The Effect of Mobilization With Movement in Individuals With Shoulder Impingement Syndrome
Condition: Shoulder Impingement Syndrome; Subacromial Impingement; Subacromial Impingement Syndrome; Subacromial Pain Syndrome; Impingement Syndrome, Shoulder
MeSH terms: Shoulder Impingement Syndrome; Syndrome; Rotator Cuff Injuries
Study type: Interventional

Summary: 
      This study conducted to see the effect of adding mobilization with movement to conventional
      physical therapy to the subject with shoulder impingement syndrome. The shoulder impingement
      syndrome is often described as anterior lateral shoulder pain that provoked during shoulder
      elevation. The pain occurs during shoulder elevation and causes limited range of motion.
      Moreover, the patients with shoulder impingement syndrome commonly had a forward head posture
      and slouching shoulder. There is a theory that illustrates the mechanical factors lead to the
      injury of the bursa or rotator cuff tendons below the subacromial space which is highly
      related to the posture and scapular movement.

      Various treatments for shoulder impingement syndrome including medical treatments such as
      anti-inflammatory drugs, subacromial decompression, and acromion resection surgery.
      Conventional physical therapy treatments for shoulder impingement syndrome included
      modalities, exercises and manual therapy. Exercise has been showed to give a significant
      effect to decrease the pain intensity, increasing the range of motion and shoulder function.
      There is evidence that supports the use of manual therapy on shoulder impingement, the recent
      technique introduced by Brian Mulligan is mobilization with movement. Mobilization with
      movement is a manual therapy technique that uses the active movement while the physical
      therapist applies an accessory force to align the positional fault of the joint. A previous
      study investigated the effect of mobilization with movement that uses the mobilization with
      movement in shoulder impingement syndrome showed different outcomes in the measurement of
      pain intensity and shoulder range of motion. As the posture may be related to shoulder
      impingement syndrome, this research will measure the cervical posture, shoulder posture, and
      muscle strength.

      Therefore, the purposes of this study will be to compare the effects of conventional physical
      therapy treatments and the conventional therapy treatments plus the mobilization with
      movement on pain intensity, shoulder range of motion, cervical and shoulder posture, shoulder
      muscle strength and shoulder function. The study hypothesis was that mobilization with
      movement is more effective in improving the investigated outcomes in individuals with
      shoulder impingement syndrome than the conventional physical therapy.
    

Detailed description: 
      Shoulder impingement syndrome causes positional fault of the subacromial and soft tissues
      below the subacromial space. This condition leads to the wrong biomechanics of precise ball
      and socket kinematics creating maximum concavity compression for shoulder stability. This
      wrong biomechanics is resulting in the injury of tissue below the subacromial space, such as
      rotator cuff tendinitis, tears of rotator cuff tendons, and subacromial bursitis. The space
      between the acromion and humeral was small varying between nine to 14 mm. However, the
      subacromial space will be decreased during the arm elevation or in the abduction and external
      rotation position. Some of the researchers defined the shoulder impingement syndrome as the
      mechanical entrapment of the rotator cuff or the subacromial bursa in the subacromial space.
      The highest compression of the structures below the subacromial space occurs when people
      elevate the arm, especially during the shoulder flexion, abduction, and rotation.

      The etiology of shoulder impingement syndrome is multifactorial, although a few common causes
      of the shoulder impingement syndrome were narrowing of the subacromial space and enlargement
      of the subacromial bursa or rotator cuff tendons. The mechanical factor is believed as the
      main cause of shoulder impingement syndrome. The postural misalignment and the movement
      control that makes the improper muscle activation and cause false movement times between
      acromion and glenoid were shown to associated with the etiology of shoulder impingement
      syndrome. Individu with the protracted shoulder is frequently associated with the anteriorly
      tilted and internally rotated of the scapula. The protracted shoulder or forward displacement
      of the acromion can be measured by the shoulder angle to the seventh cervical spinous
      process.

      The humeral head position depends on the soft tissues surrounding the subacromial region.
      During arm elevation, the humeral head position should be at the center and adjust anterior
      translation along with the acromion movement to anterior and lateral. When the humeral head
      position is faulty or not in the center, because of the anterior inferior glenohumeral
      ligament cannot restrain the abnormal humeral head translation. This condition leads to
      decreased subacromial space and irritation to the soft tissue below the acromion which causes
      the impingement syndrome.

      Study protocol 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 a clear explanation of the purposes, procedures,
      advantages, and possible risks 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 the movement group. The participant will be asked to rate
      their pain intensity using the visual analog 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 handheld 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 sports physical therapy from the Australian Physiotherapy Association and has had 5 years
      of 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. Therapeutic exercise has a wide variety of types and
      modes of exercise. 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 the correct posture to change the participant's
      behavior.

      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 mobilization with movement. Then the outcome measures will be reassessed thereafter.
      The directions of mobilization with movement are a 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 the 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 the 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.

      Sample size calculation will be performed using the formula for the test of the difference
      between 2 independent means.

      According to the G*power 3.1.9.2 program calculation, the total of this study equals 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). In this proposed study, the investigators need an equal number of participants per
      group; therefore, the drop out the calculation of 20% of 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).

      Statistical Analysis Data will be analyzed using SPSS version 23. The statistical
      significance level is set at a 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 tests if the data are not normally distributed.
    

Intervention name(s): Mobilization with movement; Conventional physical therapy
Intervention type(s): Other; Other
Intervention description(s): The physical therapist will adjust the active movement of the shoulder joint during the arm elevation or abduction and shoulder external rotation; The exercise is tailor-made and each participant will be performing some of the exercises based on the list that physical therapist prescription
Other intervention name(s): Mulligan techniques; Postural correction exercise
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: All of the eligible participants will be divided into two groups; conventional physical therapy and conventional physical therapy plus mobilization with movement
Masking: Triple (Participant, Care Provider, Outcomes Assessor)
Primary purpose: Treatment
Keywords: Shoulder impingement syndrome; Mobilization with movement; Conventional physical therapy; Pain intensity; Visual analogue scale; Range of motion; Inclinometer; Shoulder pain and disability index; Postural assessment software; Craniovertebral angle; Sagittal shoulder posture; Hand held dynamometer