Research Review By Dr. Shawn Thistle©

Date Posted:

October 2009

Review Title:

Thoracic/Cervical Spine Mobilization/Manipulation for Shoulder Conditions

Studies Reviewed:

  1. McClatchie L et al. Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults. Manual Therapy 2009; 14: 369-374.
  2. Boyles RE et al. The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Manual Therapy 2009; 14: 375-380.

Background Information:

Readers should be familiar with shoulder impingement syndrome (SIS), a generic term for a common ailment involving painful impingement of the rotator cuff beneath the acromion. This condition (of variable origin) is responsible for a large percentage of shoulder complaints. All-cause shoulder pain (including SIS) is prevalent, affecting up to 35% of the adult population. It can be recurrent, and is often disabling. Numerous potential pain generators exist in this region, but unfortunately an exact diagnosis is often illusive as many common orthopedic tests are of limited value.

A relationship between cervical and thoracic spine joint dysfunction and shoulder pain has long been suggested, and makes sense based on the segmental innervation of shoulder structures as well as functional anatomy of the region. Anecdotally, manual therapists have reported reduction of shoulder symptoms after treatment aimed at the cervical and/or thoracic spine regions, despite a lack of published literature to support this approach.

Although the two studies discussed here are small and must be considered preliminary, taken together they provide some evidence that manipulation or mobilization may represent a viable treatment option (or at least an adjunct treatment) for shoulder complaints. Larger studies that address the inherent limitations of these designs are needed to further this area of knowledge, but the potential benefit of these treatment strategies has certainly been established and we should be aware of this literature.

Study Methods & Pertinent Results:

Study #1: McClatchie et al.:
This randomized, blinded, placebo-controlled cross-over trial assessed the immediate effects of C5-7 lateral glide mobilizations on shoulder pain intensity and abduction painful arc in 21 subjects with shoulder pain (average age ~49) who were asymptomatic in the cervical spine. Both male and female subjects were included who had insidious onset shoulder pain (with a painful abduction arc) of at least 6 weeks duration that was unresponsive to standard physiotherapy including “traditional” movement, strengthening, and/or electrotherapeutic modalities. Excluded were those with neurological deficits, neck pain in the previous year, or a history of injection therapy or shoulder surgery.

All patients attended two study sessions (one mobilization and one placebo, four days apart). Lateral glide mobilizations (Grade IV+, 2 minutes at each level from C5-C7) were performed at one session with the patient seated. Placebo treatment involved the examiner simply resting their hands on the subject’s neck without the application of force. The order of the sessions was determined via coin toss.

Outcome measures included a 10cm visual analogue scale (VAS), cervical and glenohumeral ROM, and electrodynamometer measurement of shoulder abduction strength at 90°. Pertinent results follow:
  • after the cervical mobilization treatment, shoulder painful abduction arc (12.5° ± 15.6°, p = 0.002) and shoulder pain intensity (1.3cm ± 1.1cm, p < 0.001) both decreased significantly
  • 18/21 subjects (86%) showed an average VAS decrease of 1.5cm
  • following the placebo treatment there was only a 0.2cm average VAS reduction (not statistically significant), and shoulder painful arc was reduced by only 8.8°±12.7°
  • mobilization and placebo were significantly different (p = 0.0002), with mobilization demonstrating a treatment effect of -1.038
  • cervical ROM was not significantly different after mobilization or placebo treatments
Study #2: Boyles et al.:
This study, featuring a larger, younger study group (n=56, average age 32), was an exploratory, one group pre-test/post-test study investigating the short-term effects of thoracic thrust manipulation on shoulder impingement subjects. All participants underwent a standard physical examination followed by one treatment session involving thrust manipulation directed at the thoracic spine.

Before and 48 hours post-treatment, subjects completed two questionnaires: the Numeric Pain Rating Scale (NPRS) and a Shoulder Pain and Disability Index (SPADI). Pertinent results follow:
  • Overall the results were promising: 48 hour post-treatment reductions in NPRS scores for the Neer impingement sign, Hawkins-Kennedy test, resisted empty-can, resisted external and internal rotation, and active abduction were all statistically significant (p < 0.01), as was the SPADI score (p < 0.01)
  • After closer evaluation of the numbers – the individual responses to thoracic SMT were varied suggesting that subgroups of patients may exist – this is a topic for future studies

Clinical Application & Conclusions:

Despite their limitations and small size, the two studies summarized above paint a promising picture for the role of manipulation/mobilization in the management of shoulder conditions. Improvements were noted in pain levels, range of motion, and orthopedic test pain levels. Stay tuned for further research on this topic.