Effect of Scapula-focused Treatment With Additional Motor Control Exercises on Pain and Disability in Patients With Subacromial Pain Syndrome: A Randomized Controlled Trial
Phase: NA
Conditions: Shoulder Impingement Syndrome
Sponsor: University of Sao Paulo

1 
 
 
Title: Effect of scapula-focused treatment with additional motor control exercises on pain 
and disability in patients with subacromial pain syndrome: A Randomized Controlled Trial 
 
Trial registration number. ClinicalTrials.gov (NCT02695524) 
 
Date: 15/08/2019 
 
 

2 
 
BACKGROUND 
Subacromial pain syndrome (SPS) is a shoulder pain condition in which individuals 
report pain or discomfort associated with excessive overhead movements.1,2 It corresponds 
to 44%-65% of all shoulder pain complaints2,3 resulting in increased disability and reduced 
quality of life.4 Factors associated with SPS include: disorders of scapula and clavicle 
kinematics,5 glenohumeral stiffness and instability,6 muscle weakness or disorders in motor 
control.7  
The scapula plays an important role in absorption and energy transfer to maximize 
levels of upper limb freedom.8  Periscapular muscles act synergistically to allow 
scapulohumeral coupled movements. In the last decade scapula assessment and treatment 
focused on “motor control exercises” has become ubiquitous for the rehabilitation process 
of painful shoulder. The latest systematic review with meta-analysis on the on the efficacy 
of exercises demonstrated that interventions focused on the scapula should be considered 
in treating SPS, provide benefits with short-term results for shoulder pain, function9 and 
abduction ROM.9,10  
The studies included in the meta-analysis that observed the additional effects of 
motor control exercises or scapula stabilization present important methodological limitations 
such as the absence of concealed allocation, blind subjects, blind assessor and absence of 
intention-to-treat analysis11,12 that contribute to the low quality of evidence.Therefore, there 
is a need for further research through high-quality RCT that adequately assess the effects 
of scapula motor control exercises on clinical outcomes. 
 
 
 

3 
 
OBJECTIVE 
Determine the effect of adding scapular motor control exercises to a scapula-focused 
program on disability, pain, muscle strength, and ROM in patients with Subacromial Pain 
Syndrome. 
DESIGN OVERVIEW 
Controlled, randomized, superiority clinical trial, prospectively registered, two-arms, 
parallel, blind assessor, blind patient, and allocation concealment. All methodological steps 
were described by Consolidated Stands of Reporting Trials (CONSORT). 
 
METHODS 
 
Setting and Participants 
Individuals with SPS were recruited from March 2016 to June 2017 by the local health 
system. The trial was conducted in an outpatient physical treatment service provided by the 
local health system. This study was approved by the University Research Ethics Committee 
(CAAE:52563216.0.0000.5414). All participants were informed about the procedures and 
signed the consent form.   
 
Inclusion Criteria: participants with a history of shoulder pain for more than one week, 
located in the shoulder anterior-proximal region, with positive results for 3 out of 5 SPS tests: 
1) Neer; 2) Hawkins-Kennedy; 3) painful arc; 4) pain or weakness resistant to external 
rotation, and 5) Jobe.13  
 
Exclusion criteria: history of shoulder trauma or surgery; total rotator cuff or biceps brachii 
tendon rupture (imaging exam or self-report); practitioners of sports activities involving the 

4 
 
upper limbs; individuals with neurological disorders and alterations in cognitive function (e.g. 
stroke, epilepsy, multiple sclerosis, Parkinson's disease and peripheral neuropathy); 
shoulder pain for of primary involvement in the cervical or thoracic region; systemic disease 
involving the joints (e.g. rheumatoid arthritis); carpal tunnel syndrome; and those who 
underwent physiotherapeutic treatment of the shoulder in the last six months. 
 
Randomization and Intervention 
Simple randomization was carried out using a computer-generated schedule in 
Microsoft Excel (Microsoft Corporation, Redmond, Washington). Allocations were sealed, 
sequentially numbered envelopes, prepared by an individual not involved in the recruiting, 
assessment or treatment of the patients, and kept in a central locked location. 
The envelopes were opened on the first day of the treatment, and the participants 
were randomly allocated into two treatment groups: the scapula-focused group (SFG) and 
the scapula motor control group (MCG). The subjects were treated individually and blinded 
regarding treatment allocation. Due to the nature of the interventions, it was not possible to 
blind the physical therapists that conducted the interventions. 
The exercises for each group were based in a previously proposed protocol14. The 
patients assigned to the SFG performed 6 exercises with a focus on the periscapular 
muscles: 1) side lying external rotation with abduction at 0°15,16; 2) prone horizontal 
abduction with external rotation from 90º to 135º17,18; 3) Scapular punch19; 4) Knee Push20; 
5) Full Can17,20; 6) Diagonal D117. The exercise load was 60% of the one-repetition maximum 
(1-RM) during the first week because it was their first exposure to the exercises.21 The 
weekly load progression averaged about 2.5% increase/wk up to -80% of 1-RM, according 
to the strength of each participant21. The exercises were performed in 3 series of 10 
repetitions, with a 1-minute interval between repetitions during the first and fourth week. 

5 
 
From the fourth week on, the exercises were increased to 12 repetitions, and from the fifth 
to eighth week, to 15 repetitions.21 The Push up plus17,22 exercise with the feet flat on the 
floor was considered the progression exercise of the knee push.20 The load progression for 
the push-up plus exercise takes place by lifting the feet on supports and could reach a height 
of 47.5 cm23. 
The patients allocated to the MCG performed the scapula-focused exercises with the 
same progression, and six motor control exercises were added to this group. For this study, 
Motor control exercises were defined as retraction and depression movements of the 
scapula without external load (e.g., dumbbells and an elastic band) and associated with 
visual, verbal and kinestetic feedback in maintaining the posture.  The six motor control 
exercises were always performed at the beginning of each session: A) Towel Slide24; B) 
Scapular Clock24; C) PNF Scapular24; D) Modified Inferior Glide25,26; E) Scapular Orientation 
Exercise (SOE)27,28; F) Protraction and retraction in front of a mirror. From the first to the 
third week, three series of 10 movements were performed for each exercise with verbal, 
visual, and kinesthetic feedback. On the fourth week, the exercises were increased to 12 
movements, and visual feedback was removed. From the fifth to the eighth week, the 
exercises progressed to 15 repetitions, while verbal feedback was carried out only by the 
therapist. In both groups, the series of exercises were randomized into blocks at the 
beginning of each week. 
 
Outcomes measures and Follow-up 
Shoulder function was considered the primary outcome; pain, treatment effect 
perception, satisfaction, kinesiophobia, strength, ROM, and scapula position were all 
considered the secondary outcomes. 

6 
 
Function and pain: The Brazilian version of Shoulder Pain and Disability Index 
(SPADI-Br) is valid and reliable for assessment of individuals with shoulder disorders29 The 
Minimally Important Difference (MID)  considered for the questionnaire was 10 points.30 
Higher scores indicated the worse condition. 
A verbal, numerical pain rating scale was applied to measure the intensity of the pain. 
The values range from zero to ten and must be answered based on the pain intensity at the 
time of the test.31,32  
Treatment effect perception, satisfaction, and kinesiophobia: The global 
perceived effect scale assessed patient perceptions of the effect of the treatment. For the 
assessment of patient satisfaction, The MedRisk34 questionnaire was used. For assessment 
of the kinesiophobia level, the Tampa Scale of Kinesiophobia was applied.  
Strength, ROM, and scapula position: Isometric strength assessment was carried 
out using a hand-held dynamometer (Lafayette®, Lafayette Instrument Company, Ind., USA). 
Muscle strength measurements were performed in abduction, adduction, internal and 
external arm rotation36 and for specific muscles, of the serratus anterior, upper, middle and 
lower trapezius37. 
For the ROM assessment, a digital inclinometer (Lafayette®, Lafayette Instrument 
Company, Ind., USA) was used during flexion, abduction and internal and external rotation 
active movements38. Upward rotation and scapula anterior/posterior tilt movements were 
also evaluated37,39,40 . 
 
 
STATISTICAL ANALYSES: 
Sample size calculation:  Was performed with G*Power 3.1 for Windows (Universität Kiel, 
Germany) based on the primary study outcome assessed by SPADI-Br questionnaire. The 

7 
 
sample was calculated based on the questionnaire’s capacity to detect a 10-point difference 
in the global outcome score (SD=11.7), considering the clinically relevant difference, alpha 
0.05, power 80% and considering a 20% sample loss. 
Statistical analysis: Statistical analysis followed the intention-to-treat concept41,42 using the 
Statistical Package for the Social Sciences Software (SPSS). The linear mixed-effect model 
was applied for the primary and secondary variables. In the model, “Time” and “group” were 
considered fixed effects, whereas the participants were considered the random effect. The 
time by group interaction was included in the analysis to assess the difference effect 
between the groups at each follow-up, and the dependent variable baseline value was 
included as a covariate for the correction of possible differences. The significance level was 
0.05 for all analyses. The calculations of the effect size (ES) and Minimal Important 
Difference was carried out according to Armijo-Olivo et al43. The ES is calculated by dividing 
the difference between group mean scores by the pooled standard deviation of the 2 groups.  
𝐸𝑆−
𝑋𝐺1-𝑋𝐺2
𝑆pooled   and Spooled −
√𝑆12(𝑛1−1)+ 𝑆22 (𝑛2−1)
𝑛1+𝑛2−2
 
The effect size values were considered small (up to 0.2), moderate (0.5), and large (equal 
or above 0.8)44. Statistical analysis followed the intention-to-treat concept and was carried 
out by a researcher not involved in the evaluation and treatment protocols. The strength 
measures were examined with normalization to body weight (strength in kilograms/ kilogram 
of body weight X 100). 
 
 

8 
 
References:  
1  
Camargo PR, Haik MN, Ludewig PM, et al. Effects of strengthening and stretching exercises 
applied during working hours on pain and physical impairment in workers with subacromial 
impingement 
syndrome. 
Physiother 
Theory 
Pract 
2009;25:463–75. 
doi:10.3109/09593980802662145 
2  
Michener LA, McClure PW, Karduna AR. Anatomical and biomechanical mechanisms of 
subacromial impingement syndrome. Clin Biomech 2003;18:369–79. doi:10.1016/S0268-
0033(03)00047-0 
3  
Van Der Windt DAWM, Koes BW, Boeke AJP, et al. Shoulder disorders in general practice: 
Prognostic indicators of outcome. Br J Gen Pract 1996;46:519–23. 
4  
Chipchase LS, O’Connor DA, Costi JJ, et al. Shoulder impingement syndrome : Preoperative 
health status. J Shoulder Elb Surg 2000;9:12–5. 
5  
Lawrence RL, Braman JP, Staker JL, et al. Comparison of 3-Dimensional Shoulder Complex 
Kinematics in Individuals With and Without Shoulder Pain, Part 2: Glenohumeral Joint. J 
Orthop Sport Phys Ther 2014;44:646-B3. doi:10.2519/jospt.2014.5556 
6  
Ludewig PM, Reynolds JF. The Association of Scapular Kinematics and Glenohumeral Joint 
Pathologies. J Orthop Sport Phys Ther 2009;39:90–104. doi:10.2519/jospt.2009.2808 
7  
Phadke V, Camargo P, Ludewig P. Scapular and rotator cuff muscle activity during arm 
elevation: A review of normal function and alterations with shoulder impingement. Rev Bras 
Fisioter 2009;27:320–31. doi:10.1002/nbm.3066.Non-invasive 
8  
McQuade KJ, Borstad J, de Oliveira AS. Critical and Theoretical Perspective on Scapular 
Stabilization: What Does It Really Mean, and Are We on the Right Track? Phys Ther 
2016;96:1162–9. doi:10.2522/ptj.20140230 
9  
Saito H, Harrold ME, Cavalheri V, et al. Scapular focused interventions to improve shoulder 
pain and function in adults with subacromial pain: A systematic review and meta-analysis. 
Physiother Theory Pract 2018;3985:1–18. doi:10.1080/09593985.2018.1423656 
10  
Bury J, West M, Chamorro-Moriana G, et al. Effectiveness of scapula-focused approaches in 
patients with rotator cuff related shoulder pain: A systematic review and meta-analysis. Man 
Ther 2016;25:35–42. doi:10.1016/j.math.2016.05.337 
11  
Başkurt Z, Başkurt F, Gelecek N, et al. The effectiveness of scapular stabilization exercise in 
the patients with subacromial impingement syndrome. J Back Musculoskelet Rehabil 
2011;24:173–9. doi:10.3233/BMR-2011-0291 
12  
Shah M, Sutaria J, Khant A. Effectiveness of Scapular Stability Exercises in the Patient With 
the Shoulder Impingement Syndrome. Indian J Phys Ther 2014;2(1)79-84 2014;2:79–84. 
13  
Michener LA, Walsworth MK, Doukas WC, et al. Reliability and diagnostic accuracy of 5 
physical examination tests and combination of tests for subacromial impingement. Arch Phys 

9 
 
Med Rehabil 2009;90:1898–903. doi:10.1016/j.apmr.2009.05.015 
14  
Hotta GH, Santos AL, McQuade KJ, et al. Scapular-focused exercise treatment protocol for 
shoulder impingement symptoms: Three-dimensional scapular kinematics analysis. Clin 
Biomech Published Online First: 2017. doi:10.1016/j.clinbiomech.2017.12.005 
15  
De Mey K, Danneels L, Cagnie B, et al. Conscious Correction of Scapular Orientation in 
Overhead Athletes Performing Selected Shoulder Rehabilitation Exercises: The Effect on 
Trapezius Muscle Activation Measured by Surface Electromyography. J Orthop Sport Phys 
Ther 2013;43:3–10. doi:10.2519/jospt.2013.4283 
16  
Hess SA, Richardson C, Darnell R, et al. Timing of Rotator Cuff Activation During Shoulder 
External Rotation in Throwers With and Without Symptoms of Pain. J Orthop Sport Phys Ther 
2005;35:812–20. doi:10.2519/jospt.2005.35.12.812 
17  
Escamilla RF, Yamashiro K, Paulos L, et al. Shoulder muscle activity and function in common 
shoulder rehabilitation exercises. Sports Med 2009;39:663–85. doi:10.2165/00007256-
200939080-00004 
18  
De Mey K, Cagnie B, Van De Velde A, et al. Trapezius Muscle Timing During Selected 
Shoulder Rehabilitation Exercises. J Orthop Sport Phys Ther 2009;39:743–52. 
doi:10.2519/jospt.2009.3089 
19  
Reinold MM, Escamilla R, Wilk KE. Current Concepts in the Scientific and Clinical Rationale 
Behind Exercises for Glenohumeral and Scapulothoracic Musculature. J Orthop Sport Phys 
Ther 2009;39:105–17. doi:10.2519/jospt.2009.2835 
20  
Maenhout A, Van Praet K, Pizzi L, et al. Electromyographic analysis of knee push up plus 
variations: what is the influence of the kinetic chain on scapular muscle activity? Br J Sports 
Med 2010;44:1010–5. doi:10.1136/bjsm.2009.062810 
21  
American College of Sports Medicine position stand. Progression models in resistance 
training 
for 
healthy 
adults. 
Med 
Sci 
Sports 
Exerc 
2009;41:687–708. 
doi:10.1249/MSS.0b013e3181915670 
22  
Weiser WM, Lee TQ, McMaster WC, et al. Effects of simulated scapular protraction on anterior 
glenohumeral stability. Am J Sports Med 1999;27:801–5. 
23  
Lear LJ, Gross MT. An electromyographical analysis of the scapular stabilizing synergists 
during 
a 
push-up 
progression. 
J 
Orthop 
Sports 
Phys 
Ther 
1998;28:146–57. 
doi:10.2519/jospt.1998.28.3.146 
24  
Voight ML, Thomson BC. The Role of the Scapula in the Rehabilitation of Shoulder Injuries. 
J Athl Train 2000;35:364–72. doi:10.1016/B978-044306701-3.50053-0 
25  
Ben Kibler W, Sciascia AD, Uhl TL, et al. Electromyographic analysis of specific exercises for 
scapular control in early phases of shoulder rehabilitation. Am J Sports Med 2008;36:1789–
98. doi:10.1177/0363546508316281 
26  
Ekstrom RA, Donatelli RA, Soderberg GL. Surface Electromyographic Analysis of Exercises 

10 
 
for the Trapezius and Serratus Anterior Muscles. J Orthop Sport Phys Ther 2003;33:247–58. 
doi:10.2519/jospt.2003.33.5.247 
27  
Mottram SL, Woledge RC, Morrissey D. Motion analysis study of a scapular orientation 
exercise and subjects’ ability to learn the exercise. Man Ther 2009;14:13–8. 
doi:10.1016/j.math.2007.07.008 
28  
Mottram 
S. 
Dynamic 
stability 
of 
the 
scapula. 
Man 
Ther 
1997;2:123–31. 
doi:https://doi.org/10.1054/math.1997.0292 
29  
Martins J, Napoles B V., Hoffman CB, et al. The Brazilian version of Shoulder Pain and 
Disability Index: translation, cultural adaptation and reliability. Brazilian J Phys Ther 
2010;14:527–36. doi:10.1590/S1413-35552010000600012 
30  
Roy JS, Macdermid JC, Woodhouse LJ. Measuring shoulder function: A systematic review of 
four questionnaires. Arthritis Care Res 2009;61:623–32. doi:10.1002/art.24396 
31  
Farrar JT, Young JP, LaMoreaux L, et al. Clinical importance of changes in chronic pain 
intensity measured on an 11-point numerical pain rating scale. Pain 2001;94:149–58. 
32  
Turk DC, Dworkin RH, Allen RR, et al. Core outcome domains for chronic pain clinical trials: 
IMMPACT recommendations. 2003;:337–345. doi:doi:10.1016/j.pain.2003.08.001 
33  
Costa LOP, Maher CG, Latimer J, et al. Clinimetric testing of three self-report outcome 
measures for low back pain patients in Brazil: which one is the best? Spine (Phila Pa 1976) 
2008;33:2459–63. doi:10.1097/BRS.0b013e3181849dbe 
34  
de Fátima Costa Oliveira N, Oliveira Pena Costa L, Nelson R, et al. Measurement properties 
of the Brazilian Portuguese version of the MedRisk instrument for measuring patient 
satisfaction with physical therapy care. J Orthop Sports Phys Ther 2014;44:879–89. 
doi:10.2519/jospt.2014.5150 
35  
de Souza FS, Marinho C da S, Siqueira FB, et al. Psychometric testing confirms that the 
Brazilian-Portuguese adaptations, the original versions of the Fear-Avoidance Beliefs 
Questionnaire, and the Tampa Scale of Kinesiophobia have similar measurement properties. 
Spine (Phila Pa 1976) 2008;33:1028–33. doi:10.1097/BRS.0b013e31816c8329 
36  
Beshay N, Lam PH, Murrell GAC. Assessing the reliability of shoulder strength measurement: 
hand-held versus fixed dynamometry. Shoulder Elb 2011;3:244–51. doi:10.1111/j.1758-
5740.2011.00137.x 
37  
Cools AM, Johansson FR, Cambier DC, et al. Descriptive profile of scapulothoracic position, 
strength and flexibility variables in adolescent elite tennis players. Br J Sports Med 
2010;44:678–84. doi:10.1136/bjsm.2009.070128 
38  
Mullaney MJ, McHugh MP, Johnson CP, et al. Reliability of shoulder range of motion 
comparing a goniometer to a digital level. Physiother Theory Pract 2010;26:327–33. 
doi:10.3109/09593980903094230 
39  
Watson L, Balster SM, Finch C, et al. Measurement of scapula upward rotation: a reliable 

11 
 
clinical procedure. Br J Sports Med 2005;39:599–603. doi:10.1136/bjsm.2004.013243 
40  
Scibek JS, Carcia CR. VALIDATION OF A NEW METHOD FOR ASSESSING SCAPULAR 
ANTERIOR-POSTERIOR TILT. Int J Sports Phys Ther 2014;9:644–56. 
41  
Morden JP, Lambert PC, Latimer N, et al. Assessing methods for dealing with treatment 
switching in randomised controlled trials: A simulation study. BMC Med Res Methodol 
2011;11:4. doi:10.1186/1471-2288-11-4 
42  
Elkins MR, Moseley AM. Intention-to-treat analysis. J Physiother 2015;61:165–7. 
doi:10.1016/j.jphys.2015.05.013 
43  
Armijo-Olivo S, Warren S, Fuentes J, et al. Clinical relevance vs. statistical significance: Using 
neck outcomes in patients with temporomandibular disorders as an example. Man Ther 
2011;16:563–72. doi:10.1016/j.math.2011.05.006 
44  
Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd ed. New York: : 
Lawrence Erlbaum Associates 1988.