1. Case Report The effectiveness of manipulations to the thoracic spine on functional outcomes in a patient with shoulder pain: A Case Study Presented By: Jill Robison, SPT UTMB 3rd Year DPT Student

2. Objectives Introduction and purpose of the study Search Strategies/Evidence Formulation of PICO question Annotated Bibliography Analysis of the evidence Case Report Results Discussion References

3. Introduction Shoulder conditions are one of the most commonly presenting musculoskeletal impairments seen by the medical community. In recent years, increased focus on manual and manipulative therapy techniques has been observed in the physical therapy profession. Regional interdependence, a recent term discussed by Wainner and colleagues (Strunce, 2009), suggests that interventions targeting adjacent joints may directly improve outcomes in the affected joint.

4. Introduction Recent research has been targeted towards the effects of manipulations to the cervico-thoracic junction on shoulder impairments. Predicted outcomes include: reductions in pain improved ROM increased functional status.

5. The Evidence PICO Question formation Search strategy Research findings/ Results Annotated Bibliography Analysis of evidence

6. PICO Question formation Observed the clinic’s patient population and common impairments seen by the practicing therapists Performed a literature review to highlight recent topics in orthopedic research

7. PICO Question formation Conferred with supervising clinical and instructor and other clinicians for direction and advice on topic choice Selected a patient presenting with the clinical findings needed to perform a case study

8. PICO P:In patients with rotator cuff pathology presenting with signs and symptoms of subacromial impingement… I: would the combination of exercise and manipulations to the thoracic spine and/or cervicothoracic junction… C: as compared to exercise alone… O: produce better outcomes as measured by the QuickDASH assessment scale?

9. Search Strategy Review of the evidence was performed through use of the University of Texas Medical Branch’s library website The search began using the PubMed (Medline) database with a topic of “thoracic manipulation,” which resulted in 879 results Then narrowed to include “thoracic manipulation and shoulder”, which produced 29 results

10. Additional sources (CINHAL, Cochrane Database) were examined using the same key words (MeSH terms “thorax” and “shoulder”) and produced minimal findings as compared to PubMed A publically created resource was also used, Physiopedia, and references cited through articles on this database were reviewed Search Strategy

11. Results Initial results were further narrowed, to 12 articles, that were then reviewed and considered for the annotated bibliography.

12. Results The final five articles were selected based on inclusion and exclusion factors They were then more thoroughly reviewed The annotated bibliography, outlining the article and focus of the research, was then created

13. Annotated Bibliography Boyles RE, Ritland BM, Miracle BM, Barclay DM, Faul MS, Moora JH, Koppenhaver SL, Wainner RS. The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Manual Therapy. 2009; 14: 375-380. Mintken PE, Cleland JA, Carpenter KJ, Bieniek ML, Keirns M, Whitman JM. Some factors predict successful short-term outcomes in individuals with shoulder pain receiving cervicothoracic manipulation: A single-arm trial. Physical Therapy. 2010; 90(1): 26-42. Strunce JB, Walker MJ, Boyles RE, Young BA. The immediate effects of thoracic spine and rib manipulation on subjects with primary complaints of shoulder pain. The Journal of Manual & Manipulative Therapy. 2009; 17(4): 230-236. Tate AR, McClure PW, Young IA, Salvatori R, Michener LA. Comprehensive impairment-based exercise and manual therapy intervention for patients with subacromial impingement syndrome: A case series. Journal of Orthopaedic & Sports Physical Therapy. 2010; 40(8): 474-493. Walser RF, Meserve BB, Boucher TR. The effectiveness of thoracic spine manipulation for the management of musculoskeletal conditions: A systematic review and meta-analysis of randomized control trials. The Journal of Manual & Manipulative Therapy. 2009; 17(4): 237-246.

15. Limitations in high-quality evidence on this topic

16. Novel area of research

17. Need more randomized, double-blind trials

20. Validity of the Evidence Lacking homogeneity All possible evidence was not considered Randomization was obtained in 50% of the articles Successful attempts by the authors to develop homogeneity without researcher effect Overall lack of evidence in this topic and need for higher level studies

21. Challenging the hierarchy Milanese S. The use of RCT’s in manual therapy-Are we trying to fit a round peg into a square hole? Manual Therapy. 2011; 1-3. Current highest level of evidence=RCT 3 features of RCT: control group, random allocation of subjects and the blinding of patients, therapists and outcomes. Main focus of evidence based medicine: “clinical decisions should be based on the best available scientific evidence (Koes and Hoving, 1998).”

22. Challenging the hierarchy Milanese S. The use of RCT’s in manual therapy-Are we trying to fit a round peg into a square hole? Manual Therapy. 2011; 1-3. Standardization of intervention in manual therapy is impossible due to clinical reasoning and complex interventions (cannot be determined prior to pt. assessment) Randomization may lead to poorer therapeutic effects and pre-disposing patient characteristics cannot be controlled

23. Challenging the hierarchy Milanese S. The use of RCT’s in manual therapy-Are we trying to fit a round peg into a square hole? Manual Therapy. 2011; 1-3. Therapist blinding is relatively impossible as manual therapy techniques are active interventions Author suggests that lower-level evidence, for example a case-control study, may be more appropriate for this area of research

24. Importance of the evidence ST effects of thoracic manipulation = highly supported by numerous articles LT effects= not supported by evidence Combination with exercise is highly emphasized Effective treatment tool

25. Application of the evidence Useful in patients presenting with s/sx of one or more of the following: decreased shoulder ROM pain with active shoulder movements positive Neer impingement test positive Hawkins-Kennedy test pain with resisted abduction, IR, or ER pain with resisted empty can test Boyles RE, Ritland BM, Miracle BM, Barclay DM, Faul MS, Moora JH, Koppenhaver SL, Wainner RS. The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Manual Therapy. 2009; 14: 375-380.

26. Case Presentation Date of initial evaluation: February 22, 2011 Date of prescription: February 14, 2011 Pt. initials: F.B. Duration of therapy: 9 visits, 5 weeks Initial Evaluation

27. Case Presentation F.B., a 58 year-old male, referred to physical therapy with a medical diagnosis of left Rotator Cuff syndrome. Two-month history of posterior shoulder pain that is limiting his functional and recreational activities. Retired individual who is currently building an outdoor shower at his condo in Galveston. Initial Evaluation

28. Case Presentation Co-morbidities: Type II Diabetes DASH (Disabilities of the Arm, Shoulder, and Hand) -- Initial Score: 29/11, 41% Initial pain levels: 0/10 current; 10/10 @ worst Pt goals: Return to exercise and ADL activities symptom free and without restrictions or limitations Initial Evaluation

29. Case Presentation Manual Muscle Testing ROM Objective Findings Initial Evaluation

30. Case Presentation Special Tests Aggravates symptoms: Hawkins-Kennedy Impingement Test Negative for reproduction of symptoms: Neer Impingement Test and Empty Can Test Objective Findings Palpation/Reflexes and Sensation Palpation to left posterior capsule produced moderate pain Sensation and Reflex testing intact and equal bilaterally Initial Evaluation

31. Case Presentation Prognosis:Good Expected length of episode:4-6 weeks Impairments Identified ADL function Muscle performance Motor function Pain Weakness Decreased ROM Skilled intervention needed to: Decrease pain Improve function Improve motor control Increase ROM Increase strength Initial Evaluation

32. Case Presentation Problems and Goals Current Functional Status: Modified Independent with recreational and exercise activities In 4 weeks, pt. will demonstrate improvements in overall ADL status to Pre-morbid status (Independent and without difficulty) DASH score: 41% b) In 4 weeks, pt. will report improvements on the Quick DASH measurement to 10% demonstrating improved function and abilities Initial Evaluation

33. Case Presentation Problems and Goals 3. Decreased Range of Motion In 4 weeks, pt. will improve overall left shoulder ROM to WNL (equal to or better than the Right shoulder) for improved performance in overhead activities. 4. Decreased Upper extremity muscle strength d) In 4 weeks, pt. will improve overall left shoulder MMT to > 5/5 demonstrating increased tolerance for lifting and exercise activities. Initial Evaluation

34. Case Presentation Plan: 2 visits/week for an expected duration of 6 weeks Therapeutic Contents to include: AROM activities HEP Neuromuscular Re-education Therapeutic Activities Therapeutic Exercises Manual Therapy Techniques Initial Evaluation

35. Case Presentation Interventions Periscapular strengthening General UE strengthening AAROM Modalities Open chain RTC strengthening Closed chain RTC strengthening PNF techniques Manual interventions (Manipulations to the CT junction)

36. Case Presentation Interventions Treatment Progression: Initial visits (1-3) included modalities, as needed, for pain control, AAROM techniques (rope and pulley and wand exercises), periscapular and general UE strengthening exercises Visit 4-inititated TB RTC strengthening, manipulation to the CT junction performed Visit 5- initiated CKC RTC and scapular strengthening (ball on wall circles)

37. Case Presentation Interventions Treatment Progression: Visit 5-7: continued to progress intensity of exercise and monitored tolerance of this progression Visit 7: Performed a second manipulation to the CT junction Visit 8-9: Initiated PNF manual techniques in supine targeting end-range activation of the IR and ER

38. Case PresentationResults Patient response to interventions: Initially pt. reported no change in symptoms Symptoms continued to present as posterior shoulder pain with end-range movements and intense OH activities At the 4th visit, F.B. presented with a new symptom of left forearm pain that was constant Screening of the neck and manipulation to the CT junction was performed (4th visit)

39. Case PresentationResults Patient response to interventions: 5th visit (follow-up after CT manipulation): patient reported short-term relief of forearm and posterior shoulder pain after manipulation 6th and 7th visit: patient reported no forearm pain and continued to report pain in posterior shoulder

40. Case PresentationResults 8th visit (follow-up from CT manipulation): patient reported decreased pain in posterior shoulder and was able to tolerate 1 hour of intense exercise at home 9th visit: patient reported no pain with any activities and was able to tolerate push-ups for the first time since injury

42. Case PresentationResults Re-evaluation was performed on 3/23/11 Patient reported overall improvement at re-evaluation (3/23): 60% Patient reports improved tolerance for ADL activities (recreational, self care and home management) to slight symptoms Patient reported current pain levels at 0/10 and 2/10 at worst; (Initial = 0/10 current and 10/10 @ worst)

43. Case PresentationResults Summary of Objective Findings at Re-Evaluation MMT All Shoulder MMT improved to >4+/5, excluding ER (4/5) Mild pain reproduced with resisted ER and Abduction ROM Both left AROM and PROM equal to the right (full and pain free) Palpation Moderate tenderness over posterior infraspinatus Special Tests Neer Impingement Test: Negative Hawkins-Kennedy Impingement Test: Negative; (Initial-Aggravated Symptoms)

44. Case PresentationResults Goals Pt. achieved one of four goals ROM equal to unaffected UE Pt. made excellent progress towards other 3 goals Overall ADL function to pre-morbid levels Quick DASH measurement to 10 MMT to 5/5

45. Application of Evidence to Case Study Physical Therapy “thought process” for choice of intervention (manipulation to CT junction): Hawkins-Kennedy Impingement Test aggravated symptoms Decreased left shoulder ROM into abduction, flexion and ER Pain with resisted abduction, ER, and IR Pain with active shoulder movement into horizontal adduction, abduction and end-range flexion Plateau of symptom reports

46. Application of Evidence to Case Study Patient demonstrated ST improvements, in reports of symptoms, after CT manipulations No change in Quick DASH score after first trial of manipulation Advanced and initiated new exercises in conjunction to manipulation Cannot determine cause and effect of improvements

47. Discussion Evidence is lacking to support intervention Higher level studies needed to truly determine cause and effect Positive outcomes were seen in patient case, although final measure of Quick DASH was unattainable

48. Need to consider other variables to success Initiation of PNF techniques Increased RTC strength from exercise activities Natural healing time Activity modification by patient Patient education of the healing and rehabilitation process Discussion

49. Would be beneficial to have a second case study for comparison No manipulations to the CT junction All other treatment variables kept identical Although this would be higher quality of evidence, still cannot determine true cause and effect relationship Discussion

50. Conclusion F.B. had successful outcomes from manipulations to the cervicothoracic junction Useful as an adjunct treatment tool Future research attempting to determine cause and effect is warranted It is argued that lower levels of evidence may be more appropriate when determining the effectiveness of a manual therapy technique (Milanese, 2011)

51. Conclusion Patients presenting with shoulder impingement syndrome may benefit from interventions targeting adjacent joints (regional interdependence) Therapists need to consider all areas and treatment techniques in order to provide the highest quality of care possible

52. References Boyles RE, Ritland BM, Miracle BM, Barclay DM, Faul MS, Moora JH, Koppenhaver SL, Wainner RS. The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Manual Therapy. 2009; 14: 375-380. Koes BW, Hoving JL. The valueof the randomised clinical trial in the field of physiotherapy. Manual Therapy. 1998; 3(4): 179-186. Milanese S. The use of RCT’s in manual therapy-Are we trying to fit a round peg into a square hole? Manual Therapy. 2011; 1-3. Mintken PE, Cleland JA, Carpenter KJ, Bieniek ML, Keirns M, Whitman JM. Some factors predict successful short-term outcomes in individuals with shoulder pain receiving cervicothoracic manipulation: A single-arm trial. Physical Therapy. 2010; 90(1): 26-42.

53. References Strunce JB, Walker MJ, Boyles RE, Young BA. The immediate effects of thoracic spine and rib manipulation on subjects with primary complaints of shoulder pain. The Journal of Manual & Manipulative Therapy. 2009; 17(4): 230-236. Tate AR, McClure PW, Young IA, Salvatori R, Michener LA. Comprehensive impairment-based exercise and manual therapy intervention for patients with subacromial impingement syndrome: A case series. Journal of Orthopaedic & Sports Physical Therapy. 2010; 40(8): 474-493. Walser RF, Meserve BB, Boucher TR. The effectiveness of thoracic spine manipulation for the management of musculoskeletal conditions: A systematic review and meta- analysis of randomized control trials. The Journal of Manual & Manipulative Therapy. 2009; 17(4): 237-246.