Can subacromial pain be efficiently treated with thoracic manipulation? 
According to jeremy lewis theory, the acromion may not impinge tissues as previously thought, making surgery for subacromial pain unnecessary. He also suggests physical therapy and exercise as equally effective treatments for shoulder pain. Although manual therapy might only have a short-term impact and offer no change in functional outcome metrics, he makes the intriguing suggestion that adding it “could increase patient-perceived success at 4 weeks and 6 months, and acceptance of symptoms at 4 weeks.” (1) According to Dr. Lewis, manual therapy and even surgery itself could constitute placebo effects, but they are still perfectly appropriate components of a treatment strategy. Upper thoracic spinal manipulations may be a helpful, rather than ineffective, (2) component in the treatment of shoulder discomfort, according to research done in Connecticut. 60 leisurely active individuals (18–65) with shoulder pain were enrolled in the study, and they were then randomly assigned to one of three groups:
- Thoracic spine thrust manipulation (TSTM) in the supine position.
- . Seated thoracic spine thrust manipulation
- Sham manipulation
At least three indicators of subacromial discomfort were detected in all individuals as positive:
1. Anterior shoulder discomfort
2. + Neer or the test of Hawkins-Kennedy
3. traumatic arc
4. Shoulder flexion > 90 degrees AROM
5. + Pain with isometric resisted external rotation or abduction
All participants received the following baseline assessments from the researchers:
- Shoulder Score for Penn
- When the shoulder is in AROM or PROM, the scapula rotates upward and tilts posteriorly. Length of the pectoralis minor muscle
- Peak isometric force of the anterior serratus and middle and lower trapezius
When administering the baseline test, the examiner was blinded to the subject’s assignment, but not when administering the identical tests after the intervention. Following the baseline evaluation, the individuals had one of the three therapy interventions twice during a single treatment session to the spine between the levels of C7 and T4. With the exception of the Penn Shoulder Score, which was delivered 48 hours after the intervention, the same baseline assessments were administered right away after the therapy.
Results
The researchers compared all three therapies and reported the difference in test scores from baseline to post-intervention for each. The findings revealed no discernible difference in the three therapies’ effects on score change. Additionally, the researchers do not note a substantial change in score within a treatment strategy. Although they provide a number of arguments against their hypothesis—that the TSTM would have a favourable impact on one of the measured outcomes—they don’t really seem to support it. For instance, they claim that just 20% of the participants were eager to get help for shoulder pain. This suggests that the subjects may not have had sufficient discomfort or dysfunction. They nevertheless had to each test positive for three diagnostic criteria. Indeed, despite Dr. Lewis’ wistful suggestion, even the sham test failed to result in “patient (1) perceived success.” This well-conducted study appears to suggest that TSTM has no effect on scapular movement, position, or subacromial discomfort, which is unsatisfactory to the researchers. Consequently, it is not appropriate for the evidence-based management of this condition.
Reference
Lewis J. The End of an Era? J Orthop Sports Phys Ther. 2018 Mar;48(3):127-129. doi: 10.2519/jospt.2018.0102. PMID: 29490599.
Grimes JK, Puentedura EJ, Cheng MS, Seitz AL. The Comparative Effects of Upper Thoracic Spine Thrust Manipulation Techniques in Individuals With Subacromial Pain Syndrome: A Randomized Clinical Trial. J Orthop Sports Phys Ther. 2019 Oct;49(10):716-724. doi: 10.2519/jospt.2019.8484. Epub 2019 Mar 12. PMID: 30862274.
