Mobilization with movement plus exercise versus exercise alone for patients with central sensitization associated with chronic subacromial pain syndrome: a sham-controlled randomized clinical trial

Key Points

1. In patients with chronic subacromial pain syndrome and central sensitization, mobilization with movement (MWM) plus exercise showed no short-term advantages over sham-MWM or exercise alone.
2. At three-month follow-up, MWM plus exercise had no advantage over the other groups in functional disability or central sensitization symptoms, but they did have slightly less widespread mechanical hyperalgesia.

BACKGROUND AND OBJECTIVE

Subacromial pain syndrome is a common shoulder condition that can become chronic and involve central sensitization.

Mobilization with movement (MWM) is a manual therapy technique that applies specific joint mobilizations while the patient performs active movements. MWM has shown benefits for shoulder pain, but its effects on central sensitization remain unclear.

This study compared MWM plus exercise to sham-MWM plus exercise and exercise alone in patients with chronic subacromial pain syndrome and signs of central sensitization.

Subacromial pain syndrome is a common shoulder condition that can become chronic and involve central sensitization.

Clinicians should view this study as tentative evidence that mobilization with movement may improve central sensitization beyond exercise alone.

METHODS

• 63 adults with chronic subacromial pain syndrome (lasting >three months) and evidence of central sensitization were randomly assigned to three groups: MWM plus exercise, sham-MWM plus exercise, or exercise alone.

• All groups performed the same exercise program for three weeks (15 sessions total), which included stretching and strengthening exercises.

• The MWM group received additional manual therapy with posterior-lateral gliding of the humeral head during shoulder flexion (see Video 1). The sham group received hand contact without actual mobilization.

• Outcomes measured included: (1) Central Sensitization Inventory scores; (2) widespread mechanical hyperalgesia, as measured by pressure pain thresholds at the shoulder and remote sites (forearm, thigh, shin); (3) functional disability as measured by Quick DASH questionnaire.

• Assessments were performed at baseline, immediately post-treatment (three weeks), and at three-month follow-up.

VIDEO 1 – MWM TECHNIQUE

RESULTS

At three weeks post-treatment, all groups showed some improvement, but there were no significant differences between the groups for any outcome measure.

At three-month follow-up, the results were mixed. There were no significant differences between the groups for central sensitization inventory scores and functional disability.

However, the MWM group showed more improvement in pressure pain thresholds at both local (shoulder) and remote sites compared to sham and control groups. The differences were small (around 1kg) which is close to the estimated minimal detectable difference (0.5kg-1kg).

LIMITATIONS

• The study failed to use Quantitative Sensory Testing, which is recognized as the gold standard for assessing central sensitization.

• The study excluded patients with other conditions that could contribute to central sensitization, potentially limiting generalizability.

• The study lacked longer-term follow-up beyond three months to determine if benefits persist.

CLINICAL IMPLICATIONS

Subacromial pain syndrome encompasses a range of non-traumatic shoulder conditions that cause unilateral pain around the acromion during arm elevation (1) Central sensitization may contribute to pain in a subgroup of these patients (2).

MWM has been shown to reduce shoulder pain and disability in patients with subacromial pain syndrome, but its effect on central sensitization and widespread hypersensitivity remains unclear (3,4).

In this study, MWM when added to exercise resulted in slighter higher pressure pain thresholds in various body locations, which may be a sign that it reduced central sensitization better than the other treatments. However, this is questionable because it did not lead to better central sensitization scores as measured by questionnaire, or functional disability.

Further, the differences in pain pressure threshold were small, close to the minimal difference that is detectable. Further, there were no group differences in pain pressure thresholds immediately after treatment, and no good explanation why they should arise only three months later.

Clinicians should use this study as suggestive but not convincing evidence that MWM can have meaningful effects on central sensitization over and above any benefits provided by exercise.

+STUDY REFERENCE

Deniz V, Kelle B (2025) Mobilization with movement plus exercise versus exercise alone for patients with central sensitization associated with chronic subacromial pain syndrome: a sham-controlled randomized clinical trial. BMC Complement Med Ther, 25, 289.

SUPPORTING REFERENCE

1. Diercks R, Bron C, Dorrestijn O, Meskers C, Naber R, de Ruiter T, Willems J, Winters J, van der Woude HJ. Dutch orthopaedic association. Guideline for diagnosis and treatment of subacromial pain syndrome: a multidisciplinary review by the Dutch orthopaedic association. Acta Orthop. 2014;85:314–22.
2. Deniz V, Sariyildiz A. Evaluation of the segmental distribution of pain sensitivity among patients with central sensitization associated with chronic subacromial pain syndrome: A cross-sectional study. J Bodyw Mov Ther. 2024;39:176–82.
3. Deniz V, Kivrak A, Elbasan B, et al. Comparison of the effects of Mulligan mobilization with movement method and conventional rehabilitation protocol on shoulder pain and functions in subacromial pain syndrome: A prospective randomized single blind trial. Turkiye Klinikleri J Health Sci. 2021;6(1):78–87.