Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 
  • Users Online: 359
  • Home
  • Print this page
  • Email this page
Cover page of the Journal of Health Sciences


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 7  |  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


Department of Orthopedic Manual Therapy (OMT), KLE University, Institute of Physiotherapy, Belgaum, Karnataka, India

Date of Web Publication7-Jan-2015

Correspondence Address:
Dr. Jyotsna V Chitroda
KLEU Institute of Physiotherapy, JNMC Campus, Nehrunagar, Belgaum - 590 010, Karnataka
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2349-5006.148807

Rights and Permissions
  Abstract 

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 2019 Feb 19];7:92-9. Available from: http://www.ijournalhs.org/text.asp?2014/7/2/92/148807


  Introduction Top


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. [1]

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. [2]

Also referred to as adhesive capsulitis, FSS remains one of the most poorly understood shoulder conditions. [3]

The onset is insidious and usually occurs between the ages of 40 and 60 years, with a higher incidence in females. [2]

Reeves, [4] 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. [5] 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. [3] 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. [6] 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. [7]

Some authors like Grubbs, [8] and Neviaser [9] 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. [10] 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. [11]

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. [12] 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'. [13]

Bang and Deyle [14],[15] 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 [16] and a number of case reports. [17],[18]

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 Top


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.

Outcome measures

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. [19],[20],[21]

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). [22],[23]

Procedure

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. [10],[24]

Intervention

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. [25] Capsular stretches were given for anterior, posterior and inferior capsule. [26] TENS was given after the exercises for 15 min in burst mode. [15]


  Thoracic Manipulation and Rib Manipulations Top


Depending upon the presence of specific thoracic and/or rib impairment the technique [12] 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].
Figure 1: Supine technique for segmental thoracic flexion

Click here to view
Figure 2: Supine unilateral rib manipulation for rib mobility

Click here to view
Figure 3: Prone extension manipulation

Click here to view


Statistical analysis

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 Top


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.
Figure 4: Study flow diagram

Click here to view
Table 1: Subject characteristics

Click here to view


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

Click here to view


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 Top


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. [27]

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. [28] and Fernαndez-Carnero [29] et al. both demonstrated this rapid hypoalgesic effect following cervical manipulative therapy in patients with lateral epicondylalgia.

Iverson et al. [30] 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). [31]

Some authors like Grubbs, [8] and Neviaser [9] 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. [10],[24]

High velocity low amplitude thrust techniques help to restore normal articular relationship and function. It also helps to restore normal joint mechanics. [32] It causes normalization of joint functions and related local or remote symptoms [33] (mootz, trianio [34] manipulation activates Type I and Type II mechanoreceptors (Wyke, 1980). [29] 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. [35] (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. [13] 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 [14],[15],[36],[37],[38],[39] of which some studies, [8],[36],[37] 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. [40] have demonstrated an increase in lower trapezius muscle strength immediately following thoracic manipulation.   Suter et al. [41] 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., [16] 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, [42] 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 [43] 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 Top


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 Top


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.

 
  References Top

1.
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. J Orthop Sports Phys Ther 2010;40:474-93.  Back to cited text no. 1
    
2.
Brotzman SB, Wilk KE. Clinical Orthopaedic Rehabilitation. 2 nd ed. Philadelphia: Mosby; 2003.  Back to cited text no. 2
    
3.
Zuckerman JD, Rokito A. Frozen shoulder: A consensus definition. J Shoulder Elbow Surg 2011;20:322-5.  Back to cited text no. 3
    
4.
Reeves B. The natural history of the Frozen Shoulder syndrome. Scand J Rheumatol 1975;4:193-6.  Back to cited text no. 4
    
5.
Snell R. Clinical Anatomy. 7 th ed.  Baltimore: Lippincott William and Wilkins. 2003. p. 214-35.  Back to cited text no. 5
    
6.
Carette S. Adhesive capsulitis - Research advances frozen in time? J Rheumatol 2000;27:1329-31.  Back to cited text no. 6
    
7.
Crawford HJ, Jull GA. Influence of thoracic posture and movement on range of arm elevation. Physiother Pract 1993;9;143-8.  Back to cited text no. 7
    
8.
Grubbs N. Frozen Shoulder syndrome: A review of literature. J Orthop Sports Phys Ther 1993;18:479-87.  Back to cited text no. 8
    
9.
Neviaser J. Adhesive capsulitis of the shoulder: A study of the pathological findings in periarthritis of the shoulder. J Bone Joint Surg1945;27:211-22.  Back to cited text no. 9
    
10.
Maitland G. Maitland's Vertebral Manipulations. 7 th ed. Oxford, UK: Butterworth Heinmann; 2005.  Back to cited text no. 10
    
11.
Bergmann TF. Short lever, specific contact articular chiropractic technique. J Manipulative Physiol Ther 1992;15:591-5.  Back to cited text no. 11
    
12.
Lewit K. Manipulative Therapy, Musculoskeletal Medicine. Edinburgh: Churchill Livingstone, Elsevier; 2009.  Back to cited text no. 12
    
13.
Wainner RS, Whitman JM, Cleland JA, Flynn TW. Regional interdependence: A musculoskeletal examination model whose time has come. J Orthop Sports Phys Ther 2007;37:658-60.  Back to cited text no. 13
    
14.
Bang MD, Deyle GD. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. J Orthop Sports Phys Ther 2000;30:126-37.  Back to cited text no. 14
    
15.
Deyle GD, Allison SC, Matekel RL, Ryder MG, Stang JM, Gohdes DD, et al. Physical therapy treatment effectiveness for osteoarthritis of the knee: A randomized comparison of supervised clinical exercise and manual therapy procedures versus a home exercise program. Phys Ther 2005;85:1301-17.  Back to cited text no. 15
    
16.
Daniel MR, Paul WJ, James WB, Gary G, Felix L. A prospective clinical trial comparing chiropractic manipulation and exercise therapy vs. chiropractic mobilization and exercise therapy for treatment of patients suffering from adhesive capsulitis/frozen shoulder. J Am Chiropr Assoc 2008;45:12-28.  Back to cited text no. 16
    
17.
Gleberzon B. Successful chiropractic management of a centenarian presenting with bilateral shoulder pain subsequent to a fall. Clin Chiropr 2005;8:66-74.  Back to cited text no. 17
    
18.
Pribicevic M, Pollard H, Bonello R, de Luca K. A systematic review of manipulative therapy for the treatment of shoulder pain. J Manipulative Physiol Ther 2010;33:679-89.  Back to cited text no. 18
    
19.
Bijur PE, Silver W, Gallagher EJ. Reliability of the visual analog scale for measurement of acute pain. Acad Emerg Med 2001;8:1153-7.  Back to cited text no. 19
    
20.
McCormack HM, Horne DJ, Sheather S. Clinical applications of visual analogue scales: A critical review. Psychol Med 1988;18:1007-19.  Back to cited text no. 20
    
21.
Kelly AM. The minimum clinically significant difference in visual analogue scale pain scores does not differ with severity of pain. Emerg Med Journal 2001;18:205-7.  Back to cited text no. 21
    
22.
Solway S, Beaton DE, McConnell C, Bombardier C. The DASH outcome measure user's Manual. Toranto: Oranto Institute for Work and Health; 2002.  Back to cited text no. 22
    
23.
Stiller J, Timothy L. Outcome Measures of Upper Extremity Function, Clinical Evaluation and Testing, Athletic Therapy Today, Human Kinetics; 15-17 May, 2005.  Back to cited text no. 23
    
24.
Greenman PE. Principles of Manual Medicine. 2 nd ed. Baltimore, MD: Williams and Wilkins; 1996.  Back to cited text no. 24
    
25.
Hovind H, Nielsen SL. Effect of massage on blood flow in skeletal muscle. Scand J Rehabil Med 1974;6:74-7.  Back to cited text no. 25
    
26.
Ebnezar J, Essentials of Orthopaedics for Physiotherapists. Reprinted 2 nd ed. Jaypee Medical Book Publishers: New Delhi;2002. p. 226.  Back to cited text no. 26
    
27.
Leclaire R, Bourgouin J. Electromagnetic treatment of shoulder periarthritis: A randomized controlled trial of the efficiency and tolerance of magnetotherapy. Arch Phys Med Rehabil 1991;72:284-7.  Back to cited text no. 27
    
28.
Vicenzino B, Collins D, Wright A. The initial effects of a cervical spine manipulative physiotherapy treatment on the pain and dysfunction of lateral epicondylalgia. Pain 1996;68:69-74.  Back to cited text no. 28
    
29.
Fernández-Carnero J, Fernández-de-las-Peñas C, Cleland JA. Immediate hypoalgesic and motor effects after a single cervical spine manipulation in subjects with lateral epicondylalgia. J Manipulative Physiol Ther 2008;31:675-81.  Back to cited text no. 29
    
30.
Iverson CA, Sutlive TG, Crowell MS, Morrell RL, Perkins MW, Garber MB, et al. Lumbopelvic manipulation for the treatment of patients with patellofemoral pain syndrome: Development of a clinical prediction rule. J Orthop Sports Phys Ther 2008;38:297-309.  Back to cited text no. 30
    
31.
George SZ, Bishop MD, Bialosky JE, Zeppieri G Jr, Robinson ME. Immediate effects of spinal manipulation on thermal pain sensitivity: An experimental study. BMC Musculoskelet Disord 2006;7:68.  Back to cited text no. 31
    
32.
Hadelman S. Principles and Practice of chiropractic. 3 rd ed. New York: McGraw Hill; 2005.  Back to cited text no. 32
    
33.
Anderson R, Meeker WC, Wirick BE, Mootz RD, Kirk DH, Adams A. A meta-analysis of clinical trials of spinal manipulation. J Manipulative Physiol Ther 1992;15:181-94.  Back to cited text no. 33
    
34.
Triano JJ. Studies on the biomechanical effect of a spinal adjustment. J Manipulative Physiol Ther 1992;15:71-5.  Back to cited text no. 34
    
35.
Mohanty US. Manual Therapy of the pelvic complex: A compendium of iilustrated Manual Therapy techniques. 1 st ed. Mangalore. MTFI Health Care Publication; 2010.  Back to cited text no. 35
    
36.
Bergman GJ, Winters JC, Groenier KH, Pool JJ, Meyboom-de Jong B, Postema K, et al. Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and pain: A randomized, controlled trial. Ann Intern Med 2004;141:432-9.  Back to cited text no. 36
    
37.
Winters JC, Sobel JS, Groenier KH, Arendzen HJ, Meyboom-de Jong B. Comparison of physiotherapy, manipulation, and corticosteroid injection for treating shoulder complaints in general practice: Randomised, single blind study. BMJ 1997;314:1320-5.  Back to cited text no. 37
    
38.
Bronfort G, Evans R, Nelson B, Aker PD, Goldsmith CH, Vernon H. A randomized clinical trial of exercise and spinal manipulation for patients with chronic neck pain. Spine (Phila Pa 1976) 2001;26:788-97.  Back to cited text no. 38
    
39.
Walker MJ, Boyles RE, Young BA, et al. The effectiveness of manual physical therapy and exercise for mechanical neck pain: A randomized clinical trial. Spine. 2008;33:2371-2378.  Back to cited text no. 39
    
40.
Cleland J, Selleck B, Stowell T, Browne L, Alberini S, St. Cyr H, et al. Short-term effects of thoracic manipulation on lower trapezius muscle strength. J Man Manip Ther 2004;12:82-90.  Back to cited text no. 40
    
41.
Suter E, McMorland G, Herzog W, Bray R. Decrease in quadriceps inhibition after sacroiliac joint manipulation in patients with anterior knee pain. J Manipulative Physiol Ther 1999;22:149-53.  Back to cited text no. 41
    
42.
Kazemi M. Adhesive capsulitis: A case report. J Can Chiropr Assoc 2000;44:169-176.  Back to cited text no. 42
    
43.
Polkinghorn BS. Instrumental chiropractic treatment of frozen shoulder associated with mixed metastatic carcinoma. J Manipulative Physiol Ther 1995;7:98-102.  Back to cited text no. 43
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Methods
Thoracic Manipul...
Results
Discussion
Conclusion
Clinical Implication
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed4174    
    Printed55    
    Emailed1    
    PDF Downloaded472    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]