Shoulder

Article Full Title: Comparison between dry needling plus manual therapy with manual therapy alone on pain and function in overhead athletes with scapular dyskinesia: A randomized clinical trial 

Author Names: Alireza Kheradmandi, Fahimeh Kamali, Maryam Ebrahimian, Leila Abbasi

Reviewer Name: Emily Ryan, SPT

Reviewer Affiliation(s): Duke University School of Medicine Doctorate of Physical Therapy Program ‘26

Paper Abstract: Muscles’ trigger points can induce scapular dyskinesia (SD) which interferes with overhead athletes’ professional training. We aimed to evaluate effects of dry needling (DN) alone and plus manual therapy (MT) on pain and function of overhead athletes with SD. 40 overhead athletes (15 male, 25 female) aged 18-45 with at least 3 points Numeric Rating Scale (NRS) pain intensity during training were recruited and randomly allocated to the treatment group: MT followed by DN on trigger points of Subscapularis, Pectoralis minor, Serratus anterior, upper and lower Trapezius muscles; or the control group: MT alone. The effect of shoulder trigger points DN plus MT with MT alone on pain, function, Pain Pressure Threshold (PPT) and SD in athletes with SD were compared. Both the examiner and the therapist were blinded to group assignment. Both groups were analyzed. Pain, disability and SD were improved in treatment group (P < .05). On the other hand, when only MT was applied, despite reduction in pain and disability (P < .001), scapular slide only improved in hands on waist position.

Comparing the differences between groups showed a substantial reduction in pain (P < .001) and disability (P = .02) with significant improvement in scapular dyskinesia in treatment group (P = .02). Moreover, PPT significantly increased in the control group (P = .004). No adverse effects reported by the participants during this study. DN is an easy and applicable method that can synergistically reduce pain, disability and dyskinesia when it is combined with manual techniques to treat shoulder dysfunctions.

Quality Assessment of Controlled Intervention Studies

1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT – Yes
2. Was the method of randomization adequate (i.e., use of randomly generated assignment)? – Yes
3. Was the treatment allocation concealed (so that assignments could not be predicted)? – Yes
4. Were study participants and providers blinded to treatment group assignment? – No
5. Were the people assessing the outcomes blinded to the participants’ group assignments? – Yes
6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)? – Yes
7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment? – No
8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower? – No
9. Was there high adherence to the intervention protocols for each treatment group? – Yes
10. Were other interventions avoided or similar in the groups (e.g., similar background treatments)? – Yes
11. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants? – Yes
12. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power? – N/A
13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)? – Yes
14. Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis? – Yes

Key Finding #1

• Participants who received dry needling (DN) paired with manual therapy (MT) demonstrated greater improvements in scapular movement patterns. This objective finding suggests that DN may contribute to better motor control and activation of the serratus anterior and upper and lower trapezius muscles.

Key Finding #2

• Participants who receive dry needling (DN) paired with manual therapy (MT) decreases pain more than manual therapy alone. With pain reduction using DN with MT can further enhance athletes performance through the correction of muscle movement patterns.

Please provide your summary of the paper

Scapular dyskinesia is defined as impaired scapular movement and positioning, which plays a significant role in the development of pain and loss of normal shoulder function. This study was designed as a single-blinded, randomized clinical trial to compare the outcomes of combined dry needling (DN) and manual therapy (MT) versus MT alone in overhead athletes. The study recruited 40 participants (15 males and 25 females) out of 64 eligible candidates.

Patients were excluded if they had bilateral shoulder impingement, a history of fractures or dislocations in the upper extremities or vertebrae, prior upper extremity surgery, symptoms of diabetic neuropathy, generalized anxiety or depression, neurological or rheumatologic disorders, or contraindications for DN techniques.

To assess scapular dyskinesia, the Scapular Dyskinesia Test (SDT) was used, identifying cases based on scapular winging, shoulder shrugging, or immediate scapular downward rotation during shoulder flexion movements. Pain sensitivity was measured using a Numeric Rating Scale (NRS), while disability was assessed with the Persian version of the Disability of Arm, Shoulder, and Hand (DASH) questionnaire. After initial assessments, participants were randomly assigned to either the DN + MT group or the MT-only control group using a computerized blocked randomization method. Patients in both groups received scapular mobilizations consisting of three sets of 10 repetitions, with 30 seconds of rest between sets. Mobilizations included scapular distraction followed by glides in the inferior, superior, medial, and lateral directions. The DN group also received dry needling targeting the subscapularis, pectoralis minor, serratus anterior, and upper and lower trapezius muscles. DN was performed in three sessions at three-day intervals. The control group received the same manual therapy treatment but without DN. Results showed that while the control group exhibited a significantly higher pressure pain threshold (PPT) compared to the DN group, the DN group demonstrated significant reductions in scapular displacement across multiple positions. Both groups experienced significant reductions in pain and disability, as measured by the DASH questionnaire. However, the DN group had a greater improvement, with a DASH mean score of 28.5 compared to 12 in the control group, indicating that DN combined with MT provided superior pain relief and functional benefits compared to MT alone.

Scapular dyskinesia is a contributing factor to pain and disability, and its correction plays a crucial role in the treatment of overhead athletes with shoulder dysfunction. The findings suggest that incorporating DN into manual therapy may enhance treatment outcomes for this population.

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented. 

• This study may impact clinical practice when treating a patient with scapular dyskinesia by being able to use evidence-based practice to back up why dry needling (DN) with manual therapy is the effective treatment approach than just manual therapy. With the use of DN and manual therapy for patients/ athletes the pain and discomfort from their scapular dyskinesia will increase their function and eventually become painless when exercising.

Article Full Title: Manual therapy associated with upper limb exercises vs. exercises alone for shoulder rehabilitation in postoperative breast cancer

Author Names: Maria Teresa Pace do Amaral, PT, PhD; Mariana Maia Freire de Oliveira, PT, MS;

Néville de Oliveira Ferreira, PT, MS; Renata Vidigal Guimarães, PT; Luís Otávio Sarian, MD, PhD; and

Maria Salete Costa Gurgel, MD, PhD

Reviewer Name: Lea Schneider, SPT, CSCS 

Reviewer Affiliation(s): Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract: Our objective was to evaluate the effectiveness of manual therapy (MT) associated with upper limb (UL) exercises in women with impaired shoulder range of motion (ROM) after axillary lymph node dissection (ALND) for breast cancer. A randomized, prospective, blinded clinical trial with 131 women with a ROM ≤ 100° for shoulder flexion and/or abduction on the first day postoperatively were evaluated. Sixty-six women were allocated to group exercises and 65 underwent the exercises followed by MT. Shoulder ROM was measured by goniometry, and function was evaluated by the

Modified-University of California at Los Angeles Shoulder Rating Scale—the UCLA Scale, in the 1st, 6th, 12th, and 18th month after surgery. The chi-square test was used for the relationship between clinical characteristics and oncological treatment between groups, and ANOVA for repeat measures was used. No difference in recovery of shoulder ROM as well as UL function was observed between groups. Improvement in ROM was gradual from the 1st to the 18th month, and the function achieving a good classification at 18th month. MT associated with exercises did not enhance the results obtained with exercises alone for shoulder ROM and ipsilateral UL function

NIH Risk of Bias Tool:

1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT – RCT
2. Was the method of randomization adequate (i.e., use of randomly generated assignment)? – Yes
3. Was the treatment allocation concealed (so that assignments could not be predicted)? – Yes
4. Were study participants and providers blinded to treatment group assignment? – No
5. Were the people assessing the outcomes blinded to the participants’ group assignments? – Yes
6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, comorbid conditions)? – Yes
7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment? – Yes
8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower? – Yes
9. Was there high adherence to the intervention protocols for each treatment group? – Yes
10. Were other interventions avoided or similar in the groups (e.g., similar background treatments)? – Yes
11. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants? – Yes
12. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)? – No
13. Were all randomized participants analyzed in the group to which they were originally assigned,

i.e., did they use an intention-to-treat analysis? – Yes

Key Finding #1: No significant difference in shoulder ROM and UL function was found between women receiving UL exercises followed by MT and those receiving UL alone for rehabilitation after breast cancer surgery. The absence of findings could have been attributed to the order of the interventions, since the MT group participated in group UL exercises prior to receiving MT, which may have resulted in decreased kinesiophobia and subsequent increase in function/mobility.  

Key Finding #2: Individual self-reports on function may have better represented the differences between the two groups; however, there are currently no specific instruments that assess functional impairment after breast cancer treatments. 

Please provide your summary of the paper: Decreased shoulder mobility is a frequent complication of breast cancer treatment, which often includes axillary lymph node dissections (ALND) and radiation therapy. Although MT is frequently used to address UE ROM limitations caused by other pathologies, its efficacy had not yet been examined in post-operative breast cancer patients. This study included 131 women who underwent ALND for breast cancer treatment and had flexion and/or abduction ROM ≤100º . All participants completed an exercise protocol in a group setting, which included 19 movements of flexion, extension, abduction, adduction, IR and ER of the UL performed in a series of 10 rhythmic repetitions, for 45 minutes, 3 times a week. After the sessions, the intervention group received about 20 minutes of MT, including glenohumeral mobilization, scapular mobilization, and/or massage. Techniques for mobilization included gliding, oscillation, and traction for the glenohumeral joint; and adduction, abduction, elevation, depression, and IR/ER for the scapula. Therapeutic massage (friction maneuvers and deep gliding) were used in the presence of wound adherence or lymphatic cording. Shoulder flexion and abduction ROM was assessed actively using a goniometer, and self-reported function was reported through the Modified-University of California at Los Angeles Shoulder Rating Scale at months 1, 6, 12, and 18. The results yielded no significant differences in function between the two groups.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented. 

I would consider the addition of manual therapy with this patient population within my future clinical practice. Although the specific manual therapy interventions selected for this study did not demonstrate a significant difference in function compared to those who did not receive MT, I believe that patients may still benefit from the addition of this intervention. I would be interested to see if there would be a difference between these groups if the exercises were performed after the MT intervention. Additionally, there was no note of progressive overload within the exercise intervention, which may have also influenced these patients’ functional outcomes by means of underloading. Furthermore, passive range of motion was not assessed during this study, leaving the cause of the patients’ ROM limitations in question. The study also cites tight pectoral muscles to be a frequent cause of shoulder ROM limitations; however, it does not explicitly include manual therapy addressing this impairment. Further studies are needed to fully determine the potential efficacy that this intervention can have on post-operative breast cancer patients.

Article Full Title 

Comparing Digital to Conventional Physical Therapy for Chronic Shoulder Pain: Randomized Controlled Trial  

Author Names  

Sang S Pak, Dora Janela, Nina Freitas, Fabiola Costa, Robert Moulder, Maria Molinos, Anabela C Areias, Virgilio Bento, Steven Cohen, Vijay Yanamadala, Richard B Souza, Fernando Dias Correia 

Reviewer Name  

Anna Smith 

Reviewer Affiliation(s) 

Duke University  

Paper Abstract 

Background 

Chronic shoulder pain (CSP) is a common condition with various etiologies, including rotator cuff disorders, adhesive capsulitis, shoulder instability, and shoulder arthritis. It is associated with substantial disability and psychological distress, resulting in poor productivity and quality of life. Physical therapy constitutes the mainstay treatment for CSP, but several barriers exist in accessing care. In recent years, telerehabilitation has gained momentum as a potential solution to overcome such barriers. It has shown numerous benefits, including improving access and convenience, promoting patient adherence, and reducing costs. However, to date, no previous randomized controlled trial has compared fully remote digital physical therapy to in-person rehabilitation for nonoperative CSP. 

Objective 

The aim of this study is to compare clinical outcomes between digital physical therapy and conventional in-person physical therapy in patients with CSP. 

Methods 

We conducted a single-center, parallel-group, randomized controlled trial involving 82 patients with CSP referred for outpatient physical therapy. Participants were randomized into digital or conventional physical therapy (8-week interventions). The digital intervention consisted of home exercise, education, and cognitive behavioral therapy (CBT), using a device with movement digitalization for biofeedback and asynchronous physical therapist monitoring through a cloud-based portal. The conventional group received in-person physical therapy, including exercises, manual therapy, education, and CBT. The primary outcome was the change (baseline to 8 weeks) in function and symptoms using the short-form of Disabilities of the Arm, Shoulder, and Hand questionnaire. Secondary outcome measures included self-reported pain, surgery intent, analgesic intake, mental health, engagement, and satisfaction. All questionnaires were delivered electronically. 

Results 

A total of 90 participants were randomized into digital or conventional physical therapy, with 82 receiving the allocated intervention. Both groups experienced significant improvements in function measured by the short-form of the Disabilities of the Arm, Shoulder, and Hand questionnaire, with no differences between groups (–1.8, 95% CI –13.5 to 9.8; P=.75). For secondary outcomes, no differences were observed in surgery intent, analgesic intake, and mental health or worst pain. Higher reductions were observed in average and least pain in the conventional group, which, given the small effect sizes (least pain 0.15 and average pain 0.16), are unlikely to be clinically meaningful. High adherence and satisfaction were observed in both groups, with no adverse events. 

Conclusions 

This study shows that fully remote digital programs can be viable care delivery models for CSP given their scalability and effectiveness, assessed through comparison with high-dosage in-person rehabilitation. 

ClinicalTrials.gov (NCT04636528); https://clinicaltrials.gov/study/NCT04636528 

Keywords: chronic shoulder, clinical outcome, digital care, digital health intervention, musculoskeletal pain, pain management, physical therapy, remote sensing technology, telerehabilitation 

Quality Assessment of Controlled Intervention Studies 

1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT 

Randomized Controlled Trial  

1. Was the method of randomization adequate (i.e., use of randomly generated assignment)? 

Yes 

1. Was the treatment allocation concealed (so that assignments could not be predicted)? 

Yes 

1. Were study participants and providers blinded to treatment group assignment? 

No 

1. Were the people assessing the outcomes blinded to the participants’ group assignments? 

Yes  

1. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)? 

Yes 

1. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment? 

Yes 

1. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower? 

Yes 

1. Was there high adherence to the intervention protocols for each treatment group? 

Yes  

1. Were other interventions avoided or similar in the groups (e.g., similar background treatments)? 

Yes 

1. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants? 

Yes 

1. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power? 

Yes 

1. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)? 

Yes  

1. Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis? 

Yes  

Key Finding #1 

Telehealth intervention and physical therapy demonstrated improvements in chronic shoulder pain.  

Key Finding #2 

No significant difference was found between telehealth intervention and conventional physical therapy intervention for chronic shoulder pain.  

Key Finding #3 

Low effect size but average and lowest pain after treatment was found in the conventional physical therapy group.  

Please provide your summary of the paper 

Study compared treating chronic shoulder pain with conventional physical therapy in clinic to telehealth intervention. Conventional treatment included exercise with tactile cueing, patient education, motivational interviewing/cognitive behavior therapy, and manual therapy, whereas telehealth treatment included a home exercise program, patient education, and cognitive behavioral therapy. Of note is the fact that the therapists performing conventional services had fewer years of experience than the therapists performing telehealth services. Average and least pain was noted in the conventional group, but the effect size shows it is not clinically meaningful.  

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented. 

This study supports the ability of physical therapy services to be effectively delivered online for chronic shoulder pain. Tactile cueing and manual therapy were the intervention tools that telehealth clinicians were unable to implement for their patients. While these are useful tools for a physical therapist, this research supports a physical therapists ability to deliver meaningful care without utilizing those tools. This is particularly important for patients that lack the resources to go to a clinical site for any number of reasons. Adherence to physical therapy is likely more important than the delivery method of care. 

Article Full Title: The Effectiveness of Manual Therapy in supraspinatus tendinopathy 

Authors: Gamze Senbursa, Gul Baltaci, O.Ahmet Atay  

Reivewer Name: Torri Tippett 

Paper Abstract:  

Objectives: The aim of this randomized controlled study was to assess the efficacy of manual therapy in the treatment of patients with symptomatic supraspinatus tendinopathy.

Methods: Seventy-seven patients (age range, 30 to 55 years) with supraspinatus tendinopathy, were randomly assigned to one of the three treatment groups: a supervised exercise program (Group 1), a supervised exercise program combined with joint and soft tissue mobilization

(Group 2), or a home-based rehabilitation program (Group 3). All patients had rehabilitation for

12 weeks. Pain level was evaluated with a visual analogue scale (VAS) and the range of motion

(ROM) was measured with a goniometer. The Modified American Shoulder and Elbow Surgery (MASES) score was used in functional assessment. Flexion, abduction, internal and external rotation strengths were measured with a manual muscle test. All patients were evaluated before, and at the 4th and 12th week of the rehabilitation.

Results: All groups experienced significant decrease in pain and an increase in shoulder muscle strength and function by both the 4th and 12th weeks of treatment (p<0.05). There was no significant difference between the groups in terms of function (p>0.05). However, the greatest improvement in functionality was found in Group 2.

Conclusion: Supervised exercise, supervised and manual therapy, and home-based exercise are all effective and promising methods in the rehabilitation of the patients with subacromial impingement syndrome. The addition of an initial manual therapy may improve the results of the rehabilitation with exercise.

Paper Summary: 

The article “The Effectiveness of Manual Therapy in Supraspinatus Tendinopathy” evaluates the efficacy of manual therapy combined with exercise in treating symptomatic supraspinatus tendinopathy. The study was combined of 77 patients between the age range of 30-55 years old who were split into 3 groups. The groups consisted of supervised exercise program, supervised exercise program combined with joint and soft tissue mobilization (manual therapy), and a home-based rehabilitation program.  All participants underwent a 12- week program where they were assessed using the Visual Analogue Scale for pain and ROM using a goniometer. The findings of the study showed that the participants who received manual therapy exhibited the most significant improvements. While all participants showed an increase in shoulder and muscle strength the manual therapy patients exhibited more functionality. Supervised exercise and manual therapy can both improve the rehab of patients with subacromial impingement syndrome. The study showed that a combination of both is more effective for patients and will improve their functionality. 

Key Findings: 

1. All the treatment methods including supervised exercise, manual therapy, and adding a

home exercise plan are all effective treatments for supraspinatus tendinopathy. 

2. Manual Therapy alongside exercise led to the greatest improvement within patients.
3. There was no signiant difference between pain levels within groups.

Clinical Interpretation:

While all treatment groups were effective the addition of manual therapy led to faster pain relief and greater functional gains. The addition of manual therapy with subacromial impingement syndrome can enhance rehabilitation outcomes. PT’s should consider implementing manual therapy techniques alongside exercise programs. Treatment plans should be made based off the patient’s needs, symptom severity, accessibility to care, etc.  

NIH Risk of Bias Tool: 

1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT?
   • Yes, the study was described as a randomized controlled study.
2. Was the method of randomization adequate (i.e., use of randomly generated assignment)?
   • Yes, patients were randomly assigned to groups using SPSS software.
3. Was the treatment allocation concealed (so that assignments could not be predicted)?
   • N/a. The study does not explicitly mention whether allocation concealment was implemented.
4. Were study participants and providers blinded to treatment group assignment? o No, there was no mention. 
5. Were the people assessing the outcomes blinded to the participants’ group assignments?
   • No, there was no mention.
6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
   • Yes, the groups were similar at baseline in terms of age, height, weight, and pain intensity (p > 0.05).
7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
   • N/A (no mention)
8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
   • N/A. (no mention)
9. Was there high adherence to the intervention protocols for each treatment group?
   • Yes, adherence appears to be high, as all groups followed structured rehabilitation programs.
10. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

• Yes, all groups followed a structured exercise program with only the addition of manual therapy in one group.

11. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

• Yes, the study used VAS for pain, goniometry for ROM, MASES score for function, and manual muscle testing.

12. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

• N/A (no mention)

13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

• Yes, outcomes such as pain, range of motion, and strength were pre-specified and measured at defined time points.

14. Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

• N/A (no mention) 

Article Full Title 

The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness 

Author Names 

Paul A. Salamh, Morey J. Kolber, and William J. Hanney 

Reviewer Name 

Katey Wang 

Reviewer Affiliation(s) 

SPT 

Paper Abstract 

Objective: To evaluate the effect of scapular stabilization during horizontal adduction stretching (cross-body) on posterior shoulder tightness (PST) and passive internal rotation (IR). 

Design: Randomized controlled trial with single blinding. 

Setting: Athletic club. 

Participants: Asymptomatic volleyball players who are women with glenohumeral internal rotation deficit (N=60). 

Interventions: Subjects were randomly assigned to either horizontal adduction stretching with manual scapular stabilization (n=30) or horizontal adduction stretching without stabilization (n=30). Passive stretching was performed for 3- to 30-second holds in both groups. 

Main outcome measures: Range of motion measurements of PST and IR were performed on the athlete’s dominant shoulder prior to and immediately after the intervention. 

Results: Baseline mean angular measurements of PST and IR for all athletes involved in the study were 62°±14° and 40°±10°, respectively, with no significant difference between groups (P=.598 and P=.734, respectively). Mean PST measurements were significantly different between groups after the horizontal adduction stretch, with a mean angle of 83°±17° among the scapular stabilization group and 65°±13° among the nonstabilization group (P<.001). Measurements of IR were also significantly different between groups, with a mean angle of 51°±14° among the scapular stabilization group and 43°±9° among the nonstabilization group (P=.006). 

Conclusions: Horizontal adduction stretches performed with scapular stabilization produced significantly greater improvements in IR and PST than horizontal adduction stretching without scapular stabilization. 

Quality Assessment of Controlled Intervention Studies 

1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT 

Yes 

1. Was the method of randomization adequate (i.e., use of randomly generated assignment)? 

Yes  

1. Was the treatment allocation concealed (so that assignments could not be predicted)? 

N/A 

1. Were study participants and providers blinded to treatment group assignment? 

No 

1. Were the people assessing the outcomes blinded to the participants’ group assignments? 

Yes 

1. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)? 

Yes 

1. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment? 

Yes 

1. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower? 

Yes 

1. Was there high adherence to the intervention protocols for each treatment group? 

N/A 

1. Were other interventions avoided or similar in the groups (e.g., similar background treatments)? 

Yes 

1. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants? 

Yes 

1. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power? 

Yes 

1. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)? 

Yes 

1. Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis? 

Yes 

Key Finding #1 

Incorporating scapular stabilization with horizontal adduction stretching had a greater increase in internal rotation than stretching without the scapular stabilization. The mean angle of the control group without the stabilization was 43° of internal rotation, while the experimental group had a mean of 51° after intervention. 

Key Finding #2 

Incorporating scapular stabilization with horizontal adduction stretching demonstrated improvements with posterior shoulder tightness compared to the group that did not receive scapular stabilization. The control group reached 65° average posterior shoulder tightness, while the group that received stabilization reached a mean of 83° after treatment. 

Key Finding #3 

When comparing pre- and post-intervention for the control group that did not receive any scapular stabilization with horizontal adduction stretching, there was an increase in shoulder internal rotation (P= 0.006), however, there was no significant change in posterior shoulder tightness (P=0.228). 

Key Finding #4 

Muscle energy techniques can be used to increase both shoulder internal rotation and horizontal adduction and manual techniques targeting the contractile tissues responsible for the muscle energy techniques can address posterior shoulder tightness. 

Please provide your summary of the paper 

The article researched the effects of scapular stabilization during horizontal adduction stretching and its effects on posterior shoulder tightness and passive range of motion for shoulder internal rotation in youth women’s volleyball athletes presenting with GIRD (glenohumeral internal rotation deficit). This study utilized sixty asymptomatic athletes with GIRD that were randomly assigned to horizontal adduction stretching with manual scapular stabilization or without, and they all held the passive stretch for 3 repetitions of 30 second holds. Pre-test and immediate post-test results demonstrated significant improvement with passive internal rotation and posterior shoulder tightness for the experimental group. There are potential limitations to the study, due to the acute nature of the treatment and specific demographics of the participants. 

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented. 

Implementing scapular stabilization during horizontal adduction stretching is strongly supported from this study and should be considered while performing this stretch. It can be utilized for overhead athletes that present with GIRD to increase gains in shoulder internal rotation and posterior shoulder tightness.