The use of manual therapy as an adjunct to physiotherapy for persistent shoulder pain: a feasibility study

Participants of the Manual Therapy Group will receive up to 8 physiotherapy sessions within a 3-month period. Two of the sessions will be one hour duration, and the remaining sessions will be half-hour. The weekly frequency will vary, negotiated individually between the physiotherapist and the patient. Patients will receive manual therapy, exercise prescription, patient education and guidance for physical activity during the 8 sessions. Manual therapy will be applied for at least 4 of the 8 sessions using a pragmatic approach based on clinical reasoning. The techniques may include the following: • Passive joint mobilisations (Maitland concept) • Mobilisations-with-movement (Mulligan concept) • The symptom-modification approach (Lewis) • Thoracic manipulations • Soft tissue mobilisations of the cervical spine, axio-scapular and glenohumeral muscles. Techniques will be based on the patient’s specific impairments (e.g. loss of range of movement or pain during a specific movement) and their functional goals. The dosage will be dependent on the pain intensity and the patient’s tolerance. Considerations will be the starting position (e.g. supine or prone, and angle of the arm), the direction of the mobilisation, and the grade of the oscillatory mobilisation [‘depth’ and amplitude]. For the Mulligan and symptom-modification approaches, articular glides that reduce the patient’s pain during a specific movement will be applied. The glides will be applied either manually (physiotherapist’s hands) or with a manual therapy belt, during 6 to 8 repetitions of the active movement. Progressions will be based on the patient’s pain/symptom responses immediately after the application (within session) and on return for the next appointment (between sessions). A. What (materials) Patient education: Guided by resources developed and collated by the research team: • Website https://shoulderpain.org.nz/ • Set of two Microsoft® Powerpoint files developed by the research team – (1) pain neurophysiology; (2) reasons for undertaking exercise and physical activity. Exercise prescription: Strength training equipment (free weights, resistance bands). Patient diaries to document goals; progress; physical activity and exercise; pain medication; visits to other health professionals; direct and indirect treatment costs. Belts used for mobilisations-with-movement. B. What (procedures): Communication, advice and education The physiotherapist will use a person-centered approach, using a culturally responsive approach to explore the patient’s pain experience, goals and devising a rehabilitation plan; motivational interviewing and reflective listening. Websites and Powerpoint files will guide provision of information. Topic sequencing will be individualised to each patient. The therapist will send a link to applicable videos to patients who will be able to watch them as often as they find helpful. Topics: • Anatomy of the shoulder Surface anatomy of trapezius, deltoid, biceps and triceps muscles; rotator cuff; tendinopathy, partial and full tear; common age-related changes of the rotator cuff. https://shoulderpain.org.nz/your-shoulder/shoulder-anatomy • Connecting with our nervous system The messenger system: neurons, nervous system; the alarm system: sensitivity of the nervous system; factors influencing the alarm system and pain; patterns in the brain (‘neurotags’); factors influenced by the ‘alarm system’ (stress, memory, sleep, concentration, digestion, immunity). https://youtu.be/yw0NCIb73Bc https://shoulderpain.org.nz/pain-management/pain-types-and-causes • Managing shoulder pain and wellness with movement: exercise and general physical activity Role of exercise and physical activity towards general health and wellness and desensitising the nervous system; role of specific exercises to strengthen the shoulder; pacing, ‘walking the line’. https://youtu.be/Ucao9wcl81Y Exercise prescription Exercises are designed to progressively load the shoulder and to promote general physical activity. We will follow the following processes: Stage 1: Early stage rehabilitation and shoulder symptom modification Low-level exercises (motor control exercises), slow, controlled movements, focussing on quality. Stage 2: Eccentric and heavy slow resistance exercises Progress shoulder-specific exercises using the Shape-Up-My-Shoulder (SUMS) approach considering potential variables such as increasing range, load (weight), frequency, speed. Stage 3: Functional programme Progressively returning to function in terms of individual-specific work, sports, daily activities and recreation. This phase overlaps with Stage 1 and 2, and consists of a general exercise programme, including general physical activity. The programme is individualised to the patient’s requirements and goals, and progressed C. Providers The intervention will be provided by registered physiotherapists (any experience level). They will be trained by the researchers at a one-day workshop, within the month prior to start of recruitment. The Health Psychology researcher (Swain) will train the clinicians for the therapeutic relationship/cognitive skills. Follow-up sessions will be held with the principal investigator via Zoom or in person. D. How Face-to-face physiotherapy care and self-directed home exercises. E. Where University of Otago School of Physiotherapy clinics, Dunedin and Christchurch, New Zealand. F. When and how much Recruitment is planned from February to August 2023. Physiotherapy care will be provided with up to 8 sessions across a three-month period: two of them will be one hour, and the remaining ones ½-hour duration. The frequency of the sessions across the three-month period will be based on the physiotherapist’s and patients’ collaborative decision. G. Tailoring A pragmatic approach will be used, tailored to the patients’ clinical presentation and approach. Education: sequencing of information provided to the patient will be dependent on the line of the conversations and questions asked by the patient. Exercise prescription: Starting dosage of exercises will be dependent on the assessment of their ability and tolerance during specific exercises. The load (weight), repetitions, sets and frequency will be assessed to be within the patient’s tolerance of discomfort/pain. In general, exercises will be prescribed with 15 repetitions with 2 or 3 sets on a daily basis. Progression will include the number of exercises (1 exercise to up to 6 exercises), body starting position, load, number of repetitions/sets/frequency, and speed. Prescription of general physical activity (e.g. walking) will also be based on the patient’s interest, past activity level, as well as current tolerance, for example, walking 15 minutes daily. H. Modifications Any modifications to the protocol will be documented and reported. I. Safety • Physical risks may include delayed onset muscle soreness (muscle stiffness) as a normal consequence of exercise. Participants will be asked to record these in their diary and report back to the physiotherapist. The physiotherapist will be asked to record the symptoms in their clinical notes. Exercises will be modified if the muscle stiffness is considered excessive by the participant. • Exercise or manual therapy may also flare up pain. The physiotherapist will discuss with the participant what level of discomfort or pain might be expected during the exercises. In most cases such exercise-related discomfort/pain settles within 24 hours. If it lasts longer than 24 hours and the participant considers the discomfort/pain excessive, they will be asked to avoid the specific exercise and report that back to the physiotherapist. The Physiotherapist will record such response in the clinical notes, and modify the exercises at a lower intensity. • Manual Therapy: there may be discomfort and pain during the application of manual therapy. The physiotherapist will continuously ask the participant to report such discomfort while applying the technique. Their response immediately following application will be assessed, following routine physiotherapy processes. The participant will be asked to report back at the next session what the symptom response following the treatment was. The physiotherapist will record their self-reported response, and will modify manual therapy applications accordingly.