Akhtar et al. BMC Musculoskeletal Disorders (2020) 21:770 https://doi.org/10.1186/s12891-020-03787-0

RESEARCH ARTICLE Open Access

The effectiveness of routine physiotherapy

with and without neuromobilization onpain and functional disability in patientswith shoulder impingement syndrome; arandomized control clinical trial Muhammad Akhtar*, Hossein Karimi, Syed Amir Gilani, Ashfaq Ahmad and Asim Raza

Abstract

Background: The objective of the study was to compare the effects of neuromobilization (NM) techniques androutine physiotherapy on pain and functional disability in patients having shoulder impingement syndrome (SIS).Present study was aimed to discover evidence based conservative and cost effective remedy on pain andfunctional disability.

Study design: Single blinded randomized control clinical trial.

Methods: A total of 80 patients with SIS were randomly assigned into care and experimental groups (40 in eachgroup). After the baseline assessment routine physiotherapy was executed on both groups, while NM was appliedadditionally to experimental group. Pain and functional disability score were evaluated by Visual Analogue Scaleand University of California at Los Angeles rating score at baseline, 5th and 11th week. Differences in outcomebetween groups were evaluated with clinical improvement.

Results: The experimental group compared with care group at 11th week had lower mean pain score 2.15(1.66–2.64) vs 4.90(4.41–5.40); between group difference, 1.82; 95% (CI), − 2.38 to − 1.25; P < 0.001 and Partial ƞ2 = 0.33,similarly functional disability score 28.58(27.32–29.83) vs 20.10(18.84–21.36); between group difference,5.62; 95%CI,(4.32–6.92); P< 0.001 and Partial ƞ2 = 0.49 respectively. In experimental group NM was a more effective technique toreduce the pain severity and disability in SIS patients as compare to care group.

Conclusion: Neuromobilization techniques in addition to routine physiotherapy were significantly effective for thetreatment of SIS.

Trial registration: IRCT20190121042445N1, Registered 19 February 2019.

Keywords: Shoulder impingement, Neuromobilization, Functional disability

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* Correspondence: a.hunjra@gmail.comUniversity of Lahore, Lahore, Pakistan

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BackgroundThe shoulder impingement syndrome (SIS) consists ofthe rotator cuff tendonitis and bursitis of the shoulder[1]. It shows the inflammation of the supraspinatus ten-don inside the anteroinferior junction of the acromionand the greater tuberosity of the humerus. Patients withSIS report severe acute pain which increases during over-head activities as well as sleeping on affected side [2].SIS comprises of three stages, the 1st stage is defined

by edema and hemorrhage of the subacromial bursa androtator cuff muscle; it has been detected in patients whereage group is less than 25 years. The next stage indicates ir-reversible changes, which are fibrosis combine with tendi-nopathy of the rotator cuff muscle. It is highly prevalentamong 25 to 40 years old population. At 3rd stage im-pingement is evident by more severe changes, like partialor complete tears of the rotator cuff, mostly observedamong patients who are above 40 years age [3, 4].The execution of specific components of body move-

ments to generate particular mechanical incident in theneural system is called NM. Mechanical managementmay therefore be used to augment physiology in the ner-vous system [5].It has already been observed that there are three theor-

ies projected for the local etiological origin of tendonpain: 1-mechanical, 2-vascular and 3- neural [6, 7].Mechanical and vascular theories are regularly used

for the treatment of tendon pain. The mechanical theoryis based on the idea of mechanical overload of the ten-don resulting in damage to the collagen. Tendons thatreceive high strain loads such as the Achilles are oftenloaded during movement and have been suggested tosustain physiological strain up to 6–8%.The vascular theory is based on the concept that ten-

don may experience vascular compromise and neurovas-cularization. Due to lack of vascularity, the tendon is notcapable of healing because of repetitive high strain load.A study conducted by Rees JD et al. observed mechan-ical, vascular and neural theories which have proposedfor tendinopathy and point out the potential appropriateuse of NM. The use of NM has the potential to lessenthe perception of pain. The movement of the nervoussystem during NM may restore axoplasm flow, restoringnutrients to the nerves. The restoration of nerve func-tion may then lessen sensitivity (i.e ion channels) to thearea and restore normal blood flow to the tendon [7].Physiologically we may explain that a nerve which

closely passes to a joint is mostly kept in a tunnel or it isattached with collagen fibres or fascia to the nearbymusculoskeletal components. Nerves move side by sidewithin the upper limb hence the neuromobilizationgiven during management cause break of the cross link-ages. The possible effect of stretch on axons is the im-proved ion flux in stretch sensitive ion channels. The

mechanical stimulation used at low frequency, low in-tensity ultrasound is indicated to arouse neurons inmouse brain by activating voltage gated sodium and cal-cium channels. The slow elongation can cause structuralchanges in myelin sheath, axon regeneration, depositionof endoneurial collagen. The nodes of ranvier can openfurther as it causes the Schmidt- Lanterman clefts whichaffects the levels of local cytoplasm [8].The neural component is over looked due to poor

outcomes among patients with tendinopathy. MatochaMA et al. highlighted neural involvement in patientswith tendon pain and discussed the role of NM fortendon pain [9]. The utilization of neurodynamics maybe important for the treatment purposes in patientswho suffer with tendonopathies which has neuralcomponent [6, 10].

ObjectiveThe objective of the study was to compare the effects ofNM techniques and routine physiotherapy on pain andfunctional disability in patients having SIS. Present studywas aimed to discover evidence based conservative andcost effective remedy on pain and functional disability.

MethodsTrial designThe model of study was single blinded randomized con-trolled clinical trial. This controlled trial used a paralleldesign where patients were allotted by 1:1 ratio in twogroups’ experimental group as well as care group. Thesepatients had gone through a complete systemic physicalexamination that included the whole neurologic andmusculoskeletal assessments. Patients with history ofshoulder surgery, shoulder injury, trauma, shoulder jointdislocation, cervical radioculopathy and having othersystemic diseases were excluded from the study. The pa-tients with positive upper limb tension test [11], Neertest [3, 4], Hawkins Kennedy [12] Empty Can [12], pain-ful arc and cross body adduction test [13] were includedfor study.

RandomizationA sample of 80 participants was selected and allocatedin to two groups experimental and care group by usingcomputer generator method in simple random samplingtechnique.

BlindingAn independent assessor, who specialized in musculo-skeletal injuries with more than 5 year experience ofdealing patients with shoulder injury, had performed al-location of patients.

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ParticipantsDiagnosed patients with SIS was participated in this re-search. The study purpose was described to all patientsand informed consent was taken from them. After ap-proval from Institutional Review Board “The University ofLahore” and present study was completed at physiother-apy department of Social Security Hospital Gujranwala.

ProceduresAfter initial assessment, the investigator used to takedemographic details of the participants along with visualanalogue scale (VAS) and functional disability ratingscore.All the patient related information was kept confiden-

tial and they were free to quit the study at anytime.VAS was used to evaluate the severity of pain and it

was considered as primary outcome of the current study.A constant scale had been employed to inquire the pa-tients about the shoulder pain during the activity and toclassify it by indicating on a 10-mm line; it was con-nected “no pain” and the “worst pain you have ever felt”.This is common method of evaluating severity of shoul-der pain. The findings of the study indicate the VAS is ahigh reliable as well as valid method to assess the sever-ity of pain [14]. The UCLA score was used to assessfunctional disability and it has total 35 points, withhigher values indicating better shoulder condition. TheUCLA score has 5 domains; pain 10 points, function 10points, active forward flexion 5 points, strength of for-ward flexion 5 points and satisfaction of the patient 5points [15]. The score was assessed at base line, 5th and11th week. The internal consistency or reliability ofUCLA was 0.78 to 0.89 and 0.51 to 0.59 for post surgicaland non surgical respectively.

InterventionsRoutine physiotherapy was performed on both groupswhile NM was done on experimental group. Patientswere treated thrice a week on alternative days.

Table 1 List of exercises performed under experimental and routine

Experimental group (stretching and strengthing exercises+ neuromobilization)

1) STRETCHING EXERCISESa) Shoulder external rotation stretchb) Cross body posterior stretchc) Stretch for anterior aspect of shoulderd) Shoulder flexion stretch2) STRENGTHING EXERCISESa) Chair pressb) Restricted scapular retractionc) Restricted scapular protractiond) Shoulder abduction “Scaption” (0o-90o) with therabande) Shoulder scapular extension with theraband3) NEUROMOBILIZATION EXERCISESa) Neural slider techniqueb) Neural tensioner technique

Routine physical therapyThe routine Physiotherapy consisted of pulsed ShortWave Diathermy (SWD) with frequency 27.12 MHZ[16], Ultrasonic Therapy (US) with frequency 1.0 MHZand intensity 1.45w/cm2 [17] and Transcutaneous Elec-trical Nerve Stimulator (TENS) 2–200 HZ with outputcurrent < 20Ma width 200 μ seconds along with continu-ous mode. Exercises were comprised of shoulder streng-thing and stretching exercises that were performed for 5s with 10 repetitions for both experimental and caregroups as shown in Table 1 [18].

NeuromobilizationNM was applied by using Butler’s recommendations[19]. Initially, the patient performed neural sliders andgradually progressed to neural tensioners. Neural slidersconsisted of cervical lateral flexion movement, towardthe involved side, simultaneously with elbow flexion andextension movements. While moving the head in to cer-vical lateral flexion the elbow was extended. When theelbow began to flex, the cervical spine was returned toneutral position as shown in Figs. 1 and 2. Neural ten-sioners were performed to create tension in the nerve toget the desired results. The tension position was notheld for a length of time, but is released by extendingthe elbow and returning the cervical spine to neutral.Once the patient had pushed slight pain or discomfort atany point as shown in Figs. 3 and 4 [20]. NM techniquewas performed for 5 s with 10 repetitions to control thepain and improve the functional disability score to relivethe pain shown in Table 1.

Outcome measuresAs an outcome measure for pain severity (0 = no painand 10 = severe pain) VAS was used with reliability 0.94at baseline, 5th and 11th week [14]. Pain was consideredas primary outcome.UCLA score was assessed at baseline, 5th and 11th week.

The UCLA score was used to assess functional disability

physiotherapy group

Routine physiotherapy group (stretching and strengthingexercises)

1) STRETCHING EXERCISESa) Shoulder external rotation stretchb) Cross body posterior stretchc) Stretch for anterior aspect of shoulderd) Shoulder flexion stretch2) STRENGTHING EXERCISESa) Chair pressb) Restricted scapular retractionc) Restricted scapular protractiond) Shoulder abduction “Scaption” (0o-90o) with therabande) Shoulder scapular extension with theraband

Fig. 1 Neural slider starting position with elbow flexion

Fig. 3 Neural tensioner starting position cervical lateral flexion andelbow flexion

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and it has total 35 points, with higher values indicating bet-ter shoulder condition. The UCLA score has 5 domains;pain 10 points, function 10 points, active forward flexion 5points, strength of forward flexion 5 points and satisfactionof the patient 5 points [15]. The score was assessed at baseline 5th and 11th week. The internal consistency or reliabil-ity of UCLA was 0.78 to 0.89 and 0.51 to 0.59 for post sur-gical and non surgical respectively. The UCLA score wasconsidered as secondary outcome.

Sample sizeSample size calculation was derived from Yamany AAet al. study [21]. According to clinical trials, the samplesize estimation formula was implemented [22].

Fig. 2 Neural slider final position with cervical flexion along withelbow extension

Sample size ¼ 2SD2 Za=2 þ Zβ� �2

d2

Where SD = Standard deviation = 14.08, Z1 − a/2 is type1 error = 1.96, Zβ = 0.84, d = μ2 − μ1 = 10.7.Based on this a total sample size of around 80(experi-

mental = 40, care = 40) was calculated to be an adequatemean to reach the conclusion. Considering a loss of 20%follow-up, at least 80% patients followed the treatments[23]. An experimental group and a care group were re-cruited which were based on the inclusion criteria forthis study (Fig. 5). Both groups were selected by regu-larly visiting the physiotherapy department at Social Se-curity Hospital Gujranwala.

Data analysisStatistical analysisData were analyzed by using (SPSS Version 22.0) software.Qualitative data were presented in frequencies and percent-ages while mean and S. D were calculated for Quantitative

Fig. 4 Neural tensioner final position extending the elbow andreturning the cervical spine in neutral

Fig. 5 Experimental sheet/flow sheet

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data. Line chart was drawn at various times in weeks duringthe treatment vs pain score and UCLA score.Repeated measure ANOVA was applied to compare aver-

age pain score as primary outcome while average UCLAscore as a secondary outcome at different time points (base-line, 5th week, 11th week). The confidence level of 95% wasused as well as p value ≤0.05 was considered as significant.

ResultsRecruitmentThe current study was started on September 2016 andlast follow up was occurred on March 2018 and thentrial ended. It was considered regarding the number ofthe participants in each group laid within the range esti-mated (40 each group). Data was collected at Social Se-curity Hospital Gujranwala.

Participant flowOne hundred and twenty participants had been observedfor eligibility process at the time of September 2016 tillFebruary 2018, among 30 participants had not been foundeligible. The ineligible participants were excluded fromthe current study and was given the routine physiotherapytreatment. The reasons for ineligibility of the patients arepresented in Fig. 5, out of 90 eligible participants, 10 hadfurther excluded as they denied being part of study. Theabove mentioned 10 participants were also given the rou-tine physiotherapy treatment. The rest of 80 participantsdivided in an experimental group and a care group. On11th week follow-up, 12 participants left the study and 68patients had completed the whole evaluation. The causeof withdrawal is provided in Fig. 5. The participants whodid not complete treatment on 11th week measurementshad been included for further analysis. The missing values

Table 2 Comparison of Scio-demographic data of the patients

Variable Experimental group (N = 40) Control group (N = 40) P-value

Age Years 36.38 ± 8.93 34.40 ± 9.32 0.336

Gender Male 8 (20%) 14 (32.4) 0.133

Female 32 (80%) 26 (65%)

Neer test Type 1: Pain at 90° 34 (85.0%) 38 (95.0%) 0.136

Type 2: Pain at 60°-70° 6 (15.0%) 2 (5.0%)

Affected side Right 23 (57.5%) 23 (57.5%) 0.889

Left 15 (37.5%) 14 (35.0%)

Both 2 (5.0%) 3 (7.5%)

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of dropped out patients were included in the current ana-lysis by using last observation carried forward (LOCF).The experimental sheet/ flow sheet is presented

through Fig. 5.

The baseline demographic profileThe baseline characteristics are presented in Table 2.Demographic profile shows that most of the patientssuffering from SIS were female, who were 32 in experi-mental group and 26 in care group. It was also observedthat mostly patients falling in type-1 Neer classification.Neer type-1 impingement was categorized by oedema aswell as subacromial bursitis and supraspinatus muscleinvolvement. It was mostly diagnosed among those par-ticipants who were younger than 25 years of age andshown in Table 2 [3].

Primary outcomeThe results of primary outcome were reported inTable 3. For the care group, mean scores of VAS forshoulder pain were 6.78 ± 1.14, 5.0250 ± 1.79 and4.90 ± 1.58 at base line, 5th and 11th week respect-ively. For experimental group, average score of VASwas 6.95 ± 1.28, 2.15 ± 1.87 and 2.15 ± 1.55 at baseline, 5th and 11th week respectively. These results in-dicate significant difference in score of VAS. Shoulderpain of experimental group was average improved as

Table 3 Comparison of mean difference (95% CI) of between and w

Outcome measures Mean (95% CI) With

Experimental group Con

Pain assessment Baseline 6.95 (6.60–7.30) 6.78

5th week 2.15 (1.60–2.71) 5.03

11th week 2.15 (1.66–2.64) 4.90

Partial ƞ2 for time 0.79

Partial ƞ2 for interaction (time*group) 0.43

P-value for within group < 0.001 < 0.0

compared to care group at different time points (baseline, 5th and 11th week).

Secondary outcomeThe results of secondary outcome were reported inTable 4. For the care group, average UCLA score were14.50 ± 2.37, 19.07 ± 4.43 and 20.10 ± 4.08 at base line,5th and 11th week respectively. Similarly, average UCLAscore for experimental group were 14.05 ± 2.59, 27.90 ±4.13 and 28.58 ± 3.89 at base line, 5th and 11th week re-spectively. The UCLA score of experimental group wasmore improved as compared to care group at differentstages.

Outcomes and estimation

For between group comparison Comparison of VASbetween experimental and care group was assessed at11th week. Statistically significant difference wasfound with P value < 0.001 and partial ƞ2 = 0.33. Forthe main effect of time and interaction (time*group)were ƞ2 = 0.79 and ƞ2 0.43 respectively that wasshown in Table 3. Similarly, UCLA scores for func-tional disability in shoulder were compared betweenexperimental and care group at 11th week that wasfound statistically significance difference with P value< 0.001 and Partial ƞ2 = 0.49. For the main effect of

ithin group comparison and partial ƞ2 with P value

in group comparison Mean difference(95% Cl) ofbetween groupcomparison byANOVA (Experimentalvs Control)

Partialƞ2

P-value

trol group

(6.42–7.13) 1.82(−2.38 to-1.25) 0.34 < 0.001

(4.46–5.59)

(4.41–5.40)

– – –

– – –

01 – – –

Table 4 Comparison of mean difference (95% CI) of between and within group comparison and partial ƞ2 with P value

Outcome measures Mean (95% CI) Within group comparison Mean difference(95% Cl) of betweengroup comparison byANOVA (Experimentalvs Control)

Partialƞ2

P-value

Experimental group Control group

UCLA score Baseline 14.05 (13.27–14.83) 14.50 (13.72–15.28) 5.62 (4.32–6.92) 0.49 < 0.001

5th week 27.90 (26.55–29.25) 19.08 (17.73–20.42)

11th week 28.58 (27.32–29.83) 20.10 (18.84–21.36)

Partial ƞ2 for time 0.81 – – –

Partial ƞ2 for interaction (time*group) 0.49 – – –

P-value for within group < 0.001 < 0.001 – – –

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time and interaction (time*group) were ƞ2 = 0.81 andƞ2 0.49 respectively that was shown in Table 4. Overall pain severity and shoulder disability were de-creased in experimental group as compare to caregroup at 11th week.

HarmsTotal six participants were dropped out on 11th week inexperimental group, two patients were dropped out be-cause they were not satisfied with the treatment, one pa-tient dropped out due to worsening of the symptomsand three patients due to lack of time. Similarly in con-trol group four patients dropped out due to dissatisfac-tion of the treatment given to them and two participantsdue to lack of time.

DiscussionThe results of routine physiotherapy with and withoutNM during the painThe results of the current study demonstrated the im-provement of pain among the two groups with SIS at5th and 11th week. So, it was greater betterment in theexperimental group as compared to the care group. Theresults of a study by Pritam Deka revealed that NM hasfruitful effects in mitigating the pain by restoring neuro-dynamics properties in upper limb [24]. Robert J Neeet al. study has found immediate relief of pain in armwith no evidence of harmful effects and futureresearches are recommended to check long term effectsof NM on pain [25]. It was observed that the use of neu-romobilization has shown beneficial effect for shortperiod over pain [26].The results of current study were also similar with Pri-

tam Deka, who explored that neuromobilization was ef-fective treatment for pain. When neurombilizationcombined with TENS were used, more effective resultswere found on cervical radiculopathy [24]. The currentstudy determined the results to be similar to those ofMatocha MA et al. who found that pain intensity de-creased weekly basis as decreased in present study on5th and 11th week but further research is needed to help

clinicians in making education decision for implement-ing these techniques in to clinical practice [20].In a systemic review efficacy of neuromobilization was

examined, this study concluded the positive therapeuticeffects of the neuromobilization [27].

The effects of routine physiotherapy with and withoutNM on UCLA scoreThe results of the current study have shown improve-ment in UCLA scores of experimental group as compareto care group at 5th and 11th week. Findings of thisstudy indicated NM has positive effects to improveUCLA score.The given findings of our study confirm this NM is ef-

fective in improving UCLA score on 5th week and 11thweek. The similar results were also noted in the study ofRichard F. Ellis et al. who found that shoulder pain anddisability scores were significantly improved in the ex-perimental group [27].Neurophysiological result of spinal mobilization was

earlier shown that mobilization of nervous tissue en-hances peripheral blood flow, using a physiological shifttoward parasympathetic domination [28, 29].Different neuromuscular responses (like hypoalgesia,

the motor neuron pool activity, afferent discharge andchanges in the mobility of muscle) associated with neu-romobilization indirectly indicates the spinal cord medi-ated effect of the NM. Neuromobilization had an quickhypoalgesic effect on C-fibre mediated pain perception,as not on A-delta fibre mediated pain perception [30].Another reason of more improvement of function in

the experimental group may be shown the restoration ofmobility due to the biomechanical effects which areinter-linked with NM [30].

LimitationsThere are several limitations of current study that war-rant the further discussion. However, benefits of asmaller sample size were the ability to supervise the ex-ercises program and more closely interaction with pa-tients on a daily basis during the exercise sessions for

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better results. In particular, the adherence to the pre-scribed exercise intensity and program was excellent forboth exercise treatment groups. Second, the presentstudy (11 weeks) was also relatively reasonable in dur-ation compared to previous training investigations [31].Improvements in pain and functional disability score

was found in the present study which indicated that 11weeks exercise training period was a sufficient timeframe to demonstrate significant training effects.

Generalizability

Clinical considerations for effective neuromobilizationin clinical treatment After recognizing the close rela-tionship between physical capacities and life style, it islikely to be declared that implementation of NM recom-mended standard part of the treatment for SIS patientswill decrease shoulder pain and improve function. Thisstudy shows that NM is not only feasible as a part of thetreatment, but it also has a large effect size and efficientfor all the times.Patients of SIS who suffer from many challenges, so it

is important to recognize that shoulder pain and func-tional disability score constitute an important part ofoverall health and daily tasks. Since shoulder impinge-ment syndrome are known to be important key factorfor daily life activities in term of pain and function. Im-portantly, this study, as well as neuromobilization re-gimes is feasible and safe to carry out within this patientgroup.Trial Registration: IRCT20190121042445N1.

ConclusionOn the basis of results it is concluded that addition ofNM with routine physiotherapy has greater improve-ment to reduce pain severity and disability in SIS pa-tients than without NM.

AbbreviationsSIS: Shoulder Impingement Syndrome; VAS: Visual Analogue Scale;SWD: Short Wave Diathermy; US: Ultra Sonic; TENS: Transcutaneous ElectricalNerve Stimulation; NM: Neuromobilization; ANOVA: Analysis of Variance; A.CJoint: Acromio Clavicular Joint; S. D: Standard Deviation; C. I: ConfidenceInterval; UCLA: University of California at Los Angeles rating score;SPSS: Statistical Package for Social Sciences; LOCF: Last observation carriedforward

AcknowledgementsThis study was a part of Ph. D Physical therapy project (the effectiveness ofroutine physiotherapy with and without neuromobilization in patients withshoulder impingement syndrome on pain, range of motion, shoulderstrength and functional disability) supported by the University of Lahore,Lahore, Punjab, Pakistan. But in current manuscript two out comes measurespain and functional disability were assessed. Authors are extremely thankfulto all volunteers and subjects who participated in this study.

Authors’ contributionsMA: Study conception, design and analysis, interpretation of data anddrafting of manuscript. HK: Literature search, study design, analysis and

interpretation of data. AG: Revision of the manuscript and critical appraisalfor final approval to be published. AA: Drafting and data interpretation. AR:Statistical analysis and interpretation. All authors have read and approved themanuscript.

FundingThere is no funding source for this article publication.

Availability of data and materialsThe data sets used and/or analyzed during the current study are availablefrom the corresponding author on reasonable request.

Ethics approval and consent to participateEthical approval was taken from University of Lahore, Ethical reviewcommittee Professor Dr. Syed Amir Gilani Dean Faculty of Allied HealthSciences is Chairman of committee with reference No. IRB-UOL-FAHS/00238-II. The written informed consent was obtained from all participantswith the following consent statement.“I have read this consent form and agreed to participate in this study. I givemy consent to enroll myself in this study”.Participant’s signature-------------------------------- Date.

Consent for publicationNot applicable.

Competing interestsThe authors declared that Professor Dr. Amir Gilani is Chairperson of ethicalreview committee and also coauthor of our study.

Received: 9 March 2020 Accepted: 11 November 2020

References1. Gebremariam L, Hay EM, van der Sande R, Rinkel WD, Koes BW, Huisstede

BM. Subacromial impingement syndrome—effectiveness of physiotherapyand manual therapy. Br J Sports Med. 2014;48(16):1202–8.

2. Koh E-K, Jung D-Y. Effects of modified cross-body stretching on range ofmotion in Glenohumeral joint. J Korean Soc Phys Med. 2015;10(4):1–7.

3. Neer CN. Impingement lesions. Clin Orthop. 1983;173(70):7.4. Ark JW, Flock TJ, Flatow EL, Bigliani LU. Arthroscopic treatment of calcific

tendinitis of the shoulder. Arthroscopy. 1992;8(2):183–8.5. Shacklock M. Clinical neurodynamics: a new system of musculoskeletal

treatment: Elsevier Health Sciences; London. 2005.6. Kaux J-F, Forthomme B, Le Goff C, Crielaard J-M, Croisier J-L. Current

opinions on tendinopathy. J Sports Sci Med. 2011;10(2):238.7. Rees J, Wilson A, Wolman R. Current concepts in the management of

tendon disorders. Rheumatology. 2006;45(5):508–21.8. Siechen S, Yang S, Chiba A, Saif T. Mechanical tension contributes to

clustering of neurotransmitter vesicles at presynaptic terminals. Proc NatlAcad Sci. 2009;106(31):12611–6.

9. Matocha MA, Baker RT, Nasypany AM, Seegmiller JG. Effects ofneuromobilization on tendinopathy: Part I. Int J Athletic Ther Train. 2015;20(2):36–40.

10. Cook J, Purdam CR. Is tendon pathology a continuum? A pathology modelto explain the clinical presentation of load-induced tendinopathy. Br JSports Med. 2009;43(6):409–16.

11. Walsh MT. Upper limb neural tension testing and mobilization: fact, fiction,and a practical approach. J Hand Ther. 2005;18(2):241–58.

12. Sallis R. Examination skills of the musculoskeletal system. Am Acad FamPhys. 2017;9(01):16–17.

13. Park HB, Yokota A, Gill HS, El Rassi G, McFarland EG. Diagnostic accuracy ofclinical tests for the different degrees of subacromial impingementsyndrome. J Bone Joint Surg Am. 2005;87(7):1446–55.

14. McCaffery M, Pasero C. Practical nondrug approaches to pain. Pain: Clinicalmanual (2nd Ed.). 1999;399–427.

15. Oku EC, Andrade AP, Stadiniky SP, Carrera EF, Tellini GG. Translation andcultural adaptation of the modified-University of California at Los Angelesshoulder rating scale to portuguese language. Rev Bras Reumatol. 2006;46(4):246–52.

16. Kaysin MY, Akpinar P, Aktas I, Ozkan FU, Karamanlioglu DS, Hartevioglu HC,et al. Effectiveness of shortwave diathermy for subacromial impingement

Akhtar et al. BMC Musculoskeletal Disorders (2020) 21:770 Page 9 of 9

syndrome and value of night pain for patient selection: a double-blinded,randomized, placebo-controlled trial. Am J Phys Med Rehabil. 2018;97(3):178–86.

17. Benjaboonyanupap D, Paungmali A, Pirunsan U. Effect of therapeuticsequence of hot pack and ultrasound on physiological response overtrigger point of upper trapezius. Asian J Sports Med. 2015;6(3):e23806.

18. Michener LA, Walsworth MK, Burnet EN. Effectiveness of rehabilitation forpatients with subacromial impingement syndrome: a systematic review. JHand Ther. 2004;17(2):152–64.

19. Butler D, Gifford L. The concept of adverse mechanical tension in thenervous system part 1: testing for “dural tension”. Physiotherapy. 1989;75(11):622–9.

20. Matocha MA, Baker RT, Nasypany AM, Seegmiller JG. Effects ofneuromobilization on tendinopathy: Part II. Int J Athletic Ther Train. 2015;20(2):41–7.

21. Yamany AA, Salim SE. Efficacy of low level laser therapy for treatmentmyofascial trigger points of shoulder pain. World Appl Sci J. 2011;12(6):758–64.

22. Charan J, Biswas T. How to calculate sample size for different study designsin medical research? Indian J Psychol Med. 2013;35(2):121.

23. Dunning JR, Cleland JA, Waldrop MA, Arnot C, Young I, Turner M, et al.Upper cervical and upper thoracic thrust manipulation versus nonthrustmobilization in patients with mechanical neck pain: a multicenterrandomized clinical trial. J Orthop Sports Phys Ther. 2012;42(1):5–18.

24. Deka P. The combined efficacy of neural mobilization with transcutaneouselectrical nerve stimulation (tens) versus neural mobilization alone for themanagement of cervical radiculopathy; 2013.

25. Nee RJ, Butler D. Management of peripheral neuropathic pain: integratingneurobiology, neurodynamics, and clinical evidence. Phys Ther Sport. 2006;7(1):36–49.

26. Efstathiou MA, Stefanakis M, Savva C, Giakas G. Effectiveness of neuralmobilization in patients with spinal radiculopathy: a critical review. J BodywMov Ther. 2015;19(2):205–12.

27. Ellis RF, Hing WA. Neural mobilization: a systematic review of randomizedcontrolled trials with an analysis of therapeutic efficacy. J Manual ManipulTher. 2008;16(1):8–22.

28. George SZ, Bishop MD, Bialosky JE, Zeppieri G, Robinson ME. Immediateeffects of spinal manipulation on thermal pain sensitivity: an experimentalstudy. BMC Musculoskelet Disord. 2006;7(1):68.

29. Vicenzino B, Collins D, Benson H, Wright A. An investigation of theinterrelationship between manipulative therapy-induced hypoalgesia andsympathoexcitation. J Manip Physiol Ther. 1998;21(7):448–53.

30. Beneciuk JM, Bishop MD, George SZ. Effects of upper extremity neuralmobilization on thermal pain sensitivity: a sham-controlled study inasymptomatic participants. J Orthop Sports Phys Ther. 2009;39(6):428–38.

31. Hill TR, Gjellesvik TI, Moen PMR, Tørhaug T, Fimland MS, Helgerud J, et al.Maximal strength training enhances strength and functional performance inchronic stroke survivors. Am J Phys Med Rehabil. 2012;91(5):393–400.

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