|Year : 2014 | Volume
| Issue : 2 | Page : 92-99
Effect of thoracic and rib manipulation on pain and restricted shoulder mobility in subjects with frozen shoulder: A randomised clinical trial
Jyotsna V Chitroda, Anand Heggannavar
Department of Orthopedic Manual Therapy (OMT), KLE University, Institute of Physiotherapy, Belgaum, Karnataka, India
|Date of Web Publication||7-Jan-2015|
Dr. Jyotsna V Chitroda
KLEU Institute of Physiotherapy, JNMC Campus, Nehrunagar, Belgaum - 590 010, Karnataka
Source of Support: None, Conflict of Interest: None
Purpose: The purpose of this study was to determine the effects of thoracic and rib manipulation on pain and restricted shoulder mobility in subjects with frozen shoulder.
Relevance: The term frozen shoulder was first introduced by Codman in 1934 and described as "a painful condition of insidious onset that was associated with stiffness and difficulty in sleeping on the affected side." The main physical therapy program consists of thermotherapy, shoulder exercise, mobilization techniques, Codman's exercise, and capsular stretches. Recent discussion in the physical therapy community has been targeted toward addressing the thoracic spine for treating the patients with shoulder impairments.
Participants: A total of 30 subjects (mean age of 55.70 ± 9.49 years) with the diagnosis of frozen shoulder stage II and III were recruited from outpatient department of Physiotherapy of KLES Dr. Prabhakar Kore Hospital and MRC and KLES Ayurved Hospital and Research Centre, Shahpur, Belgaum.
Methods: The present randomized clinical trial was conducted on 30 subjects. They were randomly allocated into two groups. Group A (n = 15) receiving conventional therapy for 6 sessions a week for 2 weeks and Group B (n = 15) receiving thoracic and rib manipulation 3 sessions a week for 2 weeks in addition to conventional therapy. The outcome measures taken were visual analogue scale (VAS), shoulder range of motion (ROM) of flexion, abduction, internal rotation and external rotation and Disabilities of Arm Shoulder and Hand (DASH) score. The outcomes were assessed on day 1 pretreatment and day 14 posttreatment. Data was analyzed using SPSS software.
Results: The intra group mean difference in pre and postvalues for Group A were 4 ± 0.27 cm, 49.7° ±13.3°,49.3° ±13.38°, 21.4° ±7.33°, 23.9° ±7.51°, and 893.3° ±269.66° for VAS, shoulder ROM of flexion, abduction, internal rotation, external rotation and DASH scores respectively. While for Group B intra group mean differences in pre and postvalues were 5.7 ± 0.66 cm, 64.1° ±7.09°, 71.1° ±5.59°, 32.3° ±5.23°, 40.9° ±5.52°, 1073.3° ±229.42° for VAS, shoulder ROM of flexion, abduction, internal rotation, external rotation and DASH scores respectively . The intra group comparison showed statistical significance with P < 0.001.Whereas results of the between the group comparison showed that Group B showed better improvement than Group A that was statistically significant with P < 0.001.
Conclusion: Based on the results of the present study it can be concluded that thoracic and rib manipulation is effective in relieving pain, improving the shoulder range and reducing disability in patients with Frozen Shoulder.
Clinical Implication: Thoracic and rib Manipulation can be added in the treatment plan for frozen shoulder for better and speed recovery.
Keywords: Disabilities of Arm Shoulder and Hand, Frozen Shoulder, regional interdependence, rib, thoracic manipulation
|How to cite this article:|
Chitroda JV, Heggannavar A. Effect of thoracic and rib manipulation on pain and restricted shoulder mobility in subjects with frozen shoulder: A randomised clinical trial. Indian J Health Sci Biomed Res 2014;7:92-9
|How to cite this URL:|
Chitroda JV, Heggannavar A. Effect of thoracic and rib manipulation on pain and restricted shoulder mobility in subjects with frozen shoulder: A randomised clinical trial. Indian J Health Sci Biomed Res [serial online] 2014 [cited 2020 Jun 1];7:92-9. Available from: http://www.ijournalhs.org/text.asp?2014/7/2/92/148807
| Introduction|| |
Shoulder is a complex and highly mobile joint. Shoulder pain is one of the common diagnosis seen in a physiotherapy setting. Approximately, 16-20% of the population experiences shoulder pain, making it second most common musculoskeletal condition followed by low back pain. 
Frozen Shoulder syndrome (FSS) is a common condition presenting to a variety of health care practitioners including chiropractors, osteopaths, medical doctors, and physical therapists. It is characterized by dense adhesions, capsular thickening and capsular restrictions. 
Also referred to as adhesive capsulitis, FSS remains one of the most poorly understood shoulder conditions. 
The onset is insidious and usually occurs between the ages of 40 and 60 years, with a higher incidence in females. 
Reeves,  in a long-term study of the natural history of frozen shoulder, concluded that the disease is self-limiting, however, many patients suffer for more than 3 years with an average duration of 30.1 month. A disability of this duration can obviously place severe emotional and economic hardship on the affected individual. Clinical reports of the patients with adhesive capsulitis show considerable variability in methods of treatment; however, virtually all of them advocate some form of exercise to restore mobility.
The treatment options for frozen shoulder vary. It includes supervised rehabilitation, steroidal anti-inflammatory medications, oral corticosteroids, intra-articular injections, suprascapular blocks, distension arthrography, and closed manipulation, open surgical release, and arthroscopic capsular release.  Treatment by means of physiotherapy can consist of different broad range of interventions such as electrotherapy, exercises, and manual therapy approaches such as joint mobilization, soft tissue manipulation, neuromuscular therapies etc.  Relief of pain is achieved by means of massage, deep heat, ice, ultrasound therapy, Transcutaneous electrical nerve stimulation (TENS), Magneto therapy, or laser therapy, mobilization and home exercise program.  Recent discussion in the physical therapy community has been targeted towards addressing the thoracic spine for patients with shoulder impairments.
The thoracic posture and movement influences range of arm elevation. There exists a relationship between thoracic extension and range of bilateral arm elevation. Bilateral arm elevation induces an average of 15° of thoracic extension in the younger and the 13° of thoracic extension in older groups. This represents half of the available extension range in younger subjects, but nearly 70% of available range in older subjects. A large kyphosis is associated with reduced arm elevation. 
Some authors like Grubbs,  and Neviaser  have suggested the occurrence of the guarded shoulder movements in FS. At rest, the patients hold the affected arm in adduction and internal rotation. Shoulders are rounded, stooped, and arm elevation is affected in a protective manner. Thus, thoracic restrictions tend to develop.
Manipulation is defined in various ways by different authors. Maitland defines manipulation as a sudden movement or thrusts, of small amplitude, performed at a speed that renders the patient powerless to prevent it.  High velocity low amplitude (HVLA) thrust is a form of manipulation was thrust is applied with specific contact using a short lever in a spinal segment or extremity. 
Thoracic spine manipulation includes HVLA thrust techniques. These techniques consists of a high velocity but nonforceful movement of small amplitude, starting from the end position gained (i.e. after taking up the slack) and going in the direction in which the slack was taken up. Immediately afterwards we sense a considerable reduction in muscle tone and increased mobility.  Thoracic spine manipulation and its effects on the shoulder joint are explained by the concept of regional interdependence. Regional interdependence is described as a concept, 'that seemingly unrelated impairments in a remote anatomical region may contribute to, or be associated with, the patients primary complaint'. 
Bang and Deyle , reported improved outcomes in strength, function, and pain when manual physical therapy techniques for the shoulder, cervical spine, and thoracic spine were added to an exercise program for patients with shoulder impingement syndrome. These studies have seen the immediate effects, but the long term effects are not seen. These studies are done on conditions like rotator cuff tears and impingement syndrome. The Support for a chiropractic approach toward FSS is currently limited to a small pilot study  and a number of case reports. ,
Hence there is paucity of studies for use of thoracic manipulation in subjects with frozen shoulder Exploratory studies of this nature are needed and hence the present study intends to determine long term effects of the thoracic and rib manipulation on shoulder pain and ROM in subjects with frozen shoulder.
| Methods|| |
Design and subjects
The study was a Randomized Clinical Trial. The study sample included subjects with frozen shoulder. Nonprobability Convenience method was used and random allocation of subjects into two groups done by using the envelope method.
Subjects were recruited form physiotherapy OPD of KLES Dr. Prabhakar Kore Hospital and MRC, Belgaum. KLES Ayurved Hospital and Research Centre, Shahpur, Belgaum, and Urban Health Centre, Rukmininagar, Belgaum. The study period was 12 months.
Both male and female Subjects with the diagnosis of frozen shoulder were included if they met the following criteria:
- Age between 40 and 70 years
- Subjects adhesive capsulitis (Stage II and III)
- Bilateral or unilateral involvement
- Subjects with or without diabetes mellitus type II
- Those who are able to comprehend command and willing to participate in the study.
Subjects were excluded if they had (i) Any previous Surgery on the affected shoulder. (ii) Recent trauma to shoulder complex. (iii) Thoracic outlet syndrome. (iv) Cervical symptoms (tingling, numbness). (v) Rotator cuff tears of affected shoulder. (vi) Fractures involving shoulder complex. (vii) Osteoporosis of spine. (viii) Ankylosing spondilitis.
Ethical clearance was obtained from Ethical Committee, KLEU Institute of Physiotherapy before commencing the study. Informed consent was taken from the subjects.
The outcomes were assessed preintervention on day 1 and postassessment on day 14.
Visual analog scale (VAS) was used to measure pain. A scale of 10 cm was used to evaluate the intensity of pain. It is an 11 point scale where 0 represented no pain, and 10 represented unbearable pain. ,,
Range of motion (ROM) was measured using universal goniometer. Active ROM of shoulder flexion, abduction, internal rotation and external rotation were measured using standard techniques.
Disabilities of Arm Shoulder and Hand (DASH) questionnaire. DASH will be used to evaluate shoulder impairment and function. It includes symptoms (pain, weakness, stiffness, and tingling/numbness), Physical function (daily activities, house/yard chores, shopping, recreational activities, self-care, eating, dressing, eating, sexual activities, sleep and sports/performing art), social function (family care occupation, socializing with friends or family) and psychological function (self-image). ,
The procedure was explained to the subjects. Subjects diagnosed of frozen shoulder were screened for thoracic mobility and those with restricted mobility were included in the study.
Assessment of upper thoracic spine and ribs was conducted. Motion restrictions and symptom assessment were assessed during active ROM and overpressure testing for thoracic flexion, extension and bilateral rotation. Thoracic segmental mobility was assessed using central and unilateral postero-anterior passive accessory intervertebral motions (PAIVMs) applied to spinous and transverse processes. Segmental dysfunction of rib was assessed using postero-anterior PAIVMs of costovertebral joints and direct palpation of rib angles. ,
Group A was given conventional therapy for frozen shoulder that included HMP, exercises, TENS. While, Group B was given thoracic and rib manipulation in addition to conventional therapy.
Conventional therapy was given for 6 sessions in a week for 2 weeks. Hot Moist Pack (HMP) was given prior to the exercises for 15 min 1 session/day. Exercises included pendulum (Codman's) exercises with appropriate weights held in the hand in standing and the subject performing circular movements in all planes, Finger ladder exercises, self-applied multiple angle isometrics, wand exercise. Shoulder wheel exercise, Wall exercise, pulley exercise, self-stretching exercise.  Capsular stretches were given for anterior, posterior and inferior capsule.  TENS was given after the exercises for 15 min in burst mode. 
| Thoracic Manipulation and Rib Manipulations|| |
Depending upon the presence of specific thoracic and/or rib impairment the technique  was given. Manipulations were given 3 sessions in a week for 2 weeks. Subjects with thoracic flexion/opening restriction will be treated with supine technique for segmental thoracic flexion [Figure 1]. Subjects with unilateral rib dysfunction will be treated with supine unilateral rib manipulation for rib mobility [Figure 2]. Subjects with thoracic extension or closing restriction were treated with a prone extension manipulation for facilitating segmental thoracic extension [Figure 3].
The statistical analysis was done using SPSS software (IBM Corporation). Homogeneity of group was calculated using Student's t-test, Fisher Exact test and Chi square test. Inter group analysis was done by students unpaired t-test and intra group comparison was done using students paired t-test.
| Results|| |
A total of 34 subjects were screened. Four of them were excluded as they did not meet the inclusion criteria. Thirty subjects were then randomly allocated into two groups [Figure 4]. The demographics details of the subjects are given in [Table 1]. The groups were homogenous in terms of mean age, gender, affected shoulder, hand dominance, affection by diabetes.
The outcome measures at baseline were evaluated. There was no difference between the groups [Table 1].
[Table 2] For Group A pre and postintervention, within group analysis showed significant differences in outcome measures (P < 0.001). VAS score reduced from 7.3 ± 1.05 (day 1) to 3.3 ± 1.02 (day 14). ROM of flexion also improved significantly from 109.7 ± 18.4 (day 1) to 159.4 ± 7.24, (day 14). Abduction, increased from 103.7° ±19.05° (day 1) to 153° ±12.29°, (day 14).Internal Rotation increased from 34° ±11.03°(day 1) to 55.4° ±4.91° (day 14), Shoulder external rotation increased from 43.2° ±5.88° to 67.1° ±7.98° (day 14), DASH score reduced from 2048° ±302.73° (day 1) to 1155° ±191.84° (day 14).
|Table 2: Within and between group comparison of outcome measures in both the groups|
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For Group B, pre (day 1) and post (day 14) intervention there was a significant difference in outcome measures.(<0.001). VAS Score reduced from 7.6 ± 0.27 to 1.9 ± 0.69. ROM of flexion increased from 107.9° ±8.56° to 172° ±3.76°. Range of shoulder abduction increased from 98.5° ±6.43° to 169.6° ±3.79°. Range of Internal Rotation increased from 30.4° ±4.73° to 62.7° ±2.09°.
Range of motion of shoulder external rotation increased from 43° ±5.87° to 84.7° ±3.17°.
Disabilities of arm shoulder and hand score reduced from 2040° ±362.7° to 975° ±14.55°. ` Between groups analysis showed that improvement was better in Group B which was statistically significant for all the outcome measures.
The difference in VAS score postintervention between the groups was 1.4 which was statistically significant (P < 0.001).
| Discussion|| |
The present study was conducted to determine effects of thoracic and rib manipulation on pain and restricted shoulder mobility in subjects with frozen shoulder.
The result from statistical analysis of the present study showed thoracic and rib manipulation effective on pain and restricted shoulder mobility in subjects with frozen shoulder.
Both the groups showed significant reduction in VAS scores, but the manipulation group showed more reduction in pain. In the present study, both the groups were given hot moist pack which is used for superficial heating at the starting of the treatment. This reduction of pain can be due to the application of moist heat and this coincides with the study by Leclaire and Bourgouin. 
The manipulation group showed more reduction of pain. The hypoalgesic effect of manipulation may contribute to the reduction of shoulder pain and a resultant increase in shoulder motion in this study. Several authors have reported a hypoalgesic effect in distal extremities following bouts of spinal manipulative interventions. Vicenzino et al.  and Fernαndez-Carnero  et al. both demonstrated this rapid hypoalgesic effect following cervical manipulative therapy in patients with lateral epicondylalgia.
Iverson et al.  also demonstrated this effect following lumbar manipulation in patients with anterior knee pain. A recently proposed mechanism for this immediate hypoalgesia is an inhibition of C-fiber input as mediated by the local dorsal horn (George). 
Some authors like Grubbs,  and Neviaser  have suggested occurrence of the guarded shoulder movements in FS. At rest the patients holds the affected arm in adduction and internal rotation. Shoulders are rounded, stooped, and arm elevation is affected in protective manner. Thus thoracic restrictions tend to develop. Manipulating thoracic spine, can alter the biomechanical alignment of thoracic spine and thus improving range in thoracic and shoulder as well. In the present study we have included the subjects with thoracic restrictions. The assessment of upper thoracic spine and ribs for segmental mobility has been done by assessing AIVMs to spinous and transverse process which has been validated for use. ,
High velocity low amplitude thrust techniques help to restore normal articular relationship and function. It also helps to restore normal joint mechanics.  It causes normalization of joint functions and related local or remote symptoms  (mootz, trianio  manipulation activates Type I and Type II mechanoreceptors (Wyke, 1980).  These receptors exert a reflexogenic influence on muscle tone. There is an immediate decrease in pain after manipulation due to reflex decrease in muscle spasm.  (fisk) Thus HVLA applied to thoracic spine leads to improved thoracic mobility. Thereby improving range around thoracic spine and shoulder as well.
The present study suggests that thoracic spine and rib manipulation helps to reduce pain and increase the ROM around shoulder. The positive results in the present study could be explained using the concept of Regional Interdependence as described by Wainner. In our study, shoulder and thorax are considered to have regional interdependence.  Similar regional interdependence was also proven in several clinical trials and demonstrated the effective use of this regional examination and treatment approach in achieving positive functional outcomes for patients with a variety of musculoskeletal disorders ,,,,, of which some studies, ,, have investigated the effects of including cervicothoracic spine and rib manual physical therapy into an overall treatment approach for patients with shoulder pain. Cleland et al.  have demonstrated an increase in lower trapezius muscle strength immediately following thoracic manipulation. Suter et al.  have also demonstrated decreased biceps muscle inhibition following cervical manipulation and decreased quadriceps inhibition following sacroiliac manipulation, suggesting regional interdepence between these regions.
The results of present study were similar to the study conducted by Daniel et al.,  on adhesive capsulitis/Frozen Shoulder were they compared manipulation vs mobilization. Manipulation included in this clinical trial was for shoulder, cervical and thoracic spine HVLA chiropractic manipulative therapy (CMT). And another group received shoulder mobilization. They found significant reduction in SPADI scores in both the groups but CMT with exercise had a superior effect in the short-term treatment of stage 2 and stage 3 frozen shoulder and compared to mobilization group.
In a case report by Kazemi,  on secondary adhesive capsulitis in a 47-year-old female a recreational squash player showed positive results on application of spinal manipulation therapy (SMT) to the patient. The SMT of the cervical and the thoracic spine was given 3 times/week for 2 weeks. Immense improvement in ROM and pain was observed.
Polkinghom  reported successful treatment of 2 cases of adhesive capsulitis with shoulder, cervical and thoracic spine manipulation. In this study, mechanical force to use for manipulation. In present study manual force is utilized to the purpose of manipulation. The study had some limitations. The sample size was small. Long term follow-up of the patients was not done. Blinding was not done for intervention and assessing outcomes. Further studies with larger samples can be conducted. Blinding should be done in order to reduce potential bias. Thoracic and rib manipulation can be compared with other schools of manual therapy (Like Maitland, Mulligan etc.) for managing subjects with frozen shoulder.
| Conclusion|| |
Thoracic and rib manipulation is effective in reducing pain, increasing ROM and function of shoulder in subjects with frozen shoulder.
Further it was noticed that manipulation group was more effective in relieving pain and improving the shoulder ROM and function.
| Clinical Implication|| |
Thoracic and rib Manipulation can be added along with the conventional therapy in the management of Frozen Shoulder.
The manipulative therapy can also be compared with other schools of manual therapy for the management of frozen shoulder.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]