Document Type : Original Articles


1 Physical Therapy Department, School of Rehabilitation Sciences, Tehran University of Medical Sciences, Tehran, Iran

2 Student Research Committee, Tehran University of Medical Sciences, Tehran, Iran.

3 Student Research Committee, Tehran University of Medical Sciences, Tehran, Iran

4 Rehabilitation Sciences Research Center, Tehran University of Medical Sciences, Tehran, Iran


Background: Subacromial Pain Syndrome (SAPS) is one of the most common causes of shoulder pain, leading to long-lasting disability if left untreated or if there is no access to a rehabilitation center. Treating musculoskeletal shoulder pain is challenging; however, evidence suggests that a combination of Exercise Therapy (ET) and Manual Therapy (MT) can be an effective approach for addressing shoulder dysfunctions. To ensure timely treatment and prevent the pain from becoming chronic, tele-physical therapy appears to be an effective method for properly delivering ET and MT
Methods: A prospective, assessor-blind, randomized controlled clinical trial study protocol
include 33 patients with Subacromial Pain Syndrome (SAPS). These patients will be divided into three groups (11 participants in each group): the Control group (supervised Exercise Therapy (ET) + Manual Therapy (MT)), the Videoconferencing group (ET + self-release therapy), and the Video-based group (ET + self-release therapy). Self-release therapies include self-joint mobilization and self-myofascial release with a tennis ball. MT includes joint mobilization techniques and transverse friction massages. ET consists of stretching and strengthening exercises. Each patient in the three groups will receive 10 sessions of ET and MT over three weeks. Assessments will be conducted three times: at baseline, midterm, and post-treatment. The Visual Analogue Scale, function by the Shoulder Pain and Disability Index, and Range of Motion will measure pain. The Telehealth Satisfaction Scale and Physical Therapy Patient Satisfaction Questionnaire will also be assessed.
Results: Repeated measures ANOVA will be used for analysis of data after data gathering
Conclusion:This trial will focus on the assessment of tele-physical therapy based on ET and myofascial release, in comparison to a face-to-face approach with supervised ET and MT, on pain, function, Range of Motion, and patient satisfaction.


  1. Urwin M, Symmons D, Allison T, Brammah T, Busby H, Roxby M, et al. Estimating the burden of musculoskeletal disorders in the community: the comparative prevalence of symptoms at different anatomical sites, and the relation to social deprivation. Annals of the rheumatic diseases. 1998;57(11):649-55.
  2. Vincent K, Leboeuf-Yde C, Gagey O. Are degenerative rotator cuff disorders a cause of shoulder pain? Comparison of prevalence of degenerative rotator cuff disease to prevalence of nontraumatic shoulder pain through three systematic and critical reviews. Journal of shoulder and elbow surgery. 2017;26(5):766-73.
  3. Pribicevic M. The epidemiology of shoulder pain: A narrative review of the literature: IntechOpen; 2012.
  4. de Oliveira VM, Pitangui AC, Gomes MR, da Silva HA, Dos Passos MH, de Araújo RC. Shoulder pain in adolescent athletes: prevalence, associated factors and its influence on upper limb function. Brazilian journal of physical therapy. 2017;21(2):107-13.
  5. Virta L, Joranger P, Brox JI, Eriksson R. Costs of shoulder pain and resource use in primary health care: a cost-of-illness study in Sweden. BMC musculoskeletal disorders. 2012;13(1):1-11.
  6. Bhattacharyya R, Edwards K, Wallace AW. Does arthroscopic sub-acromial decompression really work for sub-acromial impingement syndrome: a cohort study. BMC musculoskeletal disorders. 2014;15(1):1-7.
  7. Miniato MA, Anand P, Varacallo M. Anatomy, shoulder and upper limb, shoulder. StatPearls [Internet]: StatPearls Publishing; 2021.
  8. Dal Maso F, Raison M, Lundberg A, Arndt A, Allard P, Begon M. Glenohumeral translations during range-of-motion movements, activities of daily living, and sports activities in healthy participants. Clinical Biomechanics. 2015;30(9):1002-7.
  9. Sahrmann S. Anonymous: Diagnosis and treatment of movement impairment syndromes St. Louis: Mosby. 2002.
  10. Diercks R, Bron C, Dorrestijn O, Meskers C, Naber R, De Ruiter T, et al. Guideline for diagnosis and treatment of subacromial pain syndrome: a multidisciplinary review by the Dutch Orthopaedic Association. Acta orthopaedica. 2014;85(3):314-22.
  11. Rhon DI, Boyles RE, Cleland JA, Brown DL. A manual physical therapy approach versus subacromial corticosteroid injection for treatment of shoulder impingement syndrome: a protocol for a randomised clinical trial. BMJ open. 2011;1(2):e000137.
  12. McConnell R, Klopper M, Rhon DI, Young JL. The influence of exercise therapy dosing on pain and functional outcomes in patients with subacromial pain syndrome: A systematic review. Shoulder & Elbow. 2022:17585732221124303.
  13. Ludewig PM, Braman JP. Shoulder impingement: biomechanical considerations in rehabilitation. Manual therapy. 2011;16(1):33-9.
  14. d’Hespeel CG. Current concepts: Rehabilitation of patients with shoulder impingement and tight posterior capsule. ORTHOPAEDIC. 2004:6.
  15. Bang MD, Deyle GD. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. Journal of Orthopaedic & Sports Physical Therapy. 2000;30(3):126-37.
  16. Conroy DE, Hayes KW. The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome. Journal of Orthopaedic & Sports Physical Therapy. 1998;28(1):3-14.
  17. Morrison DS, Frogameni AD, Woodworth P. Non-operative treatment of subacromial impingement syndrome. JBJS. 1997;79(5):732-37.
  18. Kim K, Park S, Goo B-O, Choi S-C. Effect of self-myofascial release on reduction of physical stress: a pilot study. Journal of physical therapy science. 2014;26(11):1779-81.
  19. MacDonald GZ, Penney MD, Mullaley ME, Cuconato AL, Drake CD, Behm DG, et al. An acute bout of self-myofascial release increases range of motion without a subsequent decrease in muscle activation or force. The Journal of Strength & Conditioning Research. 2013;27(3):812-21.
  20. Gutierrez-Espinoza H, Araya-Quintanilla F, Cereceda-Muriel C, Alvarez-Bueno C, Martinez-Vizcaino V, Cavero-Redondo I. Effect of supervised physiotherapy versus home exercise program in patients with subacromial impingement syndrome: a systematic review and meta-analysis. Physical Therapy in Sport. 2020;41:34-42.
  21. Miller MJ, Pak SS, Keller DR, Barnes DE. Evaluation of pragmatic telehealth physical therapy implementation during the COVID-19 pandemic. Physical therapy. 2021;101(1):pzaa193.
  22. Dantas LO, Barreto RPG, Ferreira CHJ. Digital physical therapy in the COVID-19 pandemic. Brazilian Journal of Physical Therapy. 2020;24(5):381.
  23. Bittner AK, Yoshinaga PD, Wykstra SL, Li T. Telerehabilitation for people with low vision. Cochrane Database of Systematic Reviews. 2020(2).
  24. Ramey L, Osborne C, Kasitinon D, Juengst S. Apps and mobile health technology in rehabilitation: the good, the bad, and the unknown. Physical Medicine and Rehabilitation Clinics. 2019;30(2):485-97.
  25. Kisner C, Colby LA, Borstad J. Therapeutic exercise: foundations and techniques: Fa Davis; 2017.
  26. Davies C. Frozen Shoulder Workbook: Trigger Point Therapy for Overcoming Pain & Regaining Range of Motion: New Harbinger Publications; 2006.
  27. Flatow EL, Soslowsky LJ, Ticker JB, Pawluk RJ, Hepler M, Ark J, et al. Excursion of the rotator cuff under the acromion: patterns of subacromial contact. The American journal of sports medicine. 1994;22(6):779-88.
  28. Fernández-de-las-Peñas C, Cleland J, Dommerholt J. Manual therapy for musculoskeletal pain syndromes: An evidence-and clinical-informed approach: Elsevier Health Sciences; 2015.
  29. Katz J, Melzack R. Pain control in the peroperative period, measurement of pain. Surg Clin North Am. 1999;79(2):231-52.
  30. Ebrahimzadeh MH, Birjandinejad A, Golhasani F, Moradi A, Vahedi E, Kachooei AR. Cross-cultural adaptation, validation, and reliability testing of the Shoulder Pain and Disability Index in the Persian population with shoulder problems. International journal of rehabilitation research Internationale Zeitschrift fur Rehabilitationsforschung Revue internationale de recherches de readaptation. 2015;38(1):84-7.
  31. Williams Jr JW, Holleman Jr DR, Simel D. Measuring shoulder function with the Shoulder Pain and Disability Index. The Journal of rheumatology. 1995;22(4):727-32.
  32. Surgeons AAoO. Joint motion: method of measuring and recording: Churchill Livingstone; 1965.
  33. Cools AM, De Wilde L, Van Tongel A, Ceyssens C, Ryckewaert R, Cambier DC. Measuring shoulder external and internal rotation strength and range of motion: comprehensive intra-rater and inter-rater reliability study of several testing protocols. Journal of shoulder and elbow surgery. 2014;23(10):1454-61.
  34. Jaeschke R, Singer J, Guyatt GH. Measurement of health status: ascertaining the minimal clinically important difference. Controlled clinical trials. 1989;10(4):407-15.
  35. Garrison JC, Shanley E, Thigpen C, Hegedus E, Cook C. Between-session changes predict overall perception of improvement but not functional improvement in patients with shoulder impingement syndrome seen for physical therapy: an observational study. Physiotherapy theory and practice. 2011;27(2):137-45.
  36. Mintken PE, Glynn P, Cleland JA. Psychometric properties of the shortened disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) and Numeric Pain Rating Scale in patients with shoulder pain. Journal of Shoulder and Elbow Surgery. 2009;18(6):920-6.
  37. Health Canada. Final Report National First Nations Telehealth Research Project HTF-NA402, 1998–2001. Ottawa: Publications, Health Canada; 2001. Community services in the 21st century: First Nations and Inuit telehealth services


  1. Abdolalizadeh M, Mosallanezhad Z, Saeedi A, Ghodrati M, Rezaei Rayeni Nejad A. Measurement Properties of Physical Therapy Patient Satisfaction Questionnaire (PTPSQ) in an Iranian Musculoskeletal Population. Physical Treatments-Specific Physical Therapy Journal. 2021;11(2):121-30.
  2. Beattie PF, Pinto MB, Nelson MK, Nelson R. Patient satisfaction with outpatient physical therapy: instrument validation. Physical therapy. 2002;82(6):557-65.
  3. Malliaras P, Cridland K, Hopmans R, Ashton S, Littlewood C, Page R, et al. Internet and telerehabilitation-delivered management of rotator cuff–Related shoulder pain (INTEL trial): Randomized controlled pilot and feasibility trial. JMIR mHealth and uHealth. 2020;8(11):e24311.
  4. Suso-Martí L, La Touche R, Herranz-Gómez A, Angulo-Díaz-Parreño S, Paris-Alemany A, Cuenca-Martínez F. Effectiveness of telerehabilitation in physical therapist practice: An umbrella and mapping review with meta–meta-analysis. Physical therapy. 2021;101(5):pzab075.
  5. Salawu A, Green A, Crooks MG, Brixey N, Ross DH, Sivan M. A proposal for multidisciplinary tele-rehabilitation in the assessment and rehabilitation of COVID-19 survivors. International journal of environmental research and public health. 2020;17(13):4890.
  6. Hjert CS, Wright CJ. The effects of self-myofascial release foam rolling on muscle soreness or pain after experiencing delayed onset muscle soreness: a critically appraised topic. International Journal of Athletic Therapy and Training. 2020;25(6):294-8.