Shoulder Symptom Modification Procedure (SSMP)

We wrote quite an extensive series on shoulder impingement based on Cools algorithm from the year 2008. Through the use of several clinical tests, you should be able to identify the underlying pathological mechanism for the shoulder pain your patient is experiencing. 

Usually, the problem with pain provocation tests is that they commonly rate low in terms of specificity. In other words, it’s practically impossible to isolate a single rotator cuff tendon from other structures such as the innervated bursae within the subacromial space, and form a diagnosis from the results. 

The shoulder symptom modification procedure by Jeremy Lewis (2009) looks at shoulder impingement in a way that could be described as mechanical shoulder pain. 

Once the general assessment process meaning: history taking, ROM, strength tests, and neurological testing is done the clinician and patient will identify the pain-provoking movement or positions

From there on a four-stage process begins. The painful movement is performed and the clinician applies an algorithm of the following procedures and assesses for symptom modification, in other words: pain reduction. 

Meakins et al. (2018) evaluated the SSMP regarding its inter-rater reliability and found a moderate inter-rater reliability of k = 0.47

Let’s say flexion of the shoulder is painful. 

One stage of the SSMP is targeting thoracic kyphosis. If your patient demonstrates increased thoracic kyphosis, techniques to actively extend the T-spine like ‘finger on the sternum’ can be used,  or passive techniques like taping or manual therapy are applied and then the painful movement is reassessed for change in pain. If thoracic maneuvers reduce the pain by 100% the assessment is complete and treatment targeted at the thoracic spine would start.

If thoracic modification did not alleviate symptoms 100%, the position of the scapula is altered using manual techniques for simple movements or taping for complex movements. This may happen in several planes for example elevation or protraction, or a combination of movements. 

This is different from the scapular assistance test where you are assisting the scapula to move. In scapular modification, you place the scapula in a new starting positing allowing it to move from that position without assistance.

If winging is apparent, manual stabilization or taping techniques are used. The painful movement is then reassessed.

The third stage concerns the positioning of the humeral head within the glenoid fossa. For example: using a neoprene sling or manual pressure, an AP or PA force is applied and the painful movement is reassessed.

Furthermore, the painful movement is executed whilst simultaneously contracting surrounding muscles, for example, the external rotators or humeral head depressors.

21 OF THE MOST USEFUL ORTHOPAEDIC TESTS IN CLINICAL PRACTICE

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There are a couple of orthopedic tests that are used in the SSMP or related to this post that you might find interesting:

• Shoulder Impingement Explained 
• Scapular Assistance Test
• Scapular Retractinn Test
• Scapular Dyskinesis Test
• Scapular Strengthening Exercises

References

Lewis, J. S. (2009). Rotator cuff tendinopathy/subacromial impingement syndrome: is it time for a new method of assessment?. British journal of sports medicine, 43(4), 259-264.

Cools, A. M., Cambier, D., & Witvrouw, E. E. (2008). Screening the athlete’s shoulder for impingement symptoms: a clinical reasoning algorithm for early detection of shoulder pathology. British journal of sports medicine, 42(8), 628-635.

Meakins, A., May, S., & Littlewood, C. (2018). Reliability of the Shoulder Symptom Modification Procedure and association of within-session and between-session changes with functional outcomes. BMJ open sport & exercise medicine, 4(1), e000342.