Graded Motor Imagery and Task-Oriented Exercise in Shoulder Impingement

Condition(s) studied

Investigational drug(s) / intervention(s)

Electrotherapy + Conventional Exercise Group: All participants will receive an electrotherapy program consisting of TENS (100 Hz, 20 minutes), ultrasound (1.5 W/cm², 6 minutes), and cold pack application (15 minutes), delivered 5 days per week for 6 weeks. The conventional exercise program includes wand exercises (flexion, abduction, extension, external/internal rotation), Codman exercises in multiple directions, and finger ladder exercises with a 5-second hold at end range. Strengthening exercises will be performed without resistance during the first week, followed by progressive TheraBand® resistance from week two. Posterior, anterior, and inferior capsule stretching, pectoral stretching, and shoulder-scapular mobilization will be performed under physiotherapist supervision. Exercises will be applied twice weekly for 6 weeks, with 3 sets of 10 repetitions.

The graded motor imagery program: The graded motor imagery program consists of 2 weeks of laterality training, 2 weeks of motor imagery, and 2 weeks of mirror therapy. Laterality training will be performed using the Recognise™ Shoulder app (NOI), where participants identify whether presented images show a right or left shoulder. Training will be conducted twice weekly for 2 weeks. Motor imagery includes viewing shoulder movement images (flexion 180°, abduction 180°, external rotation 90°, internal rotation 90°, extension 45°) and mentally rehearsing the movements for 3 sets of 10 repetitions. Mirror therapy requires participants to view the reflection of their unaffected shoulder and perform the imagined movements. Mirror therapy will also be applied twice weekly for 2 weeks, with 3 sets of 10 repetitions

The task-oriented exercise program: The task-oriented exercise program is based on daily activities related to DASH and SPADI items, focusing on functional shoulder movements including flexion, abduction, extension, and rotation. Exercises will be performed twice weekly for 6 weeks, 3 sets of 10 repetitions. Weeks 0-2 include placing an object on a front shelf, placing an object on a side shelf, placing the hand on the back, touching the neck, washing a plate, and wiping a wall within pain limits. Weeks 2-4 include changing an overhead light bulb, washing hair, combing hair, putting on and taking off a pullover shirt, and donning a jacket or cardigan. Weeks 4-6 include placing a 0.5-kg weight on an overhead shelf (front and side), washing or scratching the upper and lower back, and placing a wallet in the back pocket.

Study summary

This study aims to compare the effects of graded motor imagery and task-oriented exercise training in individuals with shoulder impingement syndrome. A total of 66 participants aged 25-65 years will be randomly assigned to one of three groups: conventional physiotherapy, graded motor imagery, or task-oriented exercise training. All groups will receive standardized electrotherapy, while the intervention groups will additionally complete 6-week graded motor imagery or task-oriented exercise programs.

Primary outcomes include pain intensity, shoulder range of motion, muscle strength, proprioception, functional status, kinesiophobia, laterality recognition, movement imagery ability, and patient satisfaction. Assessments will be conducted before and after the intervention by the same physiotherapist. The study aims to determine whether motor imagery-based or task-oriented rehabilitation provides additional benefits compared with conventional physiotherapy in individuals with shoulder impingement syndrome.

Eligibility

Primary outcome measure(s)

• Assessment of Muscle Strength — At baseline and at the end of the 6-week intervention period
  Muscle strength will be assessed using the Lafayette Manual Muscle Tester (MMT). Shoulder flexion, extension, abduction, internal rotation, and external rotation muscle strengths will be evaluated. Three consecutive measurements will be taken for each movement, and the mean value will be recorded.
• Assessment of Pain Intensity — At baseline and at the end of the 6-week intervention period
  Pain intensity will be assessed using a 10 cm Visual Analog Scale (VAS), ranging from '0' (no pain) to '10' (unbearable pain). Participants will rate their pain levels before and after the intervention in three conditions: at rest, during activity, and at night
• Assessment of Pain Threshold — At baseline and at the end of the 6-week intervention period
  The pain threshold will be assessed using an algometer, a device that measures the pressure at which pain is first perceived. During the measurement, the participant must remain in a relaxed position, and the tip of the algometer must be applied at a 90-degree angle to the tissue. As pressure gradually increases, the participant will be instructed to indicate the moment when pain or discomfort is first felt. This point will be recorded as the pain threshold . In this study, the Commander Echo Algometer will be used to assess pain thresholds. Measurements will be taken from the deltoid muscle, supraspinatus muscle, infraspinatus muscle, and the participant's self-reported most painful area. Each measurement will be repeated three times, and the mean value will be recorded.
• Assessment of Shoulder Range of Motion — At baseline and at the end of the 6-week intervention period
  Shoulder range of motion will be assessed using a Baseline goniometer (RMS UK Ltd., Nailsea). The joint movements to be evaluated include flexion, extension, abduction, internal rotation, and external rotation, and the results will be recorded in degrees. For each movement, three consecutive measurements will be taken, and the mean value will be used for analysis
• Assessment of Active Joint Position Sense — At baseline and at the end of the 6-week intervention period
  Active shoulder joint position sense will be assessed using a smartphone goniometer application with proven validity and reliability. Elevation angles of 40° and 100° in the scapular plane will be tested. A smartphone will be placed in an armband positioned over the biceps brachii on the tested side. With eyes open, participants will first learn the target angle through passive movement. Then, with eyes closed, the shoulder will be passively positioned at the target angle three times for familiarization. Participants will then actively reproduce the angle. The test will be repeated six times with 5 seconds of rest between trials. The same procedure will be performed for both 40° and 100° elevations on both shoulders.
• Assessment of Upper Extremity Function — At baseline and at the end of the 6-week intervention period
  Functional assessment of the shoulder will be performed using the Shoulder Pain and Disability Index (SPADI). SPADI consists of 13 items divided into two subscales: pain and disability. The pain subscale includes five questions related to shoulder pain during activities, while the disability subscale includes eight questions evaluating difficulty in performing daily activities. Both subscale scores and the total score range from 0 to 100, with higher scores indicating greater pain and disability

Trial sites (1)

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