Integrating Mulligan Mobilization with Scapular Focused Exercises Brings Increased Benefits to Rock Climbers Suffering Shoulder Impingement Syndrome

doi:10.21203/rs.3.rs-4857049/v1

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Research Article

Integrating Mulligan Mobilization with Scapular Focused Exercises Brings Increased Benefits to Rock Climbers Suffering Shoulder Impingement Syndrome

https://doi.org/10.21203/rs.3.rs-4857049/v1

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Background: Shoulder impingement syndrome is a prevalent condition among athletes, often resulting in decreased athletic performance due to altered proprioception, muscle imbalances, and altered movement patterns. This study aimed to investigate the effects of eight weeks of focused scapular training combined with mobilization on pain reduction and proprioception improvement in female rock climbers with shoulder impingement syndrome.

Methods: Thirty-six female rock climbers with shoulder impingement syndrome were randomly assigned to three groups: the scapular focused exercises group (n=12), the scapular focused exercises with mobilization group (n=12), and the control group (n=12). The intervention consisted of eight weeks of scapular-focused exercises, with or without mobilization, in addition to regular rock-climbing activities. Compared with those in the control group, significant reductions in pain and improvements in proprioception (joint position sense) were observed in both the scapular focused exercises and scapular focused exercises with mobilization groups (P≤0.005).

Results: The findings suggest that eight weeks of scapular-focused exercise, with or without mobilization, resulted in improved pain reduction and proprioception in female rock climbers with shoulder impingement syndrome. Compared with the control, the addition of mobilization to scapular-focused exercises resulted in better scores.

Conclusions: These results highlight the potential benefits of incorporating scapular exercises and mobilization into rehabilitation programs for athletes with shoulder impingement syndrome.

Trial registration: Retrospectively Registered. Ethics. research.ac.ir Identifier: IR.SSRC.REC.1402.170 on 2023-10-22

Shoulder impingement syndrome

Exercise

Mobilization

Joint position sense

Pain

Rock-climbing

Rock climbing requires significant upper body weight-bearing, leading to a high incidence of injuries in the shoulders, elbows, forearms, wrists, and hands, accounting for 42.6–71.4% of all climbing injuries, the highest among any anatomical region(1, 2). Shoulder injuries are the second most common upper extremity injury after hand injuries, accounting for 17.2% of all injuries (3). Acute traumatic injuries can occur from falls from height, resulting in fracture, acromioclavicular separation, glenohumeral dislocation, and rotator cuff tears. Chronic overuse injuries mimic those of other overhead sport athletes, including chronic rotator cuff tears, impingement, and biceps tendinitis(4).

Shoulder impingement contributes to more than half of all disorders causing shoulder pain, making it the most common cause of shoulder pain(5, 6). The disorder can significantly affect an athlete's performance, as it alters their proprioception(7, 8), muscle imbalances, motor control(9), and movement patterns(10). Shoulder impingement syndrome can be caused by several factors, including weakness of the rotator cuff muscles, morphology of the acromion, muscle imbalance, laxity or tightness of the joint capsule, dysfunctional glenohumeral and scapulothoracic kinematics, degeneration, and inflammation of the tendons or bursa(11).

A variety of treatment modalities have been suggested for shoulder impingement syndrome, including electrotherapy, exercise therapy, massage, joint mobilization, joint manipulation, extracorporeal shockwave treatment, ultrasound treatment, laser treatment, and sling exercise treatment(12, 13). Several systematic reviews have evaluated the effectiveness of these modalities in treating shoulder disorders(14). Current evidence indicates that exercise has a statistically and clinically important effect on pain reduction and improving function(15).

Exercise(16–18) and joint mobilization(19, 20) have been suggested and used for shoulder impingement syndrome in the literature. Joint mobilization is frequently utilized to address hypomobility and enhance shoulder function, with the added benefit of alleviating pain(21, 22). Scapular focused training has been suggested as a potential intervention for shoulder impingement syndrome(23, 24). Additionally, mobilization techniques have been used to improve joint mobility and reduce pain in these individuals. One such technique is Mulligan mobilization(25), which involves moving the joint in a weight-bearing position through continuous gliding and active movement. This technique is believed to help improve joint mobility, reduce pain, and optimize movement patterns in the shoulder joint(20).

Given the high incidence of shoulder injuries in rock climbers(3) and the significant impact of shoulder impingement on athletic performance, it is essential to explore effective treatment modalities for this population. Integrating mobilization techniques with scapular-focused training offers a promising approach for improving joint mobility, reducing pain, and optimizing movement patterns in individuals with shoulder impingement syndrome. Therefore, conducting this study is crucial for providing valuable insights into the impact of adding mobilization techniques to scapular-focused training in this population. The findings from this research can potentially inform more effective rehabilitation strategies for female rock climbers with shoulder impingement syndrome.

This study employed a semiexperimental and practical design, utilizing a pre-test and post-test approach as shown in Fig. 1. The research consisted of three groups: rock climbers with shoulder impingement syndrome, which were randomly assigned to one of three groups: exercise-focused on the shoulder with mobilization, mobilization, or control. After providing consent to participate in the research, 36 female rock climbers diagnosed with shoulder impingement syndrome were invited to join the study. The participants were informed that they could opt out at any time. Following ethical guidelines, written consent was obtained from all participants. The individuals were then randomly assigned to three groups: a shoulder-focused exercise with mobilization group (12 participants), a shoulder-focused exercise group (12 participants), and a control group (12 participants). Before the intervention commenced, pretests were conducted to assess pain and proprioception via specific tools. The group receiving scapular-focused exercises with mobilization engaged in a regimen of neuromuscular and stretching exercises combined with Mulligan mobilization three times a week for eight weeks. The second group focused on shoulder exercises and participated in three weekly sessions of neuromuscular, stretching, and resistance exercises for the same duration. The control group did not undergo any intervention and continued their daily activities until the post-test evaluation. The gathered data were subsequently analyzed to draw conclusions from the study.

Sample of study

In accordance with the inclusion criteria, the statistical population consisted of female rock climbers aged 18–30 years with shoulder impingement syndrome. A sample size of 33 patients was estimated via a power calculation, considering a power of 80% (1-β error probability), α = 0.05, and an effect size of 0.30. However, due to a 10% dropout rate, a total of 36 individuals were selected.

Participant Selection

The selected participants were asked to undergo preliminary examinations, and after the doctor's approval and explanation of the research criteria, they were given the opportunity to withdraw from the study at any time. Written consent forms were obtained from all participants. The participants were then randomly divided into three groups: the scapula-focused exercises with mobilization (SFEM) group (12 people), the scapula-focused exercises (SFE) group (12 people), and the control group (12 people) on the basis of the inclusion criteria. The entry criteria included female rock climbers aged 18–30 years, confirmed diagnosis of shoulder impingement syndrome by a doctor, general health (physical and mental health), Visual Analog Scale (VAS) pain score of 3–7, Body mass index (BMI) between 19–25, positivity of the Empty and Hawkins Kennedy tests, and no history of dislocation, partial dislocation or fracture.

Pain Assessment

The VAS scale measures the level of pain from 0 to 10 (Fig. 2). A score of 0 indicates no pain, whereas a score of 10 indicates uncontrollable pain. The participants were asked to choose their pain level from 0 to 10.

Proprioception Assessment (Joint Position)

Joint position sense is a specific aspect of proprioception that refers to the ability to perceive and recreate specific joint angles or positions accurately. The Biodex Multi-joint System, manufactured in the USA, was used to assess shoulder proprioception(7). Before the experiment, the subjects were trained to familiarize themselves with the device and its operation. The subjects were placed on the Biodex machine with their eyes closed and strapped to the chest to prevent trunk movement. The shoulder of the injured side was adjusted in the scapular plane at a speed of 5 degrees per second. The horizontal position of the dynamometer lever arm was set at an angle relative to 90 degrees. The subjects were asked to actively bring their shoulder to internal rotation at specified angles (45° and 90°) and hold each position for 10 seconds. The subjects were then asked to rest for 5 seconds before the process was repeated twice. The absolute value of the difference between the recorded angle and the target angle was recorded as an error (absolute angular error), and their average was used for statistical analysis.

The Scapula-Focused Exercises (SFE)

The training program consisted of 8 weeks, with 1-hour sessions conducted three times a week on nonconsecutive days. The participants were treated individually. The exercise protocol consisted of neuromuscular exercises and muscle-strengthening exercises. The neuromuscular exercises included towel slides, Proprioceptive Neuromuscular Facilitation (PNF) scapulas, inferior glides, and scapular clocks. The muscle-strengthening exercises included diagonal D1, push-up plus, full can, prone horizontal abduction with external rotation (90–135°), side-lying external rotation with abduction (0°), diagonal D2 eccentric, scapular punch, and horizontal rowing.

Each 1-hour session consisted of five exercises, including two neuromuscular control exercises and three muscle-strengthening exercises, which utilized dumbbells and elastic bands. The initial load was set at 60% of the one-repetition maximum and was increased to between 60% and 80% of the one-repetition maximum by the second week. During the first three weeks, three sets of 10 repetitions were performed for each exercise. In the fourth week, the exercises progressed to three sets of 12 repetitions, and in the fifth week, they progressed to three sets of 15 repetitions. The push-up plus exercise also underwent load progression, which was performed with the feet elevated on supports at heights of 20 cm and 40 cm.

The neuromuscular exercises progressed through an incremental increase in repetitions. The therapist provided stimuli tailored to the individual needs of each participant, ensuring proper exercise execution. The repetition protocol was gradually increased over the 8-week training period, with 10 repetitions per exercise in the first three weeks, 12 repetitions per exercise in week four, and 15 repetitions per exercise from week five to week eight (23).

Mobilization Technique

The Mulligan technique involves active accessory mobilizations of the humeral head, which are performed in various directions, including flexion, abduction, external rotation, and internal rotation(20). To execute the technique, patients were seated on a stretcher, while the physical therapist stood opposite the affected upper extremity. The physical therapist then stabilized the patient's shoulder girdle with their internal hand and used their thenar eminence to glide the humeral head. The direction of the glide was specifically chosen for treating shoulder limitations.

The patient was instructed to flex the affected shoulder until pain was felt, at which point the physical therapist maintained the gliding force to the humeral head. The therapist aimed to maintain the glide at a 90-degree angle to the plane of movement throughout the entire range, while the patient performed an active movement. The patient was reminded that the treatment should be pain free and should be stopped immediately if any pain was experienced during the treatment. The Mulligan technique lasted approximately 20 minutes and consisted of three sequences of 10 repetitions with a 30-second rest interval between each sequence.

Statistical analysis was performed via SPSS software version 26 at a significance level of 0.95 and an alpha value of less than 0.05. The demographic information of the subjects is outlined in Table. 1.

Table 1

The Demographic Information of the Subjects
Group	N	Age	Height	Weight
Scapula-Focused Exercise with Mobilization	12	24.69 ± 3.61	1.64 ± 0.03	58.50 ± 4.82
Scapula-Focused Exercise	12	25.09 ± 3.51	1.63 ± 0.03	58.22 ± 3.64
Control	12	24.39 ± 3.16	1.65 ± 0.04	58.91 ± 5.46

The Shapiro‒Wilk test was used to assess the normality of the data distribution, and the results indicated that the distribution was normal (p > 0.05). The results of the one-way analysis of variance revealed that there were no significant differences in the mean age (F (2, 32) = 0.126, p = 0.882), height (F (2, 32) = 0.562, p = 0.528), and weight (F (2, 32) = 0.065, p = 0.937) among the scapula-focused exercise with mobilization, scapula-focused exercise, and control groups. Table. 2 presents the descriptive data for the study's independent variables across all groups.

Table 2

The Mean ± Standard Deviation for Pain and Joint Position Sense (JPS) Variables
Group	Pain Pre-Test	Pain Post-Test	JPS Pre-Test	JPS Post-Test
Scapula-focused exercise with mobilization	5.64 ± 1.18	2.86 ± .91	3.96 ± .35	2.29 ± .36
Scapula-focused exercise	5.84 ± 1.21	2.94 ± .57	3.77 ± .54	2.48 ± .47
control	5.20 ± .85	5.04 ± .81	3.88 ± .43	3.92 ± .37

The analysis of repeated measures revealed a significant difference in pain scores and proprioception (joint position sense) among female rock climbers with shoulder impingement syndrome who participated in scapula-focused exercise with mobilization, scapula-focused exercises, and a control group (F (2, 32) = 81.01, p = 0.001, η2 = 0.83 for pain scores; F (2, 32) = 178.2, p = 0.001, η2 = 0.91 for proprioception scores). Post-hoc tests via the Bonferroni test indicated that both scapula-focused exercise with mobilization and scapula-focused exercise significantly reduced pain levels (p = 0.001) and improved proprioception levels (p = 0.001) compared with the control group. There was no significant difference in pain scores and proprioception between the scapula-focused exercise group and the scapula-focused exercise with mobilization group (p > 0.05).

This study investigated the effects of adding mobilization to scapula-focused exercises on pain and proprioception in female rock climbers diagnosed with shoulder impingement syndrome. The results indicated that the integration of mobilization with scapula-focused exercises led to a significant reduction in pain levels and better proprioception (joint position sense) than did the baseline and control interventions.

The results regarding the positive effects of mobilization and scapula-focused exercises in reducing pain and improving proprioception in individuals with shoulder impingement syndrome are in line with those of previous studies (15, 17–20, 23, 25, 26). The process of complex sensory experience is closely related to pain and proprioception. Abnormal movements are caused by pain, and on the contrary, pain can cause abnormal movements (27). Therefore, addressing pain is essential for improving movement patterns and overall skeletal-muscular function. The reduction in pain may be attributed to the specific design of the mobilization technique to reduce shoulder pain during active movement, as well as the ability to reduce pain with active movement. The Mobilization With Movement (MWM) technique has been shown to provide immediate pain relief in individuals with shoulder impingement by promoting proper alignment, and by targeting areas of restriction or stiffness, mobilization can help improve the overall range of motion in the shoulder joint, reduce impingement and alleviate pain. (19).

Correcting abnormal muscle tension and joint alignment may also contribute for reducing shoulder pain(28). Postural changes(8), muscle imbalances(29), and overuse(30) can cause chronic shoulder pain, which can be addressed by mobilization with scapular focused exercises.

This exercise protocol could have been effective in reducing pain and improving proprioception in shoulder impingement syndrome patients by promoting neuromuscular control, strengthening the shoulder muscles and incorporating specific exercise variations to challenge the shoulder joint in different ways. The combination of mobilization with focused scapular exercise mobilization and exercise can help optimize movement patterns in the shoulder joint, promoting proper alignment and mechanics during shoulder movements(31). By improving the coordination and balance of muscles around the shoulder, individuals can reduce unnecessary stress on the joint, leading to decreased pain and improved function. Additionally, scapula-focused exercises can increase muscle activation of the shoulder complex(28), may help to break down scar tissue, increase blood flow to the affected area, and rebuild scar tissue fibers, which can help reduce pain and improve impingement. Mobilization techniques may help reduce inflammation in affected structures by promoting blood flow and lymphatic drainage(32), which can help decrease pain associated with shoulder impingement syndrome and facilitate the healing process.

Pain reduction can improve joint position sense in patients with shoulder impingement syndrome by enhancing sensory feedback, proprioception, and neuromuscular control(33). Pain can disrupt sensory feedback from the affected shoulder, leading to impaired perception of joint position(7). By reducing pain through interventions such as joint mobilization, individuals can regain more accurate sensory information from the shoulder joint, allowing for better awareness of joint position and movement. Pain in the shoulder can affect proprioceptive signals from muscle spindles, Golgi tendon organs, joint receptors, cutaneous receptors and proprioceptive nerve signals, which are crucial for maintaining joint position sense(33). When pain is reduced, proprioceptive input from the shoulder joint is better preserved, enabling individuals to have a more precise perception of joint position and movement. Pain can alter neuromuscular control and coordination(9) in the shoulder muscles, impacting joint stability and position sense. By reducing pain, individuals can restore proper neuromuscular function, leading to improved muscle activation patterns and better joint positioning during movements. Pain can also influence movement patterns (34, 35) and compensatory strategies in individuals with shoulder impingement syndrome, potentially compromising the sense of joint position. When pain is alleviated, individuals can adopt better movement patterns, allowing for better alignment of the shoulder joint and enhanced joint position sense. When exercise is coupled with the Mulligan technique, which promotes active movement and feedback mechanisms, individuals can enhance their proprioceptive skills and control over shoulder positioning.

In conclusion, the integration of mobilization and scapula-focused exercises provides a comprehensive approach to functional rehabilitation in individuals with shoulder impingement syndrome. By addressing both structural and neuromuscular factors, this approach can help individuals restore optimal shoulder function, improve joint position sense, and reduce pain associated with impingement. Our results represent a promising avenue for enhancing rehabilitation outcomes in female rock climbers with shoulder impingement syndrome. Further research and clinical application of these findings could pave the way for more effective and individualized treatment strategies for individuals with shoulder impingement.

This study underscores the efficacy of integrating mobilization techniques with scapula-focused exercises in enhancing rehabilitation outcomes for female rock climbers suffering from shoulder impingement syndrome. The significant reductions in pain levels and improvements in proprioception highlight the importance of addressing both structural and neuromuscular factors in rehabilitation. Our findings suggest that the combination of these approaches can not only alleviate pain but also restore optimal shoulder function and enhance joint position sense, facilitating better movement patterns and reducing the risk of future injury.

SFE

Scapula-Focused Exercises

SFEM

Scapula-Focused Exercises with Mobilization

VAS

Visual Analog Scale)

BMI

Body Mass Index

PNF

Proprioceptive Neuromuscular Facilitation

JPS

Joint Position Sense

MWM

Mobilization with movement

Declarations

Ethics approval and consent to participate

The Ethics Committee affirmed the research protocol of Sport Sciences Research Institute (Code: IR.SSRC.REC.1402.170). In addition, before beginning the research process, all participants in this study provided informed consent.

Consent for publication

Not applicabale

Competing interests

The authors declare no conflicts of interest with respect to the research. Authorship, and/or publication of this article.

Funding

This study was funded by the researchers themselves, reflecting their commitment to the investigation and independence in the research process.

Author Contribution

BZ, HA, and SS developed the idea, investigation and data gathering; BZ, HA, and SS conducted the research; All authors did quality appraisal of included studies as well as writing, reading, and approving the final draft manuscript; Supervision is done by SS.

Acknowledgement

The authors would like to acknowledge the participants of this study for their time and efforts.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

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No competing interests reported.

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You are reading this latest preprint version

Integrating Mulligan Mobilization with Scapular Focused Exercises Brings Increased Benefits to Rock Climbers Suffering Shoulder Impingement Syndrome

Status:

Version 1

Abstract

Figures

Background

Methods

Sample of study

Participant Selection

Pain Assessment

Proprioception Assessment (Joint Position)

The Scapula-Focused Exercises (SFE)

Mobilization Technique

Results

Discussion

Conclusion

Abbreviations

Declarations

Declarations

Competing interests

Funding

Author Contribution

Acknowledgement

Availability of data and materials

References

Additional Declarations

Status:

Version 1