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95]
Effect of gleno‑humeral mobilisation and
mobilisation of asymptomatic cervical spine
in patients with shoulder impingement
syndrome: A pilot trial
Karthikeyan Guru, Vyas Avinashi Anilkumar, Joseley T. Sunderraj Pandian
Srinivas College of Physiotherapy and Research Center, Mangalore, Karnataka, India
Address for correspondence:
Dr. Karthikeyan Guru,
ABSTRACT
Associate Professor,
Srinivas College of Physiotherapy
and Research Center, Pandeshwara,
Mangalore ‑ 575 001, Karnataka, India.
E‑mail: gkarthispt@yahoo.co.in
INTRODUCTION
Shoulder disorders are among the most common
disorders of all peripheral joints complaints.[1,2] Shoulder
impingement syndrome (SIS) and rotator cuff tendinitis
are considered to be the most frequent cause of intrinsic
shoulder pain and disability. [3‑5] Frequent or sustained
shoulder elevation at or above 60° in any plane during
occupational tasks has been defined as a risk factor for
the development of shoulder tendinitis or non‑specific
shoulder pain.[6‑8] Impingement is a frequently described
pathological condition in an athlete performing overhead
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DOI:
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42 Saudi Journal for Health Sciences - Vol 4, Issue 1, Jan-Apr 2015
Original Article
Background and Purpose: Shoulder impingement syndrome (SIS) is believed to be
the most common cause of the shoulder pain. Repeated overhead activities with greater
force may cause SIS and results in reduction in range of motion and functional disability
with significant pain in shoulder joint. The purpose of the study was to know the effect
of addition of mobilisation of asymptomatic cervical spine for the patients with SIS.
Materials and Methods: In all, 15 subjects aged between 20-45 years with symptoms of
SIS were recruited in this study. Treatment was given for two weeks after dividing patients
randomly in three different groups that is conventional, Mulligan with conventional, and
Maitland with conventional. Shoulder elevation range of motion (ROM), pain, and functional
disabilities were measured at day 1 pre‑ and post‑treatment session as well as at the end
of 1st week and at the end of 2nd week. Results: Significant improvement (P < 0.05) was
found in ROM, pain, and function in all the three groups. Addition of asymptomatic cervical
spine mobilisation protocol in the treatment proved better significantly (P < 0.05) in improving
pain and ROM than Maitland and conventional therapy while no significant difference found
between the three groups in the improvement of function. Conclusion: Mulligan mobilisation
proved better in the improvement of ROM and pain compared with Maitland and conventional
approach. Acute and late effects of Mulligan mobilisation proved to be a better treatment
compared with other treatments, for clinical purpose.
Key words: Cervical spine mobilisation, conventional physiotherapy, manual therapy,
mobilisation with movement, shoulder impingement syndrome
activities. The vast majority of people with impingement
syndrome who are younger than 60 years of age relate
their symptoms to occupational or athletic activities that
involve frequent overhead use of arm.[1]
Shoulder impingement has been defined as compression
and mechanical abrasion of the rotator cuff structure as
they pass beneath the coracoacromial arch during elevation
of the arm.[1,8] Neer described the subacromial impingement
syndrome as a distinct clinical entity and hypothesised that
the rotator cuff is impinged upon by the anterior one‑third
of the acromion, the coracoacromial ligament and the
acromioclavicular joint rather than by merely the lateral
aspect of the acromion.[9] An imbalance between the deltoid
and the rotator cuff muscle may result in excessive superior
movement of the humeral head, causing impingement
of subacromial structures.[10] Scapular movement ensures
that the coracoacromial arch is removed from the path of
the upwardly elevating humerus, in particular its greater
tuberosity, via upward rotation of the scapula, thus avoiding
potential impingement.[10]
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Guru, et al.: Manual therapy for shoulder impingement syndrome
Excessive tensile loads may cause subacromial impingement
symptoms from a single traumatic event or repetitive
microtrauma. Cumulative microtrauma sustained by the
subacromial loading is the cause of primary impingement.
Secondary impingement is reported mainly in athletes who
participate in sports that require frequent overhead activities
like throwing.[11,12] Athletes with rotator cuff impingement
complain of pain with overhead activities such as throwing,
swimming, and over head shots in racquet sports. Activities
done at less than 90° of abduction are usually pain free. Active
movement may reveal a painful arc of abduction between 70°
and 120°. Pain may also occur with the restricted contractions
of the supraspinatus.[10]
The physiotherapy treatments have an important part to
treat the patient with shoulder impingement. Most of the
protocols are focused on strengthening the rotator cuff
muscles in addition to the restoration of normal ROM,
endurance, and pain control.[13,14] Physical modalities like
ultrasound, heat, and cold have been suggested for control
of pain. Manual therapy can also be given to restore the
ROM and function to the disabled part. It is also helpful to
relieve pain during movement.[13,14] It was found that exercise
supervised by a physical therapist is superior to placebo
and is as effective as surgical subacromial decompression
combined with post operative rehabilitation of patients
with stage‑2 primary impingement.[15] Proper strengthening
of the scapular rotators assure that the scapula follows the
humerus providing dynamic stability and assuring synchrony
of scapula‑humeral rhythm.[10]
Manual therapy techniques are also being used to treat the
patients with impingement syndrome.[16] Manual therapy
might reduce pain by stimulating joint mechanoreceptor
activities which in turn block the afferent pain signal
and reduce awareness of the pain. Manual therapy also
mechanically stretches shortened collagenous tissues and
improves interstitial fluid content resulting in restoration of
the movement.[16] Maitland technique is applied to the joints
and related soft tissues at varying speed and amplitudes using
physiological and accessory motions for therapeutic purpose.
The oscillation may have an inhibitory effect on perception of
painful stimuli by repetitively stimulating the mechanoreceptors
that block nociceptive pathways at the spinal cord or brainstem
level.[16] Cervical Sustained Natural Apophyseal Glide (SNAG)
techniques, performed on naive asymptomatic subjects, have
a sympatho‑excitatory effect, which has a potential relation to
mobilisation‑induced analgesias.[17]
Loading of the cervical spine may also be influenced by
axioscapular muscle function. Coordinated activation of
the trapezius and serratus anterior muscles is important to
optimise scapular position and load transfer from the upper
limbs to the cervical spine.[18] Increased activation of the upper
trapezius muscle was found in the subjects with shoulder
impingement.[19] The changes in axioscapular muscles’ activity
Saudi Journal for Health Sciences - Vol 4, Issue 1, Jan-Apr 2015 43
during low‑load functional tasks have been shown in patients
with chronic neck pain, which may indirectly play a role in
shoulder biomechanics.[20] Thus, cervical spine mobilisation
techniques can be used during therapy to affect more peripheral
symptoms.[21,22] Previous studies have shown that chronic elbow
pain and temporomandibular joint (TMJ) pain can be reduced
by a mobilisation intervention to the asymptomatic neck.[21,23]
Manual therapy directed toward the cervicothoracic spine and
adjacent ribs, for patients with shoulder pain, has also proved
effective.[24] It was proposed by Schneider that the restriction in
shoulder movement was perhaps not capsular but possibly due
to cervical somatic pain referring to the shoulder region and
initiating spasm in shoulder musculature.[25] The biomechanical
effects associated with manual therapy motion has been
quantified in the improvements in the signs and symptoms
away from the site of application.[24,26,27]
The effect of mobilisation of cervical spine for peripheral
symptoms, particularly when it is asymptomatic, is usually
overlooked. This effort makes it clear that assessing and treating
the central level, that is cervical spine in this case, might have an
impact in reduction of pain and improving ROM of the peripheral
joint. Further, this will provide an insight regarding the utility of
manual therapy when joint‑based techniques cannot be applied
as in case of highly irritable joints. Hence, the purpose of this
study was to compare the mobilisation of asymptomatic cervical
spine and Maitland shoulder mobilisation on ROM, pain and
functional disability in patients with shoulder impingement
syndrome. It was hypothesised that there will be significant
difference between Maitland mobilisation and mobilisation of
asymptomatic cervical spine in the improvement of the pain,
ROM and functional disability.
MATERIALS AND METHODS
Participants
In this experimental study, 15 subjects diagnosed with SIS
who volunteered to participate in this study were recruited
from the outpatients department of the rehab centre.
Permission with ethical clearance was obtained from the
Institute Ethical Committee. The patients who met the
strict inclusion criteria of the study were included based
on purposive sampling. Patients aged between 20-50 years,
with pain in elevation of shoulder above 100°, in movements
of shoulder joint in scapular plane and having positive Neer
impingement and Hawkins‑Kennedy test were included.[28]
In addition, persons with the duration of pain between
1 month and 1 year with the visual analogue scale (VAS)
Score range 4-7 in 10 cm scale were included. However,
individuals suffering from any medical conditions like
active inflammatory disease, infections and neuromuscular
conditions of shoulder or having radiating pain from cervical
spine or elbow joint were not included. Furthermore,
subjects with history of recent fracture around shoulder
joint, or with osteoporosis or with adhesive capsulitis were
excluded from participation.
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Guru, et al.: Manual therapy for shoulder impingement syndrome
Testing procedure
Patients diagnosed with impingement syndrome having pain
and reduced range of motion in shoulder were included for
the study. After getting their written consent; demographic
characteristics and relevant information to fulfil the criteria
for inclusion were collected by using a pre‑participation
questionnaire. On the first day and before the treatment,
shoulder joint elevation range of motion (SROM), pain, and
shoulder functional disability index (SPADI) were measured
as baseline values. The SROM in pain free shoulder scaption
was measured while standing using a standard goniometer.[29]
Pain was measured using a 10 cm VAS where ‘0’ shows no pain
and ‘10’ shows maximum pain.[30] The SPADI is a self‑reporting
questionnaire that consists of 13 items in two subscales:
Pain (5 items) and disability (8 items); In a visual analogue
format. Each item has 10 points and the therapist marks
points according to the patient’s ability to do activity.[31]
Patients were then randomly allocated among 3 groups
based on block randomization procedure. The groups
were based on the types of treatment: Only conventional
treatment (Group‑1), Maitland mobilisation of shoulder with
conventional treatment (Group‑2) and Mulligan Mobilisation
of asymptomatic cervical spine with Maitland mobilisation
of shoulder and conventional treatment (Group‑3). All the
patients were instructed to refrain from any pain medication
or any other sort of physiotherapy treatment. The treatment
was given on alternate days for a period of two weeks
comprising a total of six sessions at the physiotherapy
department of the hospital as well as at the patient’s home (by
making house visits), in case the patient is not able to come
to the clinic. Post‑treatment measurements of pain, ROM,
and functional disability were taken at the end of 1st day, 1st
week, and 2nd week.
Description of treatment
Participants in Group‑1 received only the conventional
treatment which consisted of the following [Figure 1]. Moist
heat pack (1) for shoulder joint for 10 minutes; Codman’s
exercise (4); self‑assisted anterior and posterior capsular
stretching (2,3) with each stretch held for 30 seconds and
performed 5 times with a 10‑second rest between each stretch;
progressive‑resisted strengthening exercises (5) for scapular
muscles using 1 Repetition Maximum) [1st week: 3 sets of 10
repetitions; upgraded in 2nd week: 3 sets of 20 repetitions].[32]
These treatments were given for all the patients in all three
groups and all were instructed to practice daily once at home
apart from the supervised practice.
Participants in Group‑2, mobilisation of shoulder with
Conventional treatment group received standard exercise
protocol as per Group‑1 with the addition of glenohumeral
joint mobilisation techniques. Maitland mobilisation of
posterior glide was given with the patient in supine position
and the therapist grasped the head of the humerus with one
hand for movements and clavicular region with other hand
44 Saudi Journal for Health Sciences - Vol 4, Issue 1, Jan-Apr 2015
for stabilisation shown in Figure 2 [Figure 2:2]. The therapist
was in a standing position to give the glides. The scapula of
the patient was further stabilised by putting a towel under it
to prevent the protraction of scapula so that the glides of the
scapula would be smoother. When there was no reactivity but
capsular hypomobility, Grade 3 or 4 accessory motions were
applied to increase range of motion while on a reactive joint,
Grade 1 or 2 were given then progressed to higher grades.
Each mobilisation was applied for 30 seconds at a rate of 1
mobilisation per 1 or 2 seconds followed with resting period
of 30 seconds. Total 3 sets of 30 repetitions were given.[17]
Participants in Group‑3, mobilisation of asymptomatic
cervical spine with mobilisation of shoulder and conventional
treatment received the protocol as per Group‑2 with the
addition of lateral cervical glide mobilisation [Figure 2:1].
Patients were positioned with the subject seated and the
thoracic spine resting against the back of the chair, head
in a neutral position, feet resting flat on the floor, and
arms relaxed with hands in their lap. The lateral aspect of
the spinous processes of C5, C6, and C7 was landmarked
on the ipsilateral side of the subject’s painful shoulder.
The examiner’s thumb remained on the lateral aspect of the
spinous process of C5, with the opposite hand placed on the
subject’s non‑affected shoulder or head for counterbalance as
a lateral movement toward the non‑painful side was applied
with the mobilizing hand.[33] Mobilisations were conducted
for two min each at C5, C6 and C7, with small amplitude
end range movements. The patient was asked to perform
abduction of the arm after application of the glide.[23]
Statistical analysis
Descriptive statistics was used to calculate the mean,
standard deviation and standard error for the purpose
of summarising the data and for further analysis for the
difference between the groups. Mean value of these
sub‑categories in each group were considered for intragroup
analysis and intergroup analysis. Mean value of the difference
of the scores between the sub‑categories were considered for
intergroup analysis. Repetitive measures Analysis of Variance
was done to know the overall effect of treatment protocols on
the parameters between the three groups and between the
three time‑measurements in each group. Every protocol was
compared with each other to know the comparative effect.
The P level was kept as 0.05 and value less than that level
was considered as significant. Analysis was done using the
software – Statistical Package for the Social Sciences (SPSS
Version 20.0).
RESULTS
In all, 15 patients were included in this pilot trial. Subject
baseline characteristics are presented in Table 1. The mean
age of the total participants was 33.6 ± 6.43 years with no
significant difference (F = 0.038, P > 0.05) between the three
groups which showed the homogeneity. The mean baseline
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Guru, et al.: Manual therapy for shoulder impingement syndrome

Figure 1: Conventional treatment 1.1: Moist heat pack application, 1.2: Self-assisted anterior capsular stretching, 1.3: Self-assisted posterior
capsular stretching, 1.4: Codman’s pendular exercise, 1.5: Progressive-resisted strengthening exercises

difference (F = 32.322 and P = 0.000) was found between the

Figure 2: Manual therapy 2.1: Mulligan’s mobilisation, 2.2: Maitland
mobilisation
ROM, pain and the disability score for the participants were
106.27 ± 3.17, 7.07 ± 0.8 and 104.33 ± 4.68 respectively.
No significant difference in shoulder disability was found
between the groups while baseline ROM and pain were
looking different (F = 5.615, P = 0.019 and F = 10.75,
P  = 0.002, respectively) between the groups. All subjects
were right‑handed, and the majority (57%) experienced
impingement syndrome on their dominant side.
Following treatment, all the groups showed significant
improvement (P = 0.000) in active shoulder range of motion
measurements, pain and functional shoulder ability between
all the level measurements using post‑hoc intragroup
analysis [Table 2]. Figures 3‑5 illustrate the mean changes
per time in ROM, pain and shoulder disability in all the
three groups. While comparing the mean differences (MD)
for the improvement in the shoulder ROM, significant
groups. In that, except the comparison between the Group‑1
and Group‑2 (where P > 0.05), all other comparisons showed
significant difference [Table 3]. That means, the comparison
of the effect of treatment between Group‑1 and Group‑2 did
not show much difference (MD = −0.90, P = 1.000) whereas
the comparison of the effect of treatment between Group‑1
and Group‑3 and between Group‑2 and Group‑3 showed
differences (MD = −8.20, P = 0.000 and MD = −14.95,
P = 0.000, respectively).
Meanwhile, the comparison of the mean differences for
improvement in the shoulder pain between the groups
showed significant difference (F = 34.887 and P = 0.000).
Again, except the comparison between Group‑1 and
Group‑2 (where P > 0.05) all other comparisons showed
significant difference. That means, comparison of the
effect of treatment between Group‑1 and Group‑2 did
not show much difference (MD = 4.441, P = 1.000)
whereas the comparison of the effect of treatment
between Group‑1 and Group‑3 and between Group‑2 and
Group‑3 showed differences (MD = 2.150, P = 0.000 and
MD = −2.150, P = 0.000, respectively).
Even the comparison among the mean differences of the
groups for improvement in the shoulder disability showed
no significant difference (F = 4.139 and P > 0.05). However,
the comparison of the effect of treatment in all the pair‑wise
comparisons also showed no significant difference. That
means, the effects on reducing the shoulder disability by all

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Guru, et al.: Manual therapy for shoulder impingement syndrome

the treatment combinations looked same either between the rapid recovery in shoulder impingement. There are studies
Group‑1 and Group‑2 (MD = 0.600, P = 1.000) or comparison to support effects of either cervicothoracic mobilisation[21,26]
of the effect of treatment between the Group‑1 and Group‑3 or Maitland mobilisation [24,27,34] on improving shoulder
and between Group‑2 and Group‑3 (MD = 8.750, P = 0.073 pain and ROM but no published study has been found
and MD = 8.150, P = 0.101, respectively). that compares the effect of Maitland mobilisation in
shoulder with mobilisation of asymptomatic cervical spine
DISCUSSION for the same. So, the present study compared the added
effectiveness of the mobilisation of asymptomatic cervical
The shoulder impingement syndrome is quite common in the spine in patients with shoulder impingent. In all, 15 patients
younger age group both in athletes as well as the common were treated for a duration of two weeks.
people. Apart from conventional physical therapy, various
manual therapy approaches have been used effectively for Pain was the most common factor in all the patients. Majority
of the patients had pain around 7 to 10 cm VAS scale.
Table 1: Baseline characteristics of the subjects in all the Impingement in the shoulder joint occurs when the soft tissue
groups occupying the sub‑acromial space is encroached upon by the
Character Group Mean SD 95% confidence F value P level coracoacromial arch which leads to impingement of tendons
interval of the rotator cuff muscles.[35] After the treatment, shoulder
Lower Upper pain reduced significantly in all the groups (P < 0.05) in the
bound bound
comparison between baseline value, readings immediately
Age 1 33.0 2.00 27.44 38.55 0.038 0.963#
after the treatment, at the end of 1st week and at the end of 2nd
2 34.20 2.61 26.93 41.46
week. A previous study also found significant decrease in the
3 33.60 4.23 21.83 45.36
intensity of shoulder pain at the end of two sessions.[23] Further,
ROM 1 105.4 1.82 103.14 104.65 5.615 0.019*
it was mentioned that if the asymptomatic cervical spine was
2 109.2 2.68 100.75 107.64
examined thoroughly through manual therapy techniques
3 104.0 2.77 105.87 112.53
during the assessment of a painful shoulder, the patient might
Pain 1 7.40 0.55 6.72 8.08 10.750 0.002*
be able to determine any immediate change in the intensity
2 6.20 0.45 6.91 8.28
of shoulder pain or improvement in active shoulder range
3 7.60 0.55 5.64 6.7
of motion.[23] But, we hadn’t examined cervical spine at any
SPADI 1 101.0 3.32 98.75 112.84 2.247 0.148#
point of time. The results of the current study indicated that a
2 105.80 5.67 101.77 110.62
statistically and clinically significant decrease in the intensity
3 106.20 3.56 96.88 105.12
of shoulder pain was observed post‑mobilisation condition,
*: Highly significant, #: Non‑significant, ROM: Range of motion,
SPADI: Shoulder functional disability index, SD: Standard deviation which lends credence to the argument that the cervical spine
might still be involved in shoulder pain in the absence of any
Table 2: Within subject (intertime) comparison among the
objective cervical limitations or symptom reproduction.[36] If
estimated marginal means of ROM, pain and SPADI any increase or decrease of pain intensity or shoulder ROM
Variables Mean square df F value Sig.(a) is noted, the clinician can be more confident that a cervical
ROM 219.006 6 442.04 0.000* component to that patient’s pain is likely to exist and that the
Pain 1.128 6 189.754 0.000* treatment could be planned accordingly to involve the cervical
SPADI 14.194 6 405.006 0.000* spine.[23] Segmental neurological modulation, neural hysteresis
*: Highly significant, ROM: Range of motion, SPADI: Shoulder functional
and biomechanical effects have been proposed as mechanisms
disability index underpinning the effects of manual therapy.[37] Furthermore, it

Table 3: Intergroup (pair‑wise) comparison of mean difference of ROM, Pain and SPADI

Dependent Group Mean Std. F value P 95% confidence
variable pairs difference error interval
ROM 1 and 2 −0.90 2.085 32.322 1.000# −6.696 4.896
1 and 3 −8.200 2.085 0.000* −20.746 −9.154
2 and 3 −14.950 2.085 0.000* −19.846 −8.254
Pain 1 and 2 4.441 0.297 34.887 1.000# −0.826 0.826
1 and 3 2.150 0.297 0.000* 1.324 2.976
2 and 3 2.150 0.297 0.000* 1.324 2.976
SPADI 1 and 2 0.600 3.398 4.139 1.000 #
−8.843 10.043
1 and 3 8.750 3.398 0.073# −0.643 18.193
2 and 3 8.150 3.398 0.101# −1.293 17.593
*: Highly significant, #: Non‑significant, ROM: Range of motion, SPADI: Shoulder functional disability index

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Guru, et al.: Manual therapy for shoulder impingement syndrome

Even in the control group we observed significant reduction

 *URXS
in pain where heating modalities might have improved
*URXS
 soft tissue healing through an accelerated metabolic rate
*URXS
 and increased blood supply.[38] Stretching techniques have
520'HJUHHV

 been found useful in increasing mobility of the soft tissues

 and subsequent improvement in ROM by elongating the

structures that have adaptively shortened and became
hypomobile over time. Stretching of anterior and posterior

capsule were also carried out as treatment in this study.

Capsular stretching might help allow the humeral head to
 move more efficiently during movements with relieving the
 pain by giving mechanical stimulation.[33] We had also used
 strengthening exercises to strengthen the rotator cuff and
%DVHOLQH 'D\ ZHHN ZHHN
deltoid muscles for treatment purpose. Usually, weakening of
7LPH
the rotator cuff causes an imbalance of the force couple about
Figure 3: Mean shoulder ROM values of all levels in all three groups the glenohumeral joint and it allows the deltoid to elevate the
proximal part of the humerus in the absence of an adequate

depressor effect from the rotator cuff. This causes a decrease
in the subacromial space and impingement of the rotator
*URXS
 cuff on the anterior aspect of the acromion.[39] Strengthening
*URXS
 *URXS exercises help improve the function by maintaining the
structures in their anatomical position after being treated
9$6VFRUH


by manual therapy. Thus, strengthening exercises are helpful
 in reduction of pain, which in turn improves the functional
ability of the patient. The exercise program was followed by

the manual therapy treatment for the experimental group,
 which might be an additional factor in relieving the pain.

However, while carr ying out comparison of mean
 difference between the groups, Group 3 (addition of
%D VH O L Q H 'D\ ZHHN ZHHN
7LPH
Mulligan mobilisation of cervical lateral glide) showed
significant (P < 0.05) improvement in pain compared to
Figure 4: Mean shoulder pain values of all levels in all three groups Group 1 and Group 2. This shows that addition of the
asymptomatic cervical spine mobilisation could have
relieved pain. In respect of our results, previous reports
 also stated that, addition of pragmatic manual therapy was
*URXS effective in reducing pain compared to exercise alone and
 *URXS
*URXS
when joint mobilisations were compared to ‘‘conventional’’
physiotherapy alone.[40] But in contrast to these findings,
63$',VFRUH

 another study found that manual therapy and home exercise

programme did not contribute a significant effect to the

pain.[38] But the subjects in that study were having chronic
rotator cuff disease, where as in our study the subjects

were having impingement syndrome. Another trial also
reported that joint mobilisation in addition to exercise and

modalities were no more effective than exercise, modalities
and Proprioceptive Neuromuscular facilitation in improving

%DVHOLQH 'D\ ZHHN ZHHN pain.[41] Some authors also found that manual therapy and
7LPH home exercise programme do not give any significant
Figure 5: Mean shoulder disability scores (SPADI) of all levels in all difference for initial effect compared to placebo treatment
three groups over pain and functional disability.[24] Kamkar et al., also
showed that strengthening exercises are also helpful to
was suggested that joint mobilisation improved outcomes by reduce pain in the patients with secondary impingement
approximately 20% relative to controls. This specific pattern syndrome as well as prevent further impingement in the
suggests that descending pathways might play a key role in healthy population, especially in athletes who are engaged
manual therapy induced hypoalgesia.[25] in overhead throwing activities.[42] However all these studies

Saudi Journal for Health Sciences - Vol 4, Issue 1, Jan-Apr 2015 47

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Guru, et al.: Manual therapy for shoulder impingement syndrome
focused on the mobilisation of shoulder joint only, with
Maitland mobilisation or Mulligan mobilisation, but they
did not focus on the correction of the positional faults that
may be present in the central level which in this case, is the
cervical spine.
Another factor which was included in this study as an
outcome measure was shoulder ROM. Patients with
SIS showed reduction in ROM due to pain because of
encroachment of rotator cuff muscle between acromion
and the head of the humerus which occurs due to abnormal
coupling action of deltoid and scapular muscles. This
abnormality leads to reduction of the space between the
head of humerus and acromion process.[16] In our study
ROM improved significantly in the initial stage in all three
groups (P = 0.000). Results of a previous study supports
our study results by saying that Mulligan mobilisation of
asymptomatic cervical spine shows better improvement
in ROM in the initial stage. [23] While comparing the
mean difference between the groups, Group 3 showed
significant (P < 0.05) improvement in ROM compared
to Group 1 and Group 2. It was also suggested that the
improvement in shoulder movements following cervical
mobilisation may have had a neurological basis by positively
affecting a nerve root impingement.[25] As these structures
re‑align to their normal position, the pain will reduce and
ROM will increase. In addition, Maitland mobilisation is
primarily done in the non‑weight bearing position and
offending movements are not performed concomitantly with
mobilisation while it is done with Mulligan’s mobilisations.
Moreover, Mulligan’s cervical lateral glide mobilisation
also aims at correction of positional fault which in turn
can improve the ROM when given in combination with
conventional treatment and Maitland mobilisation. In our
study, after the lateral glide was applied to the cervical
spine, the patients were asked to perform the offending
movement, which in this case is shoulder abduction. In
contrast to this study, a systematic review put a question
mark over the effect of manual therapy techniques over
the ROM in comparison with conventional treatment. They
reported that there was limited evidence suggesting that
manual therapy combined with exercise was more effective
than exercise alone in patients with SIS.[43] However manual
therapy was also directed towards the shoulder joint and
none of the studies focused on the involvement of central
level which in this case is the cervical spine.
The third component of our study was measurement of
functional disability. It is seen in patients with SIS that
functional ability reduces due to pain and reduced ROM in
the shoulder joint. Many studies are available to show the
effect of manual therapy over ROM and pain. As there are
no reference values to measure the severity of the functional
disability, we could not say exactly how many individuals are
disabled due to pain and reduced ROM. Shoulder disability
reduced significantly in all the groups (P < 0.05) in the
48 Saudi Journal for Health Sciences - Vol 4, Issue 1, Jan-Apr 2015
time‑wise comparison, that is comparison between baseline
value readings immediately after the treatment, at the end
of 1st week and at the end of 2nd week. The SPADI function
test is based on shoulder pain with functional activities, it
makes sense that interventions resulting in pain reduction
would also result in an improved SPADI score. As Mulligan
mobilisation is given in the weight‑bearing position, and
patient attempts an offending movement which in this case
is shoulder abduction, confidence of the patient for pain
and ROM improves. This automatically helps to improve
functional mobility of patient in his/her activities of daily
living. Maitland’s concept mainly concentrates over the
passive joint mobilisation with the help of different speed
and amplitude. In this protocol all the things are done
passively over the patient.[33] So the patients have to wait for
pain reduction to move the affected part. Hence the added
effect of Mulligan mobilisation of cervical lateral glide with
conventional treatment and Maitland mobilisation may be
most important in correcting positional fault as well as in
inducing hypoalgesic effect.
At the same time, while comparing the mean difference
between the groups, no significant difference was found
between all three groups. In accordance to this finding,
a systematic review on the effect of manual therapy over
functional disability reported that there is still controversy
for the effect of manual therapy over painful shoulder for
functional disability.[31] They found that some study showed
that there is no additional effect of manual therapy over
functional disability. Another study also showed that there
is no significant group wise difference in functional ability
in patients but significant difference within the group where
they used quality of life measures and SF‑36 score to measure
functional ability.[20]
Overall, the results of our study showed that Mulligan
mobilisation of cervical lateral glide even in asymptomatic
cervical spine with the additional help of conventional
physiotherapy along with Maitland mobilisation is helpful
to treat the patients with shoulder impingement syndrome.
Moreover patients having severe pain in the shoulder which
can be categorised as highly irritable especially in acute cases
where joint‑based techniques cannot be given to improve
the symptoms can be brought by application of techniques
away from the site of pain like in cervical spine.[24,26,27,34,44,45]
Our study has some limitations which could not be
overcome. Though we had informed patients not to
take medicine, it was out of our control to monitor the
same during the study period. Psychological factors of
the patients were out of our control which could have
influenced the effectiveness. Population of the patients was
small due to certain time limitation and blinding was not
done. We could not exclude the possibility that differences
existed in the underlying structural abnormalities within
our study population.
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Guru, et al.: Manual therapy for shoulder impingement syndrome
CONCLUSION
We conclude that Mulligan’s mobilisation with movement of
cervical lateral glide combined with conventional physical
and Maitland mobilisation proved better in the improvement
of shoulder pain, and ROM compared to other treatment
protocols. However, future studies are warranted with better
sample size, randomisation, blinding and in more controlled
ways to improve the scope of practice.
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How to cite this article: Guru K, Anilkumar VA, Sunderraj Pandian JT. Effect
of gleno-humeral mobilisation and mobilisation of asymptomatic cervical spine
in patients with shoulder impingement syndrome: A pilot trial. Saudi J Health
Sci 2015;4:42-50.
Source of Support: Nil, Conflict of Interest: None declared.

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