Thoracic manipulation article

[Kyle Feldman]

Very interesting article just published on manipulation vs sham for shoulder impingement.

What do you make of the results, method, conclusion?

How does this effect your clinical decision making?

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[Erik Kreil]

Love this article, Kyle.

I jotted down a few notes about the methods that I felt should be considered before discussing the results and conclusion:

– Only ~12 of the 60 participants were actively seeking treatment.

– The authors don’t dichotomize SPS into Primary or Secondary impingement, so patients who “fit” an umbrella impingement characterization may actually require a greater manual focus at the glenohumeral or AC joints to address associated extrinsic factors. (I wondered why subjects were excluded if they had a + Apprehension test when that is a portion of the proposed algorithm?)

– Additionally, the inclusion criteria allows the possibility that the subjects don’t fit the test cluster for Subacromial Impingement Syndrome ( + Hawkin’s Kennedy, Painful Arc, and Infraspinatus test VS. Painful Anterolateral shoulder, + Neer’s, and shoulder ABD AROM of < 90deg).

– Finally, limiting the chronicity to 6mos may “decrease the likelihood of a RTC tear,” BUT the patient could also be a 60yo with a painful arc and have + Infraspinatus test (3/4 test cluster for RTC tear) thereby increasing the likelihood.

Batting points aside, I understand what the results indicate. A patient having a positive outlook is a portion of the test cluster indicating a cervical manip, and it’s been shown that the same perception on the outcome of the thrust will yield better thoracic thrust results. To me, this reiterates the power of perception. It’s possible that the TS really does hold the “cinderella zone” with powerful regional interdependence, but I feel what’s the most consistently supported factor is the power of perception (this point harks all the way back to week 1 discussion). So I settle with: No, not everyone deserves a thoracic thrust, but addressing the TS may still be a useful adjunct emphasis to more well-supported approaches in the literature.

[jeffpeckins]

I agree that the fact that only 20% of participants were actively seeking treatment for their pain is slightly concerning. I wonder what the median pain score for the participants would have been, my guess is pretty low, so there may not have been the opportunity for as much change.

I think that the patients were excluded if they had a positive apprehension test because they likely defined a positive test as a feeling of instability, as the original test describes. That test has been altered so that a positive for pain may be an indicator for impingement, like in that algorithm we have studied.

Overall I thought the article’s methods were solid and it was a well written article. I am not surprised by the findings either. The participants received one thoracic manipulation without any other manual technique or exercise following the manipulation. None of us are doing that in the clinic, we are all following up our techniques with other treatments that will work more directly at their impairments. In my practice, I’ll try a thoracic manip and see if the patient has any less pain afterwards. If so, great, they can likely do something that would have previously been too painful for them to do. And I’ll send them home with an exercise to facilitate thoracic mobility. But its likely not going to be the cornerstone of my treatment for that patient.

[Kyle Feldman]

Erik and Jeff,
I think you both had some great points.

Jeff, viewing the apprehension test as a way to exclude instability is what I believe they were trying to do as well. This helps to make sure its more likely impingement as less instability.

The conclusions are great and prove that a strong subjective and alliance are a key foundation to treatment skills and selection.

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