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KEVIN D. HARRIS, PT, DSc1 • GAIL D. DEYLE, PT, DSc2 • NORMAN W. GILL, PT, DSc3 • ROBERT R. HOWES, PA-C4
Manual Physical Therapy for
Injection-Confirmed Nonacute
Acromioclavicular Joint Pain
S
houlder pain is a common reason for people to seek
treatment from a physical therapist. In 2003, approximately 13.7 million people in the United States
required medical care for shoulder pain,11 and the 12-
TTSTUDY DESIGN: Prospective single-cohort
study.
TTOBJECTIVES: To determine and document
changes in pain and disability in patients with
primary, nonacute acromioclavicular joint (ACJ)
pain treated with a manual therapy approach.
TTBACKGROUND: To our knowledge, there are no
published studies on the physical therapy management of nonacute ACJ pain. Manual physical
therapy has been successful in the treatment of
other shoulder conditions.
TTMETHODS: The chief inclusion criterion
was greater than 50% pain relief with an ACJ
diagnostic injection. Patients were excluded if they
had sustained an ACJ injury within the previous
12 months. Treatment was conducted utilizing a
manual physical therapy approach that addressed
all associated impairments in the shoulder girdle
and cervicothoracic spine. The primary outcome
measure was the Shoulder Pain and Disability
Index. Secondary measures were the American
Shoulder and Elbow Surgeon and global rating of
change scales. Outcomes were collected at baseline, 4 weeks, and 6 months. The Shoulder Pain
and Disability Index and American Shoulder and
Elbow Surgeon scale values were analyzed with a
repeated-measures analysis of variance.
month prevalence of shoulder
pain has been estimated to be
30%, which is second only to low
SUPPLEMENTAL
VIDEO ONLINE
back pain.50 Acromioclavicular
joint (ACJ) disease is reported
to be present in 31% of all patients with
shoulder pain.48 Additionally, as many as
TTRESULTS: Thirteen patients (11 male; mean
41% of all shoulder injuries in an athletic
 SD age, 41.1  9.6 years) completed treatpopulation involve the ACJ.33 Nearly half
ment consisting of an average of 6.4 sessions.
of the patients who sustain a grade I or
Compared to baseline, there was a statistically
II ACJ injury have a symptomatic ACJ 6
significant and clinically meaningful improvement for the Shoulder Pain and Disability Index
years after injury.43 Pain and dysfunction
at 4 weeks (P = .001; mean, 25.9 points; 95%
of ACJ origin may lead to an inability to
confidence interval [CI]: 11.9, 39.8) and 6 months
perform manual labor tasks and sports
(P<.001; mean, 29.8 points; 95% CI: 16.5, 43.0),
and difficulty with activities of daily
and the American Shoulder and Elbow Surgeon
living.
scale at 4 weeks (P<.001; mean, 27.9 points; 95%
The ACJ is a synovial joint that proCI: 14.7, 41.1) and 6 months (P<.001; mean, 32.6
vides the scapula with additional range
points; 95% CI: 21.2, 43.9).
of rotation on the thorax, which allows
TTCONCLUSION: Statistically significant and
the scapula to adjust outside of its initial
clinically meaningful improvements were observed
in all outcome measures at 4 weeks and 6
plane (posterior tipping and internal romonths, following a short series of manual therapy
tation) to follow the changing shape of
interventions. These results, in a small cohort of
the thorax as arm movement occurs.34,36
patients, suggest the efficacy of this treatment
Recent biomechanical studies demonapproach but need to be verified by a randomized
strated the ACJ’s significant role in overcontrolled trial.
all shoulder motion, which suggests that
TTLEVEL OF EVIDENCE: Therapy, level 4. J
the ACJ should not be overlooked in any
Orthop Sports Phys Ther 2012:42(2):66-80, Epub
patient with shoulder pain.36-38,58 We hy25 October 2011. doi:10.2519/jospt.2012.3866
pothesize that the nonacute symptomTTKEY WORDS: distal clavicle excision,
atic ACJ behaves in a physical manner
manipulation, mobilization, Mumford, shoulder
similar to that of other symptomatic or
Clinical Education Director, Physical Therapy Service; Fellow, Army-Baylor University Doctoral Fellowship in Orthopaedic Manual Physical Therapy, Brooke Army Medical Center,
Fort Sam Houston, TX. 2Professor, Baylor University Graduate School, Senior Faculty, Army-Baylor University Doctoral Fellowship in Orthopaedic Manual Physical Therapy,
Physical Therapy Service, Brooke Army Medical Center, Fort Sam Houston, TX. 3Graduate Program Director and Associate Professor, Army-Baylor University Doctoral Fellowship
in Orthopaedic Manual Physical Therapy, Physical Therapy Service, Brooke Army Medical Center, Fort Sam Houston, TX. 4Program Manager, U.S. Army-Baylor University
Doctorate of Science in Physician Assistant Studies in Clinical Orthopaedics, Orthopedics Service, Brooke Army Medical Center, Fort Sam Houston, TX. The Institutional Review
Board at Brooke Army Medical Center, Fort Sam Houston, TX approved this study. All participants provided written, informed consent prior to participation. The opinions and
assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Departments of the Army or Defense.
Address correspondence to Dr Kevin Harris, Physical Therapy Service, Fort Sam Houston Primary Health Clinic, 3851 Roger Brooke Drive, Fort Sam Houston, TX 78234. E-mail:
[email protected]; [email protected]
1
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degenerative joints, with loss of motion
due to pain, capsular stiffness, and/or
bony impingement. Presumably arthritic,
stiff and painful joints elsewhere in the
body have been shown to respond well to
an impairment-based manual physical
therapy approach in randomized clinical
trials.17,18,28,66
ACJ pain commonly presents with
localized superior shoulder pain, tenderness to palpation at the ACJ, and possibly
swelling in the presence of distal clavicle
osteolysis.6,23,65 Functional limitations of
ACJ pain include difficulty with resistance-training activities that place the
glenohumeral joint in an extended position.8,9,13,55 Current treatment of chronic
ACJ pain can be surgical or nonsurgical.
The operative approach, a distal clavicle
excision (DCE), or “Mumford” procedure,
is commonly performed. 9,21,49 However,
since the inception of the DCE in 1941
there have been no clinical trials to our
knowledge to define the role of the procedure relative to no intervention or lowerrisk interventions.7,26,44 Current evidence
regarding DCE as a treatment option for
nonacute ACJ pain is therefore derived
from studies comparing different surgical
techniques.9,19,21,35,49,53 Surgical complications for these procedures occur in 0%
to 64% of cases and include infection,
heterotopic ossification, joint instability, suprascapular neuropathy, and distal
clavicle fracture, in addition to complications associated with anesthesia. 3,9,12,24,59
Eskola et al20 investigated long-term results of patients managed with DCE for
complaints of ACJ pain and reported that
nearly 1 in 3 patients had poor long-term
outcomes and advised against DCE for
patients with higher functional demands
on their shoulders.
Current noninvasive management of
ACJ pain includes rest, activity modification, oral analgesics, nonsteroidal antiinflammatory medications, and ice. 9,55
However, evidence for these management
strategies is lacking.29 Injections of corticosteroids and/or anesthetic agents into
the ACJ may also be used.7-9,63 Corticosteroid injections have associated risks that
include subcutaneous fat atrophy, dermal
thinning, cellulitis, and septic arthritis.8,45
Relief of symptoms via corticosteroid
injection is reported to last anywhere
from 2 hours to 3 months and cannot
be considered a definitive treatment, as
demonstrated by multiple, separate prospective cohort studies in which 72% to
81% of patients failed to achieve a lasting
benefit.29,30,63
The only identified instance in the literature of nonsurgical management for
nonacute ACJ pain is a case report describing the use of glenohumeral mobilizations.14 However, there is evidence to
support the use of manual physical therapy for the treatment of individuals with
subacromial impingement syndrome
(SAIS).2,41,61 Systematic reviews show the
benefits of manual therapy compared
to other treatments for individuals with
SAIS.16,41 These benefits generally include
improved strength and function and decreased pain.2 Previous studies of manual
physical therapy treatment for SAIS and
nonspecific shoulder pain included techniques directed to the ACJ.2,10,51,61,68,69 Despite the body of evidence that includes
ACJ treatment, the ACJ may be overlooked when treating common pathology
of the shoulder girdle.8 There are no reported negative effects of manual therapy
directed to the ACJ in the literature.
The purpose of this study was to determine and document the short- and
long-term changes in pain and disability following the use of manual physical
therapy to treat movement impairments
and painful structures in the shoulder
girdle, upper extremity, chest, and cervicothoracic spine in patients with nonacute ACJ pain.
METHODS
Patients
T
he study was a prospective, single-cohort design. Consecutive patients presenting to the outpatient
physical therapy clinic at Brooke Army
Medical Center, Fort Sam Houston, TX,
between February 2010 and July 2010,
with a primary complaint of shoulder
pain were screened for eligibility criteria. Inclusion criteria required patients
to be 18 years of age or older, to be able
to read, write, and speak sufficient English to complete the self-report outcome
questionnaires, and report a greater
than 50% pain reduction following an
anesthetic-only ACJ injection within the
previous 30 days. Relief of pain after an
injection containing anesthetic into the
joint space of the ACJ is considered the
gold standard in diagnosing primary ACJ
pain.13,62,65 Patients were excluded if they
had a past history of the following: rheumatoid arthritis, connective tissue disorders (eg, systemic lupus erythematosus,
Sjogren’s syndrome, or polymyositis/dermatomyositis), infection, neurological
deficit, neoplastic growth in the shoulder
girdle, fracture or ligamentous injury of
any grade to the shoulder girdle within
the last 12 months, corticosteroid injection in the ACJ in the last 6 months, ACJ
surgery, or inability to attend at least 4
treatment sessions. All patients reviewed
and signed a consent form approved by
the Institutional Review Board at Brooke
Army Medical Center, Fort Sam Houston,
TX, prior to participation and the rights
of patients were protected.
Therapists
Three physical therapists participated
in the examination and treatment of all
patients in this study. The physical therapists were board certified in orthopaedic
physical therapy and were either faculty
or fellows in training in an orthopaedic
manual physical therapy fellowship program. Participating therapists had an average of 9.3 years of clinical experience
with a range of 8 to 12 years. In addition
to the common backgrounds and training of the physical therapists, a 2-hour
collaborative session on ACJ manual examination and treatment techniques and
strategies took place prior to beginning
the trial.
Examination Procedure
Patients who were eligible to partici-
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[
pate were advised of the trial. Once they
agreed to participate, the diagnostic injection (50% lidocaine, 50% marcaine)
was performed by an orthopaedic physician assistant. The diagnostic process
consisted of the patients performing an
activity to provoke their shoulder pain
and recording the associated pain level.
Following the injection, the activity was
performed in the same manner and pain
was reassessed. The patient was enrolled
in the study if there was at least a 50%
drop in the pain associated with the above
provocative activity. All patients who enrolled in the trial provided demographic
information, answered a standard medical history screening questionnaire, completed the Shoulder Pain and Disability
Index (SPADI), and completed the American Shoulder Elbow Surgeon (ASES)
scale during the initial visit. At the next
visit, all patients underwent a thorough
examination of the shoulder, chest, arm,
and cervicothoracic spine by the treating
physical therapist to determine impaired
movement and/or strength and the presence of pain and functional limitations.
Treatment was then initiated as indicated
by the results of the patient interview and
the manual examination.
Outcome Measures
Patients completed the SPADI and the
ASES scale at baseline, 4 weeks, and
6 months. The primary outcome measure was the patients’ perceived level of
pain and disability, as measured by the
SPADI, at the 6-month follow-up visit.
The SPADI and the ASES scale are commonly used shoulder-specific self-report
questionnaires that have been demonstrated to be valid, reliable, and responsive to change.57 The SPADI consists of
2 subscales, pain and disability, which
are combined to produce a total score
ranging from 0 (no pain or functional
difficulty) to 100 (highest level of pain
and functional difficulty). The SPADI
is reliable,40 valid,39 and responsive4 for
shoulder pain of musculoskeletal, neurogenic, or undetermined origin.27,56,57 The
minimal clinically important difference
research report
(MCID) for the SPADI is 10 points.42,67
The ASES scale consists of equally
weighted pain and disability subscales,
where the 2 subscales are combined to
produce a total score ranging from 0
(highest levels of pain and functional
difficulty) to 100 (no pain and no functional difficulty). The pain score of the
ASES scale is calculated from a single
pain question and a corresponding visual analog scale. The function score of the
ASES scale is calculated from the sum of
10 questions addressing function using a
4-point ordinal scale. Two of the 10 functional items on the ASES scale are left
blank so that patients may tailor the instrument by writing in additional specific
functional activities that are difficult for
them to do. The ASES scale is a reliable,
valid, and responsive instrument that
measures functional limitations and pain
in people with musculoskeletal shoulder
pathologies.54 The 2 blank write-in questions were transferred at baseline to the
4-week and 6-month forms for each patient. To minimize potential sources of
bias, all outcome measures were administered and verified by associate investigators who were not involved with treating
the patients.
Additionally, at the 4-week and
6-month follow-ups, patients answered
a global rating of change (GROC) question, based on the scale described by Jaeschke et al,31 to rate their own perception
of overall change in all symptoms. The
GROC is a 15-point Likert scale ranging
from –7 (“a very great deal worse”) to 0
(“about the same”) to +7 (“a very great
deal better”). Intermittent descriptors
of worsening or improving are assigned
values ranging from –1 to –7 and +1 to +7,
respectively. The MCID for the GROC is
arbitrary, although it has been reported
that scores of +4 and +5 indicate moderate changes in patient status and scores
of +6 and +7 indicate large changes in
patient status.31,32
Intervention
Patients attended a 30-minute clinical
session twice a week for 3 weeks after
]
enrollment. The treating therapist could
decide to add or subtract visits as needed, similar to clinical practice. Patients
were asked to keep a log of their medication usage throughout the trial. Patients
were not discouraged from engaging in
physical activities unless the therapist
determined that a specific activity was
not well tolerated and directly aggravated their shoulder condition. Patients
were not discouraged from seeking additional medical attention or receiving an
injection.
An impairment-based manual physical therapy approach was used for clinical
decision making during examination and
treatment.1 The examination focused on
identifying impairments to movement,
relevant muscular weakness, painful
structures, functional limitations, and
was tailored to the patients’ tolerance
based on the severity and behavior of
their symptoms. The manual therapy
treatment was also tailored to patient
tolerance and focused on addressing the
impairments identified during the examination.17,18 Treatment primarily consisted
of passive joint mobilization. Although
the majority of treatment was focused
on the ACJ, manual physical therapy
treatments were also administered to
the glenohumeral, sternoclavicular, and
scapulothoracic joints, as well as the rib
cage and cervicothoracic spine if impairments in those regions were judged by
the physical therapist to contribute to the
patient’s pain, stiffness, functional limitation, or disability.2 The physical therapists continued this tailored approach
through subsequent treatment sessions
by examining the patient to determine
the response to each intervention and
repeating or progressing the techniques
that produced the desired effects.
The primary treatment techniques
were passive accessory glides of the distal end of the clavicle with the upper extremity in various physiological positions
selected to make the ACJ treatment technique less painful. At other times, positions were selected to be more consistent
with a position of pain during activity.
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Commonly used ACJ and glenohumeral
joint mobilization techniques and progressions are described in APPENDIX A.
Descriptions of these commonly used
cervicothoracic techniques can be found
in several recent publications.5,25,42,52,60,64
The treating physical therapist documented the quantity of manual treatment performed on each body region. In
this study, 1 “treatment” was operationally defined as 3 periods of 30 seconds
of mobilization (grades I-IV) or 1 thrust
manipulation. The physical therapist
could supplement in-clinic treatment
with home exercises that reinforced the
manual treatment, such as active-assisted shoulder flexion in supine or assisted
shoulder internal rotation (APPENDIX B).
However, no strengthening or self-mobilization exercises were prescribed by
the physical therapists before the 4-week
follow-up visit.
At the 4-week follow-up visit, patients
received instructions for a home-exercise
program that consisted of strengthening
and range-of-motion exercises. The patients were provided with handouts containing pictures and clear instructions
on dosing and exercise progressions.
Colored elastic bands were provided for
progressive-resistance strengthening.
The exercises prescribed were intended
to supplement the manual physical therapy provided in the clinic and were chosen from a list of routinely used exercises
(APPENDIX B). Patients were instructed to
perform the home exercises 3 times per
week and were given a log to track their
compliance. “Good” compliance was determined to be performance of the program at least twice per week.
Patients were invited back to the clinic
4 months after enrollment to determine if
any “booster” treatments were necessary.
Treatment resumed if the patient and
physical therapist mutually agreed that
additional treatment was likely to be beneficial. There was no limit on the number
of subsequent treatment sessions. Finally,
patients returned to the clinic 6 months
after enrollment for the final assessment
of the outcome measures. Patients were
Assessed for eligibility, n = 223
Excluded, n = 208:
• Less than 50% pain relief
after injection, n = 3
• Did not meet inclusion
criteria, n = 189
• Declined to participate, n = 8
• Presented with
contraindications, n = 1
• Sustained recent trauma,
n=4
• Received corticosteroid
injection, n = 3
Enrolled, n = 15
Attended initial appointment, n = 14
Never returned for initial
appointment, n = 1
Treatment provided twice per week
for 3 wk
4-wk follow-up, n = 13
Unable to make time commitment,
n=1
6-mo follow-up, n = 13
FIGURE 1. Flow diagram of patient recruitment and retention.
also asked about the medications they
were taking for their shoulder pain, their
current activity level, home exercise program compliance, any subsequent injuries, and whether they had sought other
care for their shoulder pain.
Data Analysis
The study had a single-group, withinsubjects, repeated-measures design, with
1 independent variable and 3 dependent
variables. The independent variable was
time with 3 levels (baseline, 4 weeks,
and 6 months). The dependent variables
were the SPADI, ASES scale, and GROC
values. Descriptive statistics, including
frequency counts for categorical variables and measures of central tendency
and dispersion for continuous variables
were calculated to summarize the data.
Statistical model assumptions of normality and sphericity were assessed and the
Greenhouse-Geisser correction was used
for any comparisons found to violate the
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[
sphericity assumption. The primary outcome of interest was change in SPADI
values over time. This was examined
with a 1-way repeated-measures analysis of variance, with the alpha level set
at .05, and time (baseline, 4 weeks, and
6 months) as the within-subjects factor.
The ASES scale values were also analyzed in this manner. Planned pairwise
comparisons were performed to examine
the differences between baseline and the
follow-up periods using Sidak correction
and with 95% confidence intervals (CIs)
also calculated for mean differences. An
intention-to-treat analysis was planned
to account for any dropouts, with missing
data substituted by the “last value carried
forward” method. Frequency distributions and a mean value were determined
for the GROC. All data were analyzed using SPSS Version 16.0 for Windows software (SPSS Inc, Chicago, IL).
research report
TABLE 1
]
Baseline Demographics
Variable
Value
Patients, n
13
Gender (male/female), n
11/2
Age (mean  SD), y
41.1  9.6
Median symptom duration (range), mo
6 (2-240)
Dominant side affected, n
6
Normal radiographs per radiologist, n
4
Taking medication for shoulder, n
5
100
90
80
70
60
50
40
RESULTS
T
wo hundred twenty-three patients with a primary complaint of
shoulder pain were screened for
possible eligibility criteria. Of the 26 patients who were offered participation, 6
declined due to the time commitment,
2 did not want the injection, and 3 did
not achieve at least 50% pain relief following the injection. Fifteen patients,
therefore, met the inclusion criteria and
consented to participate in the study. One
participant failed to return after enrollment but before any treatment, and another patient began treatment but only
completed 2 treatment sessions due to
military training requirements (FIGURE 1).
Thirteen patients (mean  SD age,
41.1  9.6 years; 85% male; symptom
duration range, 2 to 240 months) completed treatment as prescribed and returned for follow-up visits at 4 weeks and
6 months (TABLE 1). The average number
of treatment sessions was 6.4, which
included booster visits for 3 patients.
Between baseline and the 6-month follow-up visit, none of the patients sought
additional medical care, had a subse-
34.6
30
20
10
8.7*
4.8†
0
Baseline
4 wk
6 mo
FIGURE 2. Means and standard deviations for the Shoulder Pain and Disability Index (SPADI) scores. Two
subscales, consisting of pain and disability, are combined to produce a total score ranging from 0 (no pain or
functional difficulty) to 100 (highest levels of pain and functional difficulty). The minimal clinically important
difference for the SPADI is 10 points.42,67 *Significant difference from baseline (P = .001). †Significant difference
from baseline (P<.001).
quent injection, decreased their activity
level, or increased medication usage for
their shoulder pain. Home exercise program compliance was judged to be good
in 54% and poor in 15.4% of the cohort;
however, by the 6-month follow-up visit,
30.8% stopped the exercises for reasons
unrelated to their symptoms or functional limitations.
The repeated-measures analysis of
variance was statistically significant for
the SPADI (F = 29.2, P<.001) and the
ASES scale (F = 34.3, P<.001). Post hoc
comparisons revealed statistically significant and clinically meaningful improvements compared to baseline for the
SPADI at 4 weeks (P = .001; mean, 25.9
points; 95% CI: 11.9, 39.8) and 6 months
(P<.001; mean, 29.8 points; 95% CI: 16.5,
43.0) (FIGURE 2) and the ASES scale at 4
weeks (P<.001; mean, 27.9 points; 95%
CI: 14.7, 41.1) and 6 months (P<.001;
mean, 32.6 points; 95% CI: 21.2, 43.9)
(FIGURE 3). The mean  SD GROC at 4
weeks was 5.4  1.3, which corresponds
to “quite a bit better.” The average  SD
GROC value at 6 months was 6.3  0.6,
which corresponds to “a great deal better.” Individual outcomes at each time
point are displayed in TABLE 2.
For the 1 patient who began treatment
and dropped out, the intention-to-treat
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100
Cx SCJ
Tx
2% 1%
4%
92.0*
87.4*
90
80
70
GHJ
15%
59.5
60
50
ACJ
78%
40
30
20
10
0
Baseline
4 wk
6 mo
FIGURE 3. Means and standard deviations for the American Shoulder and Elbow Surgeon (ASES) scores. Minimal
clinically important difference is 6.4. The ASES consists of equally weighted pain and disability subscales, where
the 2 subscales are combined to produce a total score ranging from 0 (highest levels of pain and functional
difficulty) to 100 (no pain and no functional difficulty). *Significant difference from baseline (P<.001).
TABLE 2
Individual Outcomes
SPADI
Patient
ASES
GROC
Baseline
4 wk
6 mo
Baseline
4 wk
6 mo
4 wk
6 mo
1
16.2
6.9*
4.6
73.3
98.3
98.3
7
6
2
29.2
12.3
2.3
53.3
61.7
98.3
4
7
3
13.9
2.3
4.6*
48.3
96.7
88.3
6
6
4
44.6
16.2
6.2
73.3
83.3
98.3
5
6
5
27.7
5.4
1.5
65.0
81.7
96.7
5
6
6
17.7
3.1
0.0
71.7
98.3
100.0
6
7
7
25.4
6.2
2.3
76.7
85.0
90.0
3
7
8
64.6
3.9
20.0
38.3
74.0
53.3
6
6
9
22.3
13.9*
1.5
68.3
88.3
98.3
4
6
10
22.3
2.3
1.5
56.7
100.0
100.0
7
7
11
31.5
9.2
7.7
66.7
96.7
90.0
7
5
12
67.7
30.0
10.0
51.7
75.0
85.0
4
6
13
66.2
1.5
0.0
30.0
96.7
100.0
6
7
Abbreviations: ASES, American Shoulder and Elbow Surgeon scale; GROC, global rating of change;
SPADI, Shoulder Pain and Disability Index.
*Change value did not exceed minimal clinically important difference compared to baseline.
analysis was conducted by carrying the
last value (baseline value) forward. At
4 weeks, the average improvement in
SPADI values obtained from this analysis
was 24.0 points (P<.001; 95% CI: 13.2,
34.9). As a sensitivity analysis, these results were similar to the analysis of the
completers; therefore, we determined
that the findings were not sensitive to a
more conservative analysis.
The ACJ was the primary focus of
treatment and 78% of all manual therapy treatment performed in this study
targeted that joint (FIGURE 4). All patients
FIGURE 4. Treatment provided, with “treatment”
operationally defined as 3 periods of 30-second
mobilizations (grades I-IV) or 1 repetition of a
thrust manipulation (grade V). Abbreviations: ACJ,
acromioclavicular joint; Cx, cervical spine; GHJ,
glenohumeral joint; SCJ, sternoclavicular joint; Tx,
thoracic spine.
received manual physical therapy treatment for the ACJ and had at least 1 additional region or joint treated with manual
physical therapy techniques. All 450
treatments performed in this study were
grade III or IV mobilizations or grade V
thrust manipulations into the resistance
range of joint motion; no grade I or II
joint mobilizations were performed.
DISCUSSION
W
e observed a positive and clinically meaningful improvement in
patients who had ACJ pain and
dysfunction, as measured by the SPADI
and ASES scale, following an average of
6.4 treatment sessions using an impairment-based manual physical therapy
approach. The benefits were noted at 4
weeks and persisted to 6 months. These
observed changes are clinically important
because they exceeded the MCID for the
SPADI and the ASES scale. We can be
reasonably confident in this observation
because the lower boundaries of the 95%
CIs exclude the MCID for both outcome
measures at both time points.47 Additionally, the raw SPADI scores at 4 weeks and
6 months approached those of an asymptomatic population.15 The GROC values
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[
indicated moderate to large overall improvement. The observed outcomes in this
cohort are consistent with those of other
studies that used a similar impairmentbased manual therapy approach for the
treatment of subacromial impingement,2
mechanical neck pain,64 knee osteoarthritis,17,18 and lumbar spinal stenosis.66
The manual therapy approach utilized
in this study was pragmatic and is generalizable to typical outpatient orthopaedic
physical therapy settings. Although we
had the ability to confidently diagnose
primary ACJ pain in our patients by using a gold standard criterion, a diagnostic injection is typically not necessary in
clinical practice. This manual therapy
approach, when the history and examination findings suggest ACJ involvement,
may be a reasonable strategy even in the
absence of a diagnostic injection. In this
cohort, the majority of treatment provided was specifically directed to the ACJ.
The sample, relative to the number
of patients screened for this pathology,
was small due to the necessity of recruiting a homogenous group of patients who
presented with nonacute primary ACJ
pain. However, additional benefits may
be derived from treating the ACJ in patients with SAIS because the ACJ may
be responsible for some of the symptoms
associated with SAIS.22,36,46 The ACJ also
may influence the overall function of the
shoulder girdle, suggesting that it be included in the examination of shoulder
conditions. The observed changes in this
trial contradict the opinion by Buttaci et
al8 that physical therapists have little to
offer patients with chronic ACJ pain.
The pain and disability scores in our
cohort of patients were similar at baseline, as measured by the ASES scale, to
those of a cohort of patients who elected
surgical intervention after a diagnosis
of primary ACJ pain.9 Additionally, the
short-term and long-term outcomes observed in this study were similar to the
outcomes of patients who underwent
surgery.9 This suggests that a manual
physical therapy approach may be a noninvasive option for the population tradi-
research report
tionally treated with surgery.
Clinical Reasoning
The impairment-based manual therapy
approach utilized in this study was a
complex patient-centered process that
utilized clinical reasoning and careful
clinical decision making. At every encounter, the physical therapist judged
the likely tolerance of the patient to the
manual forces used in the examination
and treatment to limit the possibility
of increasing symptoms while achieving timely improvement. These judgments included how much to examine
the patient globally, which movements
to examine, how vigorously to mobilize,
how to monitor pain while treating impaired movement, and the appropriate
dosage of mobilizations in a given session. Other treatment decisions included
when to layer in additional mobilization
techniques and exercises specifically for
the ACJ or other regions, and in what
manner to progress a manual technique
or exercise. Patients were commonly
progressed within 2 to 3 visits to higher
grade mobilizations in increasingly demanding positions of function based on
their response to mobilizations in more
neutral positions (APPENDIX A). Exercises
were carefully dosed, initially selected to
reinforce manual treatment of movement
impairments, and later progressed and
tailored to include strengthening.
Limitations
The outcomes of this prospective cohort should be interpreted with caution
because, due to the study’s single-group
design, a cause-and-effect relationship
between the intervention and observed
outcomes experienced by the patients
cannot be inferred. As such, the efficacy
of the intervention program cannot be
generalized to a larger population. Potential confounding variables were addressed at the 6-month follow-up visit.
None of the patients reported outside
treatment and 3 of the 5 patients who
were taking medication prior to treatment did not require medication after
]
completion. Home exercise program
compliance was 54% and the strengthening exercise program did not begin until
after the 4-week follow-up. An improvement due to the passage of time is a possible explanation in this design; although,
due to the chronic nature of the patients’
symptoms (median duration, 6 months;
range, 2-240 months) at enrollment in
the study, this is unlikely. Each of these
factors may influence the magnitude and
direction of change in pain and function
in future trials and should therefore be
considered accordingly.
The results of this trial offer preliminary data for future research investigating interventions for nonacute ACJ pain.
Future studies should include comparisons between this approach and other
approaches or sham treatment and could
possibly include comparisons of this
impairment-based manual therapy approach to steroid injections or surgery.
Moreover, the contribution of the ACJ
to the signs and symptoms associated
with other shoulder conditions should
be investigated.
CONCLUSION
S
tatistically significant and
clinically meaningful short-term
and long-term improvements in
shoulder pain and disability were observed in a prospective cohort of 13 patients with nonacute ACJ pain who were
treated with 6 sessions of impairmentbased manual therapy. Because this was
a small cohort of patients without a comparison group, the efficacy of this intervention cannot be determined. However,
the positive changes observed are similar
to those seen in randomized trials of other orthopaedic conditions treated with a
similar manual therapy approach. These
results may provide clinical guidance as
preliminary evidence of a low-risk, lowcost, pragmatic approach for the treatment of nonacute ACJ pain. t
KEY POINTS
FINDINGS: Statistically significant and
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clinically meaningful reductions in
shoulder pain and disability were observed in a prospective cohort of patients with nonacute ACJ pain treated
using an impairment-based manual
therapy approach for an average of 6.4
treatment sessions. These results remained at 6 months.
IMPLICATIONS: Physical therapists should
consider using a comprehensive manual
therapy approach to manage patients
with nonacute ACJ pain.
CAUTION: As a single-group study, cause
and effect cannot be inferred.
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APPENDIX A
COMMONLY USED ACROMIOCLAVICULAR JOINT
MOBILIZATIONS AND LINES OF PROGRESSION
Caudal Glide Progression
Arm at side
Arm in
abduction
Prone, arm
flexed
Impairments with caudal glide commonly found
with difficulty in elevating arm
Loaded
position
Progression of position and grade
of mobilization
Caudal Glides, Grades I-V
• P
atient position
- Supine, arm at side, minimal glenohumeral joint (GHJ) extension
• Therapist position
- Place the tips of both thumbs on the superior surface of the clavicle adjacent to the acromioclavicular joint (ACJ); spread fingers out for stability
- Position forearms in line with the caudal movement at the ACJ
• Mobilization technique
- Graded oscillatory mobilization is applied by the arms, acting through stable thumbs
- May span the joint or be proximal to joint along distal clavicle
- May alter angle to a more medially directed force
Alternate Technique for ACJ Caudal Glides
• L ay “passive thumb” along distal clavicle
• Apply caudally directed force through opposite pisiform
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APPENDIX A
Caudal Glides in Abduction
• P
atient position
- Supine, arm abducted, minimal GHJ extension
• Therapist position
- Place the tips of both thumbs on the superior surface of the clavicle adjacent to the ACJ;
spread fingers out for stability
- Position forearms in line with the caudal movement at the ACJ
• Mobilization technique
- Graded oscillatory mobilization is applied by the arms, acting through stable thumbs
- May span the joint or be proximal to joint along distal clavicle
- May alter angle to a more medially directed force
Caudal Glides in Prone Flexion
• P
atient position
- Prone upper extremity flexed overhead with forearm
resting on chair
• Therapist position
- Standing at patient’s head
- Thumbs on distal clavicle, fingers splayed out for
stability
• Mobilization technique
- Apply caudally directed mobilization
Caudal Glides in Loaded Position
• P
atient position
- Prone on elbows
• Therapist position
- Standing
- Thumbs on distal clavicle
• Mobilization technique
- Caudal
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APPENDIX A
Caudal Glides in Loaded Adduction
• P
atient position
- Prone on elbows
- Leaning to ipsilateral side
• Therapist position
- Standing
- Thumbs on distal clavicle
• Mobilization technique
- Caudal
Caudal Glides in Loaded Position
• P
atient position
- Prone
- Arm abducted and off plinth
- Hand in contact with surface
• Therapist position
- Standing
- Thumbs on distal clavicle
• Mobilization technique
- Caudal glide
Anterior to Posterior (AP) Glide Progression
Seated, internal
rotation bias
Arm at side
Impairments with AP glide commonly found
with difficulty in horizontal adduction or internal
rotation
Seated
Seated, flexed,
horizontally
adducted
Progression of position and grade
of mobilization
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APPENDIX A
AP Glides in Supine, Grades I-V
• P
atient position
- Supine
• Therapist position
- Place the tips of both thumbs on the anterior surface of the clavicle adjacent to the ACJ; spread
fingers out for stability
- Position forearms in line with the posterior movement at the ACJ
• Mobilization technique
- Graded oscillatory mobilization is applied by the body and arms, acting through stable thumbs
- Pad of the outer thumb should feel the joint motion (feel for the stationary acromion process)
- Variations: use the pisiform to apply posterior mobilization or use acromioclavicular (AC) shear
test technique
AP Mobilization in Sitting, Grades I-V
AP Mobilization in Sitting, Grades I-V
• P
atient position
- Seated
• Therapist position
- Standing perpendicular to shoulder
- Apply 1 hand along distal clavicle
- Apply the other hand across posterior acromion
• Mobilization technique
- Apply graded AP mobilization
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APPENDIX A
AP Mobilization, Grades I-V, for Internal Rotation Bias
• S
ame as previous technique, except preposition patient in internal rotation
• Progress position, grade, and/or dosage
as tolerated
AP Mobilization in Flexion, Grades I-V, for Horizontal Adduction Bias
• P
atient position
- Seated or standing
- Forearm resting on stable surface (plinth, cabinet, etc)
• Therapist position
- Perpendicular to shoulder
- AP hand position
• Mobilization technique
- Apply graded AP mobilization
Posterior-to-Anterior (PA) Mobilization in Prone, Grades I-V
• P
atient position
- Prone
- Arm off table
• Therapist position
- Standing near axilla of patient
- Place the tips of both thumbs on the posterior distal
clavicle
• Mobilization technique
- Apply graded PA mobilization
- May combine with previous "loaded" techniques
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APPENDIX A
Clavicle Rotation (Wiggle)
• P
atient position
- Supine
• Therapist position
- Stand near the patient's shoulder, facing toward the clavicle
- Gently grip the mid clavicle, using the thumbs on the inferior edge and fingertips superiorly
• Mobilization technique
- Apply a gentle mobilization force using a rocking or "wiggling" motion through repetitive wrist
flexion and extension
- Works as a nice, easing technique following direct AC and/or sternoclavicular (SC) joint
mobilizations
APPENDIX B
LIST OF THERAPEUTIC EXERCISES
To be performed in a well tolerated and painless manner.
Range of Motion
These may be performed as passive, active-assisted, or active movements, as determined by the therapist.
• Flexion in upright or supine position
• Internal rotation using a cane behind the back
• Anterior chest and shoulder stretch (pectoralis major stretch)
• Horizontal adduction
Strengthening
• Pain-free push-up progression
- Start with wall push-ups not exceeding 90° of elbow flexion
- Progress to varying angles of trunk inclination
• Resisted tubing
- Internal rotation
- External rotation
- Flexion to 90°
- Abduction in the plane of the scapula to 90°
• Scapular stabilization progression (scapular retraction/protraction)
- Progression
• On all fours with elbows straight
• Incline push-up position
• Regular push-up position
80 | february 2012 | volume 42 | number 2 | journal of orthopaedic & sports physical therapy
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