapy Association. 
 
Flow chart of procedure  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Shoulder impingement syndrome 
Assessment 
Meet the inclusion criteria  
Conventional 
Mobilization with movement 
Conventional 
physical therapy 
by PT (E) 
Data Analysis    
Age allocation 
Randomized 
Conventional 
physical therapy 
by PT (E) 
Mobilization with 
movement         
by PT (S) 
Rest 
Pre intervention 
Visual analogue scale (VAS) & range of motion 
(ROM) (Baseline, weeks 1,2,3 and 4)  
Photogrammetry, hand held dynamometry 
(HHD), shoulder pain and disability index 
(SPADI) (baseline, weeks 2 and 4) 
Post intervention 
(VAS, ROM, Photogrammetry, HHD, SPADI) 

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8. Data collection process  
This study will recruit shoulder patients around Jakarta city, the age between 20 and 60 years. The patients with 
shoulder impingement syndrome will be recruited by online brochures and leaflets. 
All eligible participants will receive clear explanation of purposes, procedure, advantages and possible risk of this 
study. Each participant will be asked to sign an informed consent after they understand and accept to participate in this 
study.  
Based on the assessment form, the participant will be assessed by the examiner and researcher. The participants’ age 
will be used to grouping the participants into the conventional or mobilization with movement group. The participant will 
be asked to rate their pain intensity using the visual analogue scale during the maximum shoulder abduction.  
Shoulder range of motion will be assessed using the bubble inclinometer during shoulder abduction in the standing 
position, internal and external rotation in the supine position with 90° shoulder abduction and 90° elbow flexion. Cervical 
and shoulder with the instruction to the participants to stand in their relaxed posture will be recorded by photogrammetry. 
Muscle strength of shoulder abductors, external rotators and internal rotators will be assessed using the hand held 
dynamometer. The shoulder function will be recorded by the shoulder pain and disability index. 
Conventional physical therapy 
For the conventional group, PT (E), who has had certified level 1 sport physical therapy from Australian 
Physiotherapy Association and has had 5 years working experience, will treat the participants with the conventional and 
postural correction exercise. This therapist will be blinded by unknowing the group allocation. The participants will 
receive the conventional intervention, the postural correction exercise and 10 minutes rest. Then the outcome measures 
will be reassessed thereafter. The participants in the conventional group will receive conventional physical therapy 
including stretching, modality, ice, therapeutic exercise, passive mobilization, and postural correction exercise. The 
conventional physical therapy is adjustable or tailor made depending on the patient’s specific conditions.  
The therapeutic exercise has a wide variety of types and modes of exercises. The postural correction exercises 
consist of rotator cuff muscle strengthening with eccentric-concentric, scapular stabilization exercise, and postural 
awareness. In addition, these exercises include motor control therapeutic exercise for the relearn process and motor control 
of correct posture to change the participant’s behaviour. 
Mobilization with movement 
For the mobilization with movement group, PT (S) will know the code to treat the participants using the 
conventional or mobilization with movement protocol. Moreover, this therapist will apply the mobilization with 
movement technique. The participants will receive the conventional intervention, the postural correction exercise and the 

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mobilization with movement. Then the outcome measures will be reassessed thereafter. The directions of mobilization 
with movement is posterolateral glide, when the participants raise their arm to perform shoulder abduction until the 
overhead movement. The therapist will place one hand on the participant’s scapula to stabilize movement, while placing 
the thenar eminence of the other hand on the medial of humeral head. The treatment belt will be placed on the participant’s 
shoulder on top of the PT (S)’s hand.  
The therapist will provide sustained posterolateral and inferior glide while the participants will be asked to move 
the shoulder freely in the pain free angle. PT (S)’s hands will move along with the movement to sustain the glide along 
treatment plane with upward rotation of the scapula. The mobilization with movement dose will be 3 sets of 10 repetitions 
with rest interval 30 seconds between sets, twice a week for 4 weeks. 
9. Outcome measurement/Data analysis 
- Primary outcome  
Pain intensity (visual analogue scale) 
Shoulder function (shoulder pain and disability index) 
- Secondary outcome 
 (bubble inclinometer) 
Muscle strength (hand held dynamometer) 
Postural alignment (photogrammetry) 
 
- Assessment of efficacy 
 
 
The assessments that will be used in this study are standard, reliable and commonly used in the clinic. They 
have very low risk and are safe to be used in clinic. Moreover, the physical therapy intervention that will be used in 
this study are safe, proven by the previous study to treat the shoulder impingement syndrome and commonly used in 
the clinic. 
 
- Assessment of safety 
This study does not include any injection or invasive approach, or taking any medications and does not require 
any modification of patient treatment programs.  
Before giving an informed consent, the participants will be asked whether they have any condition listed in 
exclusion criteria or any other conditions that may preclude participation in any aspect of the study.  
The researcher will explain the procedure, purpose, advantages and possible risk of this study. The researcher 
will demonstrate each test prior to evaluation and will explain the procedures for each intervention. Moreover, the 
researcher will observe participants’ feeling during assessment. 

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- Statistics to be used or process for data analysis 
Data will be analysed by using SPSS version 23. The statistical significance level is set at p-value < 0.05.  
- Shapiro-Wilk will be used to examine the distribution of the data  
- Descriptive statistics for demographic data, mean and standard deviation for continuous, cumulative frequency 
for categorical and median for ordinal variables, will be calculated. 
- Two-way mixed design ANOVA (two group x four time) for parametric data. If the data are significant the 
post hoc analysis will be performed using Bonferroni.  
- Friedman test if the data are not normally distributed.