Motor Control Retraining Exercises On Shoulder Dysfunction Post Mastectomy
Phase: NA
Conditions: Post Mastectomy
Sponsor: Cairo University

 
March 11, 2025 
 
MOTOR CONTROL RETRAINING EXERCISES  
ON SHOULDER DYSFUNCTION 
 POST MASTECTOMY 
 
 
 
 
 
BY 
ESRAA TAREK MOHAMED HASHEM 
 
 
 
 
 
 
 
Submitted in A Partial Fulfillment of the Requirements of Doctoral 
Degree in Department of Physical Therapy for Surgery 
 Faculty of Physical Therapy 
 Cairo University 
2025

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SUPERVISORS 
 
Prof.Dr. AMAL MOHAMED ABD EL BAKY 
Professor of Physical Therapy for Surgery 
Faculty of Physical Therapy 
Cairo University 
 
 
Prof.Dr. ASHRAF ELSEBAIE MOHAMED 
Professor of General and Plastic Surgery 
Faculty of Medicine 
Cairo University 
 
 
Assist. Prof.Dr. KHADRA MOHAMED ALY 
Assistant Professor of Physical Therapy for Surgery 
Faculty of Physical Therapy 
Cairo University 
 

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CHAPTER Ι 
INTRODUCTION 
Breast cancer is a global public health issue. It is one of the most frequent 
neoplasms among women. Each year, around 2.3 million new patients are 
detected worldwide. Breast cancer detection and screening have improved 
because of increased public attention, breast cancer awareness and advancements 
in breast imaging (Łukasiewicz et al., 2021).  
Breast cancer surgeries can be either lumpectomy or mastectomy. They 
also include sentinel lymph node biopsy (SLNB) or axillary lymph node 
dissection (ALND) to determine the axillary lymph node condition (Loh et al., 
2015). The most common complications following mastectomy are pain, 
ipsilateral lymphedema of the upper limb (UL), reduced range of motion (ROM) 
of the shoulder, flexion and abduction is limited to 90°, and external rotation is 
limited to 40°, and postural changes (Basilio et al., 2014). 
Normal pain free ROM of the upper limb demand appropriate movement 
at the glenohumeral joint and the scapula-thoracic articulation. Synchronization 
between the muscles functioning across these joints allows for coordinated joint 
motion, which is necessary for arm raising (Shamley et al., 2014).  
Post mastectomy, the possibility of soft tissue changes may disrupt the 
normal scapular kinematics. It has been associated with greater scapular anterior 
tilting and internal rotation and reduced upward rotation. There is a relation 
between soft tissue alterations and shoulder biomechanical changes. Prolonged 
upper trapezius over-activation and tightness could lead to a muscular imbalance 
of the upper trapezius-serratus anterior couple. This imbalance would result in 
decreased upward rotation and increased scapular internal rotation (Lang et al., 
2022). 
 
 

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Normal pain free motion of the arm and shoulder requires mobility in the 
scapula-thoracic, glenohumeral, acromioclavicular and sternoclavicular joints. 
Under healthy conditions elevation of the arm is accompanied by scapula 
retraction, lateral rotation and posterior tilt. However, when scapula-thoracic 
motion is disproportionate to glenohumeral motion, the potential exists for 
microtrauma and long-term pain (Trundle et al., 2014). 
Motor control retraining refers to neuromuscular control of the body (trunk 
and limbs) in static postures and functional tasks using the process of initiating, 
directing, and grading purposeful voluntary movement. It’s necessary for the 
optimization of upper limb movement patterns, which helps the load spread 
evenly among multiple movement system components. The presence of 
uncontrolled movement may cause tissue overload that in turn can lead to pain, 
damage, and various musculoskeletal conditions. (Śliwiński et al., 2021). 
Statement of the problem: 
Do motor control retraining exercises have an effect on shoulder 
dysfunction post-mastectomy? 
Purpose of the study: 
The purpose of the study is to evaluate the effect of motor control retraining 
exercises on shoulder dysfunction post mastectomy. 
Significance of the study: 
The GH joint significantly depends on muscle control and mid-range 
stability. To guarantee that functional tasks is performed normally, Glenohumeral 
and scapulothoracic motions must interact and coordinate during arm raising to 
prevent the humerus head from striking the coracoacromial arch and seriously 
jeopardizing the soft tissue tissues around the shoulder from impingement. (Neto 
et al., 2018).  
 
 

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Motor control and strengthening exercises can improve function in 
shoulder impingement patients by realigning the scapula and changing muscle 
recruitment patterns. Peripheral musculoskeletal impairments can be associated 
with cortical reorganisation. Movement retraining using the principles of motor 
control retrain muscle recruitment patterns and improve scapular kinematics, 
reducing subacromial impingement, thus improving function and reducing pain 
(Worsley et al., 2013). 
Furthermore, the need of this study is developed from the lack in the 
quantitative knowledge and information in the published studies about the effect 
of motor control retraining exercises on shoulder dysfunction post-mastectomy. 
Delimitations:  
      This study will be delimited in the following aspects: 
1.Subjects: 
      Sixty patients suffering from post-mastectomy shoulder dysfunction will be 
randomly divided into two equal groups (Group A and Group B) each one has 
30 patients. Patients’ age will range from 40 to 55 years.  
2.Equipment and tools:  
2.1. Measurement equipment:  
• Hand-held dynamometer: for measurement of muscle strength (Mañago 
et al., 2017). 
• Digital inclinometer: for measurement of shoulder flexion, abduction and 
scapular upward rotation (An et al., 2021). 
• Shoulder Pain and Disability Index (SPADI): for measurement of shoulder 
disability (Alsanawi et al., 2015). 
2.2. Therapeutic procedures: 
• Motor control retraining exercises of the scapular musculature. 
• Traditional physical therapy. 
 

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Hypothesis:  
It will be hypothesized that:  
Motor control retraining exercises have no effect on shoulder dysfunction post-
mastectomy.  
Basic Assumptions:  
It will be assumed that: 
• All patients will continue in the study.  
• All patients will follow the instructions during the treatment. 
• All patients are free from any chronic impairment. 
• The clinical method of measurement will be reliable and valid. 
Definitions of terms:  
         The following terms will be defined for the clear understanding of the 
terminology that will be used in the present study:  
Mastectomy: 
Mastectomy is a procedure consisting of invasive breast removal due to 
some anatomical and functional changes previously diagnosed. Surgical 
treatment ranges from lumpectomy to mastectomy, with or without removal of 
axillary lymph nodes (Basilio et al., 2014).   
Motor control: 
Motor control is defined as the ability of the nervous system to control 
posture and movement for a given motor task and encompasses all the motor, 
sensory and integrative processes associated with the planning and execution of 
the task (van Dieën et al., 2018). 
Shoulder Pain and Disability Index (SPADI):  
        The SPADI is a self-administered questionnaire that contains thirteen items 
which assess two domains (pain and disability) (Shamley et al., 2012).  It has an 

6 
 
8-item subscale to evaluate disability and a 5-item subscale to measure pain. Each 
subscale is summed and transformed to a score out of 100. A mean is taken of the 
two subscales to give a total score out of 100, higher score indicating greater 
impairment or disability (Breckenridge and McAuley, 2011). The Arabic 
version of SPADI has excellent validity and reliability (Alsanawi et al., 2015) 
Instrumented digital hand-held dynamometer: 
          It is an ergonomic hand-held device for objectively providing reliable, 
accurate readings that conform to most manual muscle testing protocols. It has 
good to excellent validity and reliability for most measures of isometric muscle 
strength particularly for proximal muscle groups. It has a large, easy-to-read LCD 
screen that displays results in both pounds and kilograms (mentiplay et al., 
2015). 
Digital inclinometer: 
          A digital inclinometer is used to measure shoulder flexion, abduction and 
upward rotation of scapula. It has digital screen that display the angle at which 
the inclinometer is situated allowing direct joint angle measurements (An et al., 
2021). 
 
 
 
 
 
 
 
 

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CHAPTER ΙΙ 
REVIEW OF RELATED LITERATURES 
       The review of the related studies and literature of the main concept of this 
study will be presented under the following headings: 
1.Mastectomy: 
1.1. Definition: 
Mastectomy is a surgical procedure in which all or part of the breast is 
removed. The term is derived from the Greek word mastos, which means 
"woman's breast" and the Latin term ectomia, which means "excision 
of"(Goethals and Rose, 2022). Excision of the in-breast neoplasia and a 
reduction in the likelihood of local recurrence (LR), regional recurrence 
(RR), or the development of a new primary breast tumour are the goals of 
surgical treatment for breast cancer (Kaidar et al., 2020). 
1.2. Types and techniques. 
There are several types of mastectomy procedures (Lazaraviciute and 
Chaturvedi, 2017):  
• Halsted’s Radical Mastectomy: A radical (Halsted) mastectomy is a type 
of mastectomy in which all axillary tissue, breast tissue, and Pectoralis 
major and minor muscles are removed. 
• Patey’s Mastectomy: A modified radical (Patey) mastectomy is a type of 
mastectomy in which breast tissue and the axillary nodes, are removed. 
•  Total or Simple Mastectomy: A total or simple mastectomy is a type of 
mastectomy that involves the removal of breast tissue and the involved skin 
with or without axillary surgery. The pectoralis fascia is usually preserved, 
but the axillary tail is removed. 

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• Skin Sparing Mastectomy ±Nipple Sparing Mastectomy: It is a type of 
mastectomy in which the breast tissue is removed but the skin envelope is 
left intact. 
1.3. Mastectomy complications:  
1.3.a Post mastectomy pain syndrome (PMPS): 
The PMPS is a neuropathic pain condition that occurs in and around the surgical 
site and lasts for more than three months after the procedure (Basilio et al., 2014). 
1.3.b Lymphoedema: 
Lymphoedema occurs due to accumulation of protein-rich fluid in the 
extracellular spaces. It occurs because of the physical trauma caused by 
radiotherapy and surgery, which hinder the lymphatic system and cause chronic 
or recurrent swelling of the affected side. the most common region is the arm, but 
chest and upper back are also often involved. Women state symptoms like pain, 
stiffness, heaviness, loss of sensation, movement restrictions and weakness of the 
upper limb (Celenay et al., 2020). 
1.3.c Axillary Web Syndrome: 
Axillary web syndrome (AWS), also known as cording, usually appears 
during the 1st: 5th weeks post breast cancer surgery. During shoulder flexion or 
abduction, a palpable, clearly visible, painful stretched band is seen beneath the 
skin. The cords are always seen in the axilla and may cross the antecubital fossa 
and extend down into the medial ipsilateral arm, into the forearm, and 
occasionally to the radial aspect of the wrist and into the base of the thumb (Da 
Luz et al., 2017). 
1.3.d Musculoskeletal complications: 
The musculoskeletal complications involve reduced shoulder flexion, 
abduction ROM to 90°, and external rotation to 40° and Postural alterations, 
especially in vertebral column and scapular area. These alterations involve 

9 
 
elevated and abducted scapula and increased thoracic kyphosis and cervical 
lordosis. Forward head and slight trunk rotation, and structural scoliosis may also 
occur (Basilio et al., 2014).  
After breast cancer treatment, the shoulder range of motion (ROM) is 
restricted in 1.5%-50% of women and the pain is present in 12 % -51% (with up 
to one third experiencing some pain after 5 years) and the quality of life (QOL) 
is also compromised (Ibrahim et al., 2018). 
1.4 Radiotherapy complications (de França et al., 2015): 
• Breast and axillary fibrosis. 
• Glenohumeral Joint limitation. 
• Neuropathy, chronic pain in the breast area.  
• The scar adherence.  
1.5 Chemotherapy complications (de França et al., 2015):  
• Fatigue. 
•  Ataxia. 
•  Neurotoxicity. 
2. Shoulder complex: 
2.1. Anatomy: 
The shoulder complex is composed of 4 small joints, primarily the 
glenohumeral (GH) joint, the acromioclavicular (AC), sternoclavicular (SC), and 
scapulothoracic (ST) joints. the glenohumeral (GH) joint is thought to be the most 
mobile joint and primarily depends on muscle control and mid-range stability 
(Bakhsh and Nicandri, 2018). 
As shown in figure (1), A complex network of muscular anatomy provides 
multiple functions of the shoulder. Rotator cuff muscles constitute of the 
supraspinatus, infraspinatus, teres minor, and subscapularis. These muscles allow 

10 
 
synergistic co-contraction to guide movement and anchor the scapula (Bakhsh 
and Nicandri, 2018). Fig. (1) 
 
Fig. (1): Muscles and Fascia of the Shoulder (Adopted from Lam and Bordoni, 2021). 
There are numerous muscles attached to the scapula. The trapezius, the 
levator scapulae, the rhomboids, the serratus anterior, the pectoralis minor and 
the subclavius muscles achieve significant contribution to scapulothoracic 
motion. The serratus anterior supports the medial angle against the chest wall, 
and the trapezius rotates and elevates the scapula in synchronization with 
glenohumeral movement (Ribeiro et al., 2016). 
2.2. Biomechanics: 
Glenohumeral joint stability is impacted by the musculature functioning 
far from the shoulder itself. Large torques can be generated about the shoulder 
joint by the action of latissimus dorsi, serratus anterior, pectoralis major, and 
deltoid due to their cross-sectional anatomy and distance from the joint centre of 
rotation (Levine and Rigby, 2018).  
The scapulothoracic articulation consists of a space between the posterior 
surface of the thoracic rib cage and the anterior surface of the scapula. The 
movement of the scapula on thorax is smooth due to the neurovascular, muscular, 
and bursal structures (Ribeiro et al., 2016).  

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Arm raising depends on coordination between glenohumeral and 
scapulothoracic motions, which ensures that functional tasks can be performed 
without the humerus' head striking the coracoacromial arch and putting the soft 
tissue structures surrounding the shoulder joint at risk of impingement. Shoulder 
muscles, which are functionally classified as stabilizers and prime movers, make 
up the dynamic structures. Timed interaction between these two groups of 
muscles is essential to achieve a smooth and physiologic scapulohumeral rhythm 
(Neto et al., 2018). 
Scapulohumeral rhythm refers to the relationship between the 
glenohumeral and scapular components with a ratio of 2:1, respectively. The first 
30–60° of arm elevation occur at the glenohumeral joint, during which the scapula 
remains fixed or moves side to side on the chest wall (setting phase). During full 
shoulder elevation from 0° to 180°, glenohumeral movement is 120° and scapular 
motion is 60° (Rizzi et al., 2016).  
2.3. Shoulder dysfunction post mastectomy: 
The mechanics of the shoulder joint can be impacted by fibrosis following 
radiotherapy and surgical scars due to anchoring of soft tissue or pain-inhibited 
mobility. Females who received postsurgical radiotherapy experienced 
considerably higher shoulder morbidity (17%) compared to a group who didn’t 
receive radiotherapy (2%) (De Groef et al., 2015). 
  Additionally, patients who undergo mastectomy are nearly six times 
more likely to have shoulder limitations than patients who undergo breast-
conserving surgery and despite advances in surgical techniques and postoperative 
care, pain and functional limitation continue to pose problems (De Groef et al., 
2015). 

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Decreased scapular upward rotation, reduced posterior tilting, and 
excessive scapular internal rotation have been identified as altered scapular 
positioning patterns in patients with shoulder disorders (Struyf et al., 2011). 
 It was reported that after mastectomy there is increased scapular internal 
rotation in the involved shoulder which decreases the width of the subacromial 
space, so it increases the risk of rotator cuff compression and tendinopathy and 
disrupt the shoulder motion (Borstad and Szucs, 2012). 
3.motor control retraining exercises: 
3.1. definition: 
Motor control is defined as the ability of the nervous system to control 
posture and movement for a given motor task and encompasses all the motor, 
sensory and integrative processes associated with the planning and execution of 
the task (van Dieën et al., 2018). 
3.2. components: 
The motor control retraining package was targeted at correcting movement 
impairments of the scapula by re-educating muscle recruitment. There were two 
components to the package (Worsley et al., 2013): 
1. Motor control exercises to correct alignment and coordination, which 
involve a) learning optimal scapular orientation at rest and then controlling 
optimal orientation during active arm movements; b) muscle specific 
exercises for trapezius and serratus anterior 
2. Manual therapy techniques commonly used in clinical practice to manage 
symptoms, e.g. used to lengthen tight muscles or reduce active trigger point 
pain presentations. 
 
 

13 
 
3.3. physiological effect: 
 Improper control is characterized by changes in muscle activation levels. 
More specifically, lower activity of the serratus anterior, higher activity of the 
upper and lower trapezius, and lack of coordination between the different parts 
of the trapezius have been observed. This inadequate muscle control is believed 
to contribute to a reduction of amplitude in posterior tilting and lateral rotation of 
the scapula during arm elevation. Lower activity of the infraspinatus and 
subscapularis as well as inadequate coactivation of the scapulohumeral muscles 
have also been reported. This abnormal muscle control is most likely associated 
with a reduction of the subacromial space leading to impingement (Hawkes et 
al., 2019). 
Motor control include production of reflexive, automatic, adaptive and 
voluntary movements and the performance of efficient, coordinated, goal-
directed movement patterns which involves multiple body systems (input, output, 
and central processing). Evidence suggests exercise program mainly focusing on 
motor control principle for the scapulothoracic joint has been a promising 
treatment option for shoulder impingement (Hara, 2020). 
 
 
 
 
 
 
 
 
 

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CHAPTER III 
     SUBJECTS, MATERIALS AND METHODS 
In this part of the study, the materials and methods will be presented under the 
following headings: subjects, equipment, procedures of the study and the statistical 
procedures.   
1-Subjects:  
1.1. Sample size: 
       Sample size calculation was done using, shoulder function as reported in 
(Mohite and Kanase, 2014), with 90% power at α = 0.05 level, number of 
measurements 2, for 2 groups and effect size = 0.45 using F-test MANOVA 
repeated measures within and between interaction. The minimum proper sample 
size is 54 subjects, adding 6 (11%) subjects as drop out, so total sample size is 60 
subjects 30 in each group. The sample size was calculated using the G*Power 
software (version 3.0.10) (figure 2).  
 
Figure (2): sample size calculation 
 

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       sixty patients suffering from post-mastectomy shoulder dysfunction will 
participate in this study. Their ages will range from 40 to 55 years. The 
participants will be selected from Cairo university hospitals. 
1.2. Design of the study:  
In this randomised controlled trial study (RCT), the patients will be randomly 
assigned into two equal groups (30 patients for each group): 
1.2.a. Group A (study group): 
This group will include 30 patients with post mastectomy shoulder 
dysfunction who will receive motor control retraining exercises in addition to 
their conventional physical therapy program, three sessions per week for 8 weeks, 
for 45:60 minutes according to patient’s ability (Bae et al.,2011). 
 1.2.b. Group B (control group): 
This group will include 30 patients with post mastectomy shoulder 
dysfunction who will receive conventional physical therapy program in the form 
of shoulder joint mobilization, posterior capsule stretching and shoulder range of 
motion exercise (ROM) (Codman’s pendulum exercises) for 30 minutes 
according to patient’s ability, three sessions per week for 8 weeks (Duzgun et al., 
2019; Yiasemides et al., 2011). 
1.3. Criteria for the patient selection:   
1.3.a -Inclusion Criteria:  
The subject selection will be according to the following criteria:  
• Female patients with age range between 40-55 years. 
• All patients have shoulder dysfunction. 
• Patients were 2 months to 4 months post modified radical mastectomy or 
axillary lymph node dissection. 
• Patients received their radiotherapy or chemotherapy or both. 
 
 

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1.3.b- Exclusion Criteria:  
The potential participants will be excluded if they meet one of the 
following criteria: 
• Rheumatoid arthritis. 
• History of trauma or accidental injuries. 
• Neurological involvement (stroke, Parkinsonism). 
• History of surgery on involved shoulder. 
• Diabetic patient. 
• Moderate and severe lymphoedema. 
2-Tools and equipment:  
2.1. Measurement tools and equipment:  
All Measurements will be taken before the treatment (pre-treatment) and after 8 
weeks (post-treatment).  
2.1.a- Shoulder Pain and Disability Index (SPADI): 
The SPADI is a self-administered questionnaire that contains thirteen items which 
assess two domains (pain and disability) (Shamley et al., 2012).  It has an 8-item 
subscale to evaluate disability and a 5-item subscale to measure pain. Each 
subscale is summed and transformed to a score out of 100. A mean is taken of the 
two subscales to give a total score out of 100, higher score indicating greater 
impairment or disability (Breckenridge and McAuley, 2011). The Arabic 
version of SPADI has excellent validity and reliability (Alsanawi et al., 2015) 
2.1.b- Instrumented digital hand-held dynamometer: 
          Hand-held dynamometry (Lafayette manual muscle tester) will be used to 
measure isometric strength of shoulder flexion and abduction. It is an ergonomic 
hand-held device for objectively providing reliable, accurate readings that 
conform to most manual muscle testing protocols. It has good to excellent validity 
and reliability for most measures of isometric muscle strength particularly for 

17 
 
proximal muscle groups. It has a large, easy-to-read LCD screen that displays 
results in both pounds and kilograms. It also has a weight capacity of up to 300 
lbs. (mentiplay et al., 2015). Fig. (3). 
                       
 
                         Fig. (3) Lafayette hand-held dynamometer      
2.1.c- Digital inclinometer: 
A digital inclinometer is used to measure shoulder flexion, abduction and upward 
rotation of scapula. It has digital screen that display the angle at which the 
inclinometer is situated allowing direct joint angle measurements (An et al., 
2021). 
2.2. Therapeutic Equipment and Tools: 
Motor control retraining exercises for scapular muscles. 
3-Procedures of the study: 
3.1. Measurement procedures: 
3.1.a. The Shoulder Pain and Disability Index (SPADI):  
To answer the questions, the patient is instructed to place a mark on the 100mm 
straight line, this line represents a continuum between "no pain" (zero) and "the 
worst pain that the patient could feel" (ten) for pain dimension and "no difficulty" 
(zero) and "so difficult it requires help" (ten) for the disability dimension, 
respectively. To calculate a final percentage score for assessing shoulder 

18 
 
dysfunction, a mean is taken of the two subscales to give a total score out of 100, 
higher score indicating greater impairment or disability (Brindisino et al., 2021). 
The Arabic version of SPADI has excellent validity and reliability (Alsanawi et 
al., 2015) 
3.1.b- Instrumented digital hand-held dynamometer: 
A handheld dynamometer will be used to assess maximal strength pre-treatment 
and post treatment. Maximal strength tests for shoulder flexion and abduction 
will be measured. When applying the manual resistance for each test the handheld 
dynamometer is used to obtain force measures. Two trials were performed for 
each shoulder motion (Scibek and Carcia, 2012). 
Each test consisted of the subject maximally contracting against the external force 
until this external force, applied by the tester, caused a “break” in the test position 
of the subject. The force required to break the test position was then recorded as 
the relative strength of the specific muscle (Scibek and Carcia, 2012). Fig. (5) 
                                     
 
Fig. (5) 
3.1.c- Digital inclinometer: 
Digital inclinometer provides a real-time digital reading of angles with respect to 
either a horizontal or vertical reference (An et al., 2021). 
Scapular upward rotation will be measured with subjects in the resting position 
and then with the shoulder elevated to 60 and 120 in the scapular plane. The angle 

19 
 
between the scapular spine root and posterolateral acromion will be measured in 
the resting position and with the shoulder joint elevated 60 and 120 Scapular 
upward rotation will be measured similarly (An et al., 2021). Fig. (6) 
                                          
 
fig. (6) 
 
Shoulder flexion ROM will be measured with the patient elevating the arm as high 
as possible in the sagittal plane without any extension of the spine (Clausen et 
al., 2017). Fig. (7a) 
Shoulder Abduction ROM will be measured with the patient elevating the arm as 
high as possible in the frontal plane without lateral flexion of the spine (Clausen 
et al., 2017). Fig. (7b) 
      
 
Fig. (7) 

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3.2. Therapeutic procedures: 
3.2.a- Motor control retraining exercises: 
The motor control retraining package was targeted at correcting movement 
impairments of the scapula by re-educating muscle recruitment. There were two 
components to the package: (Worsley et al., 2013). 
1. Motor control exercises to correct alignment and coordination, which 
involve a) learning optimal scapular orientation at rest and then controlling 
optimal orientation during active arm movements; b) muscle specific 
exercises for trapezius and serratus anterior 
2. Manual therapy techniques commonly used in clinical practice to manage 
symptoms, as trigger point therapy and pectoralis minor supine manual 
stretch will be performed as necessary. 
          During the motor control exercises, scapular position is optimised in 
relation to the thorax, initially by being altered manually by the therapist on a 
subject specific basis. This involved the therapist using observation and palpation 
to alter orientation/alignment of the scapula and clavicle using the following 
guidelines (Worsley et al., 2013). 
• Acromion should be higher than the superior medial border of scapula.  
• the spine of the scapula should be 15-25° rotated in the coronal plane, 
medial border and inferior angle of scapula should be tight against the rib 
cage and the clavicle should have a slight posterior rotation in the frontal 
plane.  
• The participant is then taught to actively reproduce this orientation using 
visual (in a mirror), auditory (from therapist) and kinaesthetic cues such as 
palpation. 

21 
 
           Once the scapula is placed into an optimal position, the participant is asked 
to control the orientation of the scapula whilst lifting their arm to 90° humeral 
elevation in the frontal, sagittal, and scapular planes (Worsley et al., 2013). 
• Movements is performed at a slow, controlled pace and repeated for 2 
minutes (i.e. 10 times).  
• Once the participant regains sufficient control of scapular orientation 
during arm movements, muscle specific motor control exercises will be 
introduced.  
• These exercises require the participant to initiate and maintain the optimal 
scapular orientation whilst muscle specific recruitment of serratus anterior 
and lower trapezius (Worsley et al., 2013). 
3.2.b- Conventional physical therapy program for both groups:  
• Joint mobilization exercises: 
Distraction of the glenohumeral joint, posterior glide and caudal glide is 
applied to the patients in a supine lying position at a frequency of two to three 
oscillations/ second for one to two minutes. At the resting position rhythmic 
oscillations grade I and II were applied. Resting position is position in which the 
joint capsule and ligaments are most relaxed and with the maximum play (Joshi 
et al., 2020). 
• Posterior capsule stretching: 
          The patient is lying on her side. With the arm in a 90° flexion, the scapula 
is fixed at the lateral side. Stretching is performed at the elbow with a downward 
force. each stretch is repeated ten times for 20 seconds, between each stretching 
A 30-second break was given (Duzgun et al., 2019). 
• Codman/ pendulum exercise: 
          These are self-mobilization techniques that use the effects of gravity to 
distract the humerus from the glenoid fossa. They help relieve pain through gentle 

22 
 
traction and oscillating movements and provide early motion of joint structures 
and synovial fluid. No weight will be used initially. When the patient will tolerate 
stretching, a weight will be added to the hand or as wrist cuffs to cause further 
distraction force. To direct the stretch force to glenohumeral joint, stabilize the 
scapula against the thorax manually or with a belt (Patel, 2022). 
4.Statistical procedures: 
The collected data will be statistically analysed using: 
• Descriptive statistics (mean and standard deviations). 
• Inferential statistics: unpaired t-test will be used to compare subjects’ 
characteristics of the two groups.  
• Repeated measures MANOVA will be used to compare all dependent variables 
within and between groups. 
• Statistical analysis will be conducted using SPSS for Windows, version 20 
(SPSS, Inc., Chicago, IL). Statistical significance will be set at the (p< 0.05). 
 
 
 
 
 
 
 
 
 
 
 

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