Research Review By Dr. Rob Rodine©

Date Posted:

January 2010

Study Title:

The immediate effects of thoracic spine and rib manipulation on subjects with primary complaints of shoulder pain


Strunce JB, Walker MJ, Boyles RE & Young BA

Author's Affiliations:

Rehabilitation Department, Northern Navajo Medical Center

Publication Information:

The Journal of Manual & Manipulative Therapy 2009; 17(4): 230-236.

Background Information:

Previous reviews have addressed the impact of spinal manipulation for complaints in nearby, but seemingly unrelated areas. To illustrate, McClatchie et al. looked at cervical manipulation for shoulder complaints, Boyles et al. investigated thoracic manipulation for shoulder complaints, and Cleland et al. investigated the use of thoracic manipulation for neck pain (please re-read Related Reviews below).

These studies demonstrated that regional manipulation showed a positive effect on the nearby area of complaint. Of particular relevance, Boyles et al. demonstrated improvement in pain levels, range of motion and response to orthopaedic tests in the shoulder 48 hours following thoracic manipulation in patients with shoulder impingement.

Given the prevalence of shoulder complaints, and particularly ‘shoulder impingement syndrome,’ it is important to offer patients management options that address all facets of their complaint (no pun intended). This includes addressing the functional deficits of the primary area and associated soft tissue restrictions while also addressing regional areas that may contribute to the symptomatology. However, the responsible clinician must have more than personal confidence that such treatment approaches will benefit the patient. This is where research should and can guide our management strategies.

In this study, Strunce et al. evaluated the effect of one session of thoracic manipulation, pragmatically applied, to the signs and symptoms of shoulder impingement syndrome.

Pertinent Results:

The study included 22 consecutive subjects who presented with shoulder pain and met the inclusion criteria. One subject was excluded following evidence of a rotator cuff tear, leaving 21 (10 male, 11 female). Their mean age was 47 (range 21-62, SD12.6) and the symptom duration was 4.2 months (1-18, SD 4.89).

One or more thoracic and/or upper rib segmental restrictions (identified within this paper as ’impairments’) were found in every subject. Cervico-thoracic restrictions were found in 70% of subjects, upper thoracic flexion restrictions in 100%, thoracic extension restrictions in 7% and unilateral rib restrictions in 79%.

Outcome measures of pain levels (100 mm VAS) and range of motion were taken at baseline and immediately post-treatment.

Pertinent Results Include:
  • All outcome measures showed statistically significant improvement when compared to baseline measurements (p<0.01).
  • Pre-treatment VAS scores were 63.1 (SD 2.8) and 31.2 (SD 4.4) post-treatment.
  • Pre-treatment flexion ROM was 106.8° (SD 30.0) which improved to 145.2° (SD 26.4) post-treatment.
  • Pre-treatment abduction ROM was 98° (SD 32.1) which improved to 135.7° (SD 32.5) post-treatment.
  • Pre-treatment rotation ROM was 128.3° degrees (SD 32.1) and 157.8° (SD 22.7) post-treatment.
  • A 15 point global rating of change score (GRC) showed a mean of 4.2, indicating moderate improvement.
  • No adverse events were reported during this study.

Clinical Application & Conclusions:

As more and more professions continue to investigate the use of spinal manipulation for musculoskeletal pain, new insights are gained within the technical, philosophical and scientific aspects of this unique skill-set. This is certainly apparent in the current trend of research surrounding spinal manipulation for shoulder complaints.

Previous reviews have looked at the use of manipulation in the cervical and thoracic spine for shoulder complaints. An additional set of reviews has looked at thoracic spine manipulation for the treatment of neck pain (see Cleland et al. reviews linked below). Both of these reviews, while limited, address a regional impact of spinal manipulation. Meaning, improving the function (and motion) of a seemingly asymptomatic area with the aim of decreasing pain and improving function in a nearby area of complaint through improved global mechanics and the possibility of a central effect on pain.

While limited this study helps generate new questions and will guide future related research. While the chiropractic profession has followed similar principles in its approach to ‘dysfunction,’ our scientific community would be wise to explore these theories with applicable and appropriate research designs so results can be integrated by all manual medicine practitioners.

Study Methods:

Consecutive patients referred for physical therapy for a primary complaint of shoulder pain were invited to participate, though a timeline for this open invitation was not offered. Subjects were required to be between the ages of 18 and 65 years, have a primary complain of shoulder pain, demonstrating a decreased range of gleno-humeral motion and positive Hawkins-Kennedy and Neer impingement tests. Subjects were excluded if they demonstrated signs of a rotator-cuff tear via special imaging, showed clinical signs of adhesive capsulitis or demonstrated a cervical origin of pain.

Historical intake and clinical examination was performed by the primary author, a board-certified orthopaedic manual physical therapist, who also performed all treatments. Manipulation was targeted towards joints that demonstrated segmental dysfunction. This was determined through assessment during active range of motion testing using Maitland’s palpatory technique labeled central/unilateral posterior-anterior passive accessory intervertebral motions.

The same techniques are utilized to assess segmental rib motion at the rib angles and costovertebral joints. Despite symptom response being listed within the physical examination methods, the authors did not identify if the dysfunctional segments were identified with or without pain upon palpation.

Each patient received a different type and number of manipulations, dependent upon their individual presentation, making this a pragmatic treatment design. Manipulation performed to the cervicothoracic region was performed in a seated position with an element of distraction. Thoracic manipulation was performed in a supine position, with anterior-posterior directed forces and an element of flexion. Rib manipulations were performed in either a supine position, with an anterior-posterior directed force and an element of flexion, or in a prone position, with posterior-anterior directed forces along the angles of the ribs.

Clinical outcome measures consisted of shoulder range of motion, a 100mm Visual Analogue Scale for pain levels and a 15 point global rating of change scale. Outcomes were measured following physical examination and again immediately following treatment.

Study Strengths / Weaknesses:

The study’s pragmatic nature adds strength to its results as it more accurately emulates how practitioners assess and treat on an individual basis, rather than becoming fixed into highly controlled intervention rules. This increases the external validity of the study, making it more applicable to the field practitioner. However, removing precise control over the intervention weakens internal validity, making the results somewhat harder to interpret and transfer with other research.

Also, this study evaluated subjects followed for one intervention session only. Given the positive results the study offers, it would be interesting to see the subjects followed over the course of a more complete treatment plan.

The authors of this study must be commended. They have done an excellent job or communicating their methods and concepts of manipulation without creating scientific ‘pot-holes’ in their manuscript. Their description of regional interdependence provides an excellent theory of how treating a nearby region will have a mechanical effect on the area of complaint.

Meanwhile, the authors clearly state that no cause-and-effect relationship can be stated based on this study and that regional interdependence offers no scientific mechanism of support, being merely a theory.