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Effects of stretching and strengthening exercises with and without manual therapy on scapular kinematics, function, and pain in individuals with shoulder impingement: a randomized controlled trial [with consumer summary]
Camargo PR, Alburquerque-Sendin F, Avila MA, Haik MN, Vieira A, Salvini TF
The Journal of Orthopaedic and Sports Physical Therapy 2015 Dec;45(12):984-997
clinical trial
8/10 [Eligibility criteria: No; Random allocation: Yes; Concealed allocation: Yes; Baseline comparability: Yes; Blind subjects: No; Blind therapists: No; Blind assessors: Yes; Adequate follow-up: Yes; Intention-to-treat analysis: Yes; Between-group comparisons: Yes; Point estimates and variability: Yes. Note: Eligibility criteria item does not contribute to total score] *This score has been confirmed*

STUDY DESIGN: Randomized controlled trial. OBJECTIVE: To evaluate the effects of an exercise protocol, with and without manual therapy (MT), on scapular kinematics, function, pain, and mechanical sensitivity in individuals with shoulder impingement syndrome (SIS). BACKGROUND: Stretching and strengthening exercises effectively decrease pain and disability in individuals with SIS. There is still conflicting evidence regarding the efficacy of adding MT to an exercise therapy regimen. METHODS: Forty-six patients were assigned to 1 of 2 groups, both groups receiving a 4-week intervention. The intervention for one group consisted of stretching and strengthening exercises. The other group received the same intervention supplemented by MT targeting the shoulder and cervical spine. All outcomes were measured pre- and post-intervention at 4 weeks. Outcome measures consisted of: scapular kinematics in the scapular and sagittal planes during arm elevation, pain assessed with a visual analogue scale, mechanical sensitivity assessed with pressure pain threshold, and function as determined through the DASH questionnaire. The study is registered at www.ClinicalTrials.gov (NCT02035618). RESULTS:Independent of the intervention group, small, clinically irrelevant changes in scapular kinematics were observed post-intervention. A significant group x time interaction effect (p = 0.001) was found for scapular anterior tilt during elevation in the sagittal plane, with the exercises plus manual therapy group increasing 3.0 degrees (95%CI -1.5 to 7.5) relative to baseline compared to a decrease of 0.3 degrees (95%CI -4.2 to 4.8) in the exercise only group. Pain, mechanical sensitivity, and the DASH score improved similarly for both groups by the end of the intervention period. CONCLUSION: Adding MT to an exercise protocol did not enhance improvements in scapular kinematics, function, and pain in individuals with SIS. The noted improvements in pain and function are not likely explained by changes in scapular kinematics. LEVEL OF EVIDENCE: Therapy, level 1B.

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