MAPS: Maitland-Australian homecontact us
find us on facebook find us on linkedin

Robert J. Fluegel, PT, COMT
MAPS Faculty, Fellow in Training, MAPS Orthopedic Manual Therapy Fellowship

Chris R. Showalter, PT, OCS, COMT, FAAOMPT, Fellowship Program Director

Mobilization combined with Stabilization is SUPERIOR compared to Stabilization alone in Non-Specific Mechanical Neck Pain (NSMNP)

sign up for email updates from MAPS

Regional Interdependence Maybe, Maybe Not, in Shoulder Impingement

August 13, 2013

Research Commentary

Chris Showalter PT, OCS, COMT, FAAOMPT

MAPS Clinical Director

Full Disclosure: This month’s Research Commentary discusses a peer- reviewed research article Co-authored by MAPS Research Consultant Chad Cook and MAPS Senior Faculty Members Ken Learman, Steve Houghton, Chris Showalter, and Bryan O’Halloran. The synopsis and link to Manual Therapy are found below.

Regional Interdependence...Maybe,

Maybe Not, in Shoulder Impingement

The concept of regional interdependence is not new. Practicing clinicians have long noted the interrelationships that occur between neighboring regions. In fact, according to Maitland, and others, a complete and thorough examination of a particular region REQUIRES the clinician to fully examine the primary area (e.g., shoulder) AND neighboring secondary areas (e.g., cervical spine) to clear the area, and ensure that symptoms are not originating from secondary areas.

Numerous recent research studies have suggested a role for the concept of regional interdependence including the following:

  • Thrust manipulation of the cervicothoracic spine provides positive short term effects in patients with shoulder pain (Mintken 2010); N=80, 49 had a positive outcome, short term effects (after three treatments).
  • Thrust manipulation of the thoracic spine effects patients with signs of rotator cuff tendinopathy (Muth 2012); N=30, Thrust did not lead to change in ROM or scapular kinematics, but did slightly reduce shoulder pain, short term effects (after one treatment).
  • Thoracic spine +/- rib thrust effects shoulder pain and ROM (Strunce 2009); N=21, 51% reduction in shoulder pain, 8 degrees of improvement in ROM, short term effects (after one treatment).
  • Thrust manipulation of the thoracic spine influences cerebral hemodynamics responses in healthy individuals (Sparks 2013); N=10, short term effects (after one treatment), likely due to supraspinal mechanisms.
  • Cervical lateral glide mobilization reduced pain and increased painful arc ROM (McClatchie 2009); N=21, short term effects (after one treatment).

We sought to further examine the value of regional interdependence in actual shoulder impingement patients in our E pub June 21, 2013 study in Manual Therapy (in print):

“The addition of cervical unilateral postero-anterior mobilization in the treatment of patients with shoulder impingement syndrome: A randomized clinical trial,� by Chad Cook, Ken Learman, Steve Houghton, Chris Showalter and Bryan O’Halloran.

Unlike prior studies we included ONLY patients with TRUE shoulder impingement syndrome (SIS). Shoulder Impingement patients were included in the study only if they demonstrated the following:

  • Signs of internal or external impingement
  • Report of pain or dysfunction with overhead activities
  • Report of pain during active shoulder movements
  • Positive Neer/Hawkins-Kennedy test
  • Report of non-traumatic and recent onset within 12 months • Painful Flexion arc between 60° and 120°
  • Report of baseline pain of ≥ 2/10 on a 11 point scale (NPRS)


Exclusion criteria included any one of the following:

  • Neck pain
  • Presence of any Red Flags
  • History of frozen shoulder, or disorders of the acromioclavicular joint
  • Degenerative arthritis of the glenohumeral joint
  • Known calcifying tendonitis (identified by X-Ray)
  • Shoulder instability, post traumatic shoulder disorders, or prior shoulder surgery
  • Elbow, Wrist, or Hand pain

The study design was a multicenter, randomized, single-blinded, clinical trial where both groups received evidence-based treatment to the shoulder (per Kuhn 2009), and one group also received cervical manual therapy. The design was pragmatic, whereby; practicing clinicians were given the latitude to treat as they normally would in clinical practice. Sample size was relatively large at N=68.

QuickDASH was the primary outcome measure, while other measures included:

  • Comparative pain (NPRS)
  • Rate of Recovery (RoR)
  • Patient acceptable symptom state (PASS)

Unlike prior studies, treatment effect was determined throughout the entire management of the patient and thus captures effects beyond only the short term, as has been common in prior regional interdependence studies.

Our findings showed:

  • 86% reported an acceptable PASS score at discharge.
  • Both groups demonstrated significant within group improvements from baseline (average improvements of 59.7% for pain and 53.5% for QuickDASH)
  • NO between group differences were found in those who did and did not receive neck manual therapy


    1. The addition of cervical mobilization did NOT affect outcomes in true shoulder impingement patients.
    2. We found NO support for the concept of regional interdependence between the shoulder and the cervical spine in true shoulder impingement syndrome patients.

Article Follows (with weblink)

Cheers and Enjoy,

Chris R. Showalter PT, OCS, COMT, FAAOMPT

© Chris R. Showalter and Maitland Australian Physiotherapy Seminars Not to be reproduced, copied or retransmitted in any manner without author’s express written permission

Directing others to the MAPS website ( is permissible.

The addition of cervical unilateral posterior–anterior mobilisation in the treatment of patients with shoulder impingement syndrome: A randomised clinical trial

By Cook C, Learman K, Houghton S, Showalter C, O’Halloran B

E-published online 21 June 2013. Manual Therapy

Abstract :

Shoulder impingement syndrome (SIS) is a complex, multi-factorial problem that is treated with a variety of different conservative options. One conservative option that has shown effectiveness is manual therapy to the thoracic spine. Another option, manual therapy to the cervical spine, has been studied only once with good results, evaluating short-term outcomes, in a small sample size. The purpose of this study was to investigate the benefit of neck manual therapy for patients with SIS. The study was a randomised, single blinded, clinical trial where both groups received pragmatic, evidence-based treatment to the shoulder and one group received neck manual therapy. Subjects with neck pain were excluded from the study. Comparative pain, disability, rate of recovery and patient acceptable symptom state (PASS) measures were analyzed on the 68 subjects seen over an average of 56.1 days (standard deviation (SD) = 55.4). Eighty-six percent of the sample reported an acceptable change on the PASS at discharge. There were no between-groups differences in those who did or did not receive neck manual therapy; however, both groups demonstrated significant within-groups improvements. On average both groups improved 59.7% (SD = 25.1) for pain and 53.5% (SD = 40.2) for the Quick Disabilities of the Shoulder and Hand Questionnaire (QuickDASH) from baseline. This study found no value when neck manual therapy was added to the treatment of SIS. Reasons may include the lack of therapeutic dosage provided for the manual therapy approach or the lack of benefit to treating the neck in subjects with SIS who do not have concomitant neck problems.

Where to find the Articles


The addition of cervical unilateral posterior–anterior mobilisation in the treatment of patients with shoulder impingement syndrome: A randomised clinical trial

Cook C, Learman K, Houghton S, Showalter C, O’Halloran B

2) Maitland GD, Vertebral Manipulation, London, Butterworth-Heinemann, 5th Ed, 1986


Some Factors Predict Successful Short-Term Outcomes in Individuals With Shoulder Pain Receiving Cervicothoracic Manipulation: A Single-Arm Trial

Mintken P, Cleland J, Carpenter K, Bieniek M, Keirns M, Whitman J


The Effects of Thoracic Spine Manipulation in Subjects With Signs of Rotator Cuff Tendinopathy

Muth S, Barbe M, Lauer R, McClure P


The immediate effects of thoracic spine and rib manipulation on subjects with primary complaints of shoulder pain.

Strunce J, Walker M, Boyles R, Young B


Using Functional Magnetic Resonance Imaging to Determine if Cerebral Hemodynamic Responses to Pain Change Following Thoracic Spine Thrust Manipulation in Healthy Individuals

Sparks C, Cleland J, Elliott J, Zagardo M, Wen-Ching Liu


Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults.

McClatchie L, Laprade J, Martin S, Jaglal SB, Richardson D, Agur A.


Exercise in the treatment of rotator cuff impingement: a systematic review and a synthesized evidence-based rehabilitation protocol.

Kuhn J

Back To Research Commentary
Find a COMT Course Schedule Course Descriptions Register for Courses Faculty
Looking for a COMT? This list of Certified Orthopedic Manual Therapists (or COMTs) includes all COMT graduates worldwide, as well as MAPS faculty. We suggest that you visit this page often to check course confirmation status and to find new courses which are added frequently. Our seminars incorporate the teaching of Geoff Maitland and others who have contributed to what has become known as the "Maitland-Australian Approach". Registering for classes is easy. Submit full payment with the registration form. Reservations are limited and are on a first come, first serve basis. Come meet our world-class faculty. Each of our faculty has experience in a wide variety of manual therapy practices and specialty areas.


© 2007 All rights reserved.