The Effects of Manual Therapy and Scapular Exercise for the Pectoralis Minor in Individuals With Shoulder Pain

Shoulder pain is the third common problem, after problems of spine. Abnormal scapular kinematics, so called scapular dyskinesis, is believed to be associated with shoulder pain. Studies showed that individuals with shoulder problems demonstrate less upward rotation, posterior tilt and external rotation during shoulder movement. The shortness of the pectoralis minor (PM) is one of the factors leading to scapular dyskinesis. Short pectoralis minor has been shown to prevent scapula from tilting posterior and rotating externally during shoulder motion. The decreased scapular posterior tilt and external rotation may decrease subacromial space and result in impingement. However, although many assessment methods have been used to assess PM tightness or shortness, no study has tested the validity of these testing methods. Moreover, although stretching exercises for PM have been shown to increase the PM length, previous studies found that PM stretching exercises did not restore scapular kinematics and did not further decrease pain and improve function. Shoulder pain and discomfort has also been reported during stretching. Therefore, rather than stretching exercise, other types of treatment that can specifically increase the PM length and restore scapular kinematics may be needed. Manual therapy could specifically increase the flexibility of PM, and scapular orientation exercises could improve scapular kinematics. These types of treatment may be better options. However, to our knowledge, no study has investigated whether manual therapy combined with scapular orientation exercises could improve scapular kinematics, pain and function. Therefore, the first part of this study is to investigate which tests for length or tightness of PM can predict the scapular dyskinesis. The second part of the study is to investigate the effects of manual therapy and scapular orientation training on PM length, scapular kinematics, pain, and function in subjects with shoulder pain. In the first part of the study, 67 healthy subjects will be recruited. In the second part, 62 patients with shoulder pain will be recruited and randomized into either a PM treatment group or a control group. While no treatment will be provided for the healthy subjects in the first part, subjects with shoulder pain in the second part will receive 12 sessions of treatment in 4-6weeks, with 30-40 minutes per session. Patients in the control group will receive general shoulder strengthening exercise, while patients in the PM treatment group will have additional manual therapy and scapular orientation exercise. The measures include tests of PM length, scapular kinematics in the first and second parts, and pain and shoulder disability were also additionally assessed in the second part.

Study Overview

• Status: Completed
• Conditions: Shoulder Pain; Scapular Dyskinesis; Shoulder Impingement
• Intervention / Treatment: Procedure: pectoralis minor intervention group; Procedure: shoulder strengthening group

• Study Type: Interventional
• Enrollment (Actual): 100
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Yin-Liang Lin, PhD; Phone Number: +886-2-2826-7288; Email: yllin1020@nycu.edu.tw
• Study Contact Backup: Name: Yi-zhen Li, BS; Phone Number: 0983125066; Email: a0983125066@gmail.com

Study Locations

• Taiwan
  • Taipei, Taiwan, 112
    • National Yang-Ming University
  • Taipei, Taiwan
    • Cheng Hsin General Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 20 years to 60 years (Adult)
• Accepts Healthy Volunteers: Yes
• Genders Eligible for Study: All

Description

Inclusion Criteria(patients with shoulder pain) :

1. the patients with shoulder pain from 20 - 60 years old
2. Active arm elevation close to 150 degrees
3. Shoulder pain at least 3 months

Inclusion Criteria (healthy people) :

1. the people from 20 - 40 years old
2. no any symptoms or injuries on shoulder one year ago

Exclusion Criteria:

1. Adhesive capsulitis
2. Pathologies of cervical origin
3. History of acute trauma, previous surgery, or fracture in the affected shoulder
4. Corticoid injection in the last 3 months
5. Platelet Rich Plasma injection in the last 1 year
6. Other manual and exercise physical therapy in the last 6 weeks
7. Anyone suffering from neurological diseases and nerve damage
8. Vulnerable subjects

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: pectoralis minor intervention group; The participants in pectoralis minor group will received manual therapy for pectoralis minor by investigators, the technique including stretch and soft tissue mobilization. The participants asked to perform the scapular control exercise and shoulder strength exercise. Participants will be correct scapular resting position and then do elevation in scapular plane.Four exercises for shoulder strength will do shoulder flexion, abduction, internal and external rotation with thera-band.	Procedure: pectoralis minor intervention group; The subjects in pectoralis minor group will received manual therapy for pectoralis minor by physical therapist, the technique including stretch and soft tissue mobilization. The subjects asked to perform the scapular control exercise and shoulder strength exercise.Subjects will be correct scapular resting position and then do elevation in scapular plane.Four exercises for shoulder strength will do shoulder flexion, abduction, internal and external rotation with thera-band.
Active Comparator: shoulder strengthening group; The participants in the scapular strengthening group will be asked to do four exercises for shoulder strength, including shoulder flexion, abduction, internal and external rotation with thera-band.	Procedure: shoulder strengthening group; The subjects in the scapular strengthening group will be asked to do four exercises for shoulder strength, including shoulder flexion, abduction, internal and external rotation with thera-band.
No Intervention: Healthy subject group; Healthy participants will be recruited. No Intervention will be provided. The correlation between measures of pectoralis minor length and scapular kinematics will be assessed. Measurement will be the same as pectoralis minor intervention group and shoulder strengthening group

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Pectoralis minor length	Measurement of pectoralis minor length: distance between coracoid process and fourth rib taken with a tape measure on resting position.	Change from baseline pectoralis minor length after 12 times intervention up to 6 weeks
Pectoralis minor index	The pectoralis minor length was divided by the participant's height and multiplied by 100 to calculate the pectoralis minor index	Change from baseline pectoralis minor index after 12 times intervention up to 6 weeks
Pectoralis minor tightness test I	Pressed the coracoid process of the subjects to make the scapula flat on the treatment bed.If flat the bed for negative,unable to flat the bed for positive.	Change from baseline pectoralis minor tightness test I after 12 times intervention up to 6 weeks
Pectoralis minor tightness test II	Subjects will forward flexion 30 degrees,and pressed the coracoid process.If physical therapist felt tightness for positive.	Change from baseline pectoralis minor tightness test II after 12 times intervention up to 6 weeks
Round shoulder posture test I	Measured the distance between the posterior border of the acromion and the table surface.	Change from baseline round shoulder posture test I after 12 times intervention up to 6 weeks
Round shoulder posture test II	Measured the vertical distance between the posterior acromion and the treatment bed,then divided by thorax thickness and multiplied by 100.	Change from baseline round shoulder posture test II after 12 times intervention up to 6 weeks
Scapular kinematics	Scapular kinematics, including anterior/posterior tilt, upward/downward rotation, and internal/external rotation in scapula plan elevation at 30°, 60°, 90°, and 120°, will be calculated and will be described with degree (°).	Change from baseline scapular kinematics after 12 times intervention up to 6 weeks

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Visual analog scale	Scores ranging from 0 (no pain) to 10 (maximum pain)	Change from baseline visual analog scale after 12 times intervention up to 6 weeks
Disabilities of the Arm, Shoulder, and Hand (DASH)	A maximum score of 100 indicates the worst possible condition	Change from baseline DASH after 12 times intervention up to 6 weeks
Patient-Specific Functional Scale (PSFS)	Identify 3 important activities that they were unable to perform. A minimum score of 0 is unable to engage in these activities, and a maximum score of 10 can still perform these activities as efficiently as before without shoulder pain.	Change from baseline PSFS after 12 times intervention up to 6 weeks
Global rating of change (GRC)	Independently score self-perceived improvement in a patient. A minimum score of -5 is the worse situation compared to before treatment. Compared to before treatment, a score of 0 means no change.Compared to before treatment, a score of 5 means full recovery.	After 12 times intervention up to 6 weeks

Collaborators and Investigators

• Sponsor: National Yang Ming University
• Collaborators: Cheng-Hsin General Hospital

Study record dates

Study Major Dates

• Study Start (Actual): November 17, 2021
• Primary Completion (Actual): August 12, 2022
• Study Completion (Actual): March 22, 2023

Study Registration Dates

• First Submitted: September 28, 2021
• First Submitted That Met QC Criteria: October 22, 2021
• First Posted (Actual): November 2, 2021

Study Record Updates

• Last Update Posted (Actual): March 23, 2023
• Last Update Submitted That Met QC Criteria: March 22, 2023
• Last Verified: March 1, 2023

More Information

Terms related to this study

• Keywords: pectoralis minor length; pectoralis minor index; scapular kinematic
• Additional Relevant MeSH Terms: Pain; Neurologic Manifestations; Wounds and Injuries; Joint Diseases; Musculoskeletal Diseases; Shoulder Injuries; Arthralgia; Shoulder Impingement Syndrome; Shoulder Pain
• Other Study ID Numbers: YM110136E

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No