The present study demonstrated statistically significant improvements in pain, range of motion (ROM), and functional disability in both groups; however, participants receiving telerehabilitation with self-Mulligan technique exhibited significantly greater improvements compared to those receiving telerehabilitation alone. These findings highlight the added value of incorporating manual therapy concepts, even in a self- applied or remotely guided format, into rehabilitation programs for patients with subacromial pain syndrome (SAPS). The significant reduction in pain scores (VAS) and improvement in ROM across all planes in Group A can be explained by the biomechanical correction principle of the Mulligan Concept, particularly Mobilization with Movement (MWM). This technique is believed to correct minor positional faults in the glenohumeral joint, thereby restoring normal arthrokinematics, reducing nociceptive input, and improving movement efficiency. When combined with structured telerehabilitation exercises, it likely created a synergistic effect addressing both mechanical dysfunction and neuromuscular control.(25)

Subacromial pain syndrome (SAPS), often used almost the same as subacromial impingement syndrome, is counted among the most common reasons of shoulder pain and in many primary care or orthopedic clinics it usually makes around 44-65% of all shoulder issues. It actually covers a wide range of problems like rotator cuff tendinopathy, partial or sometimes full-thickness rotator cuff tears, subacromial bursitis and even calcific tendinopathy in some cases. The condition mostly happens because of repeated mechanical compression of the rotator cuff tendons and the subacromial bursa between humeral head and the acromion, which slowly leads to inflammation, micro- trauma and then degenerative type changes over time. The usual presentation is pain in overhead activities and a kind of reduced ROM and gradually people also struggle with day-to-day and work-related movements.

The overall burden of SAPS is quite high, not only due to pain and disability in the person but also in the wider community since it affects productivity and increases health- care use. Management is mostly done with a mix of medications, physiotherapy and in some cases surgery too. Conservative management like physiotherapy-based rehab is still the main approach because it is non-invasive and generally works well. Inside this, manual therapy methods such as the Mulligan Mobilization with Movement (MWM) have gained a lot of attention since they seem to help joint movement, reduce pain and show improvement in function.

Subacromial Pain Syndrome (SAPS) is a multifactorial musculoskeletal condition characterized by pain and functional limitation in the shoulder, primarily arising from structures located within the subacromial space, including the rotator cuff tendons (especially supraspinatus), subacromial bursa, and the long head of the biceps tendon. The pathophysiology of SAPS is complex and involves a combination of mechanical, degenerative, and inflammatory processes that evolve over time. Traditionally described as "impingement syndrome," the condition was thought to result mainly from mechanical compression of soft tissues between the humeral head and the acromion during shoulder elevation. However, contemporary understanding recognizes that intrinsic tendon degeneration plays an equally, if not more, significant role. Repetitive overhead activities, poor scapular kinematics, and altered glenohumeral biomechanics lead to microtrauma within the rotator cuff tendons, resulting in tendinopathy characterized by collagen disorganization, neovascularization, and increased ground substance. This degenerative process weakens the tendon structure, making it more susceptible to partial or full- thickness tears. Additionally, inflammation of the subacromial bursa contributes to pain and reduced range of motion, further exacerbating functional disability.

Biomechanically, the shoulder joint relies on a delicate balance between mobility and stability. The coordinated action of the rotator cuff muscles and scapular stabilizers is essential for maintaining proper alignment of the humeral head within the glenoid fossa. In SAPS, this balance is disrupted due to muscle imbalances, weakness, or neuromuscular control deficits, particularly involving the serratus anterior and lower trapezius. These alterations result in abnormal scapular movement patterns, commonly referred to as scapular dyskinesis, which reduces the subacromial space during arm elevation and increases stress on soft tissues. Over time, this leads to cumulative tissue damage and persistent pain. Furthermore, postural abnormalities such as forward head posture and rounded shoulders contribute to altered scapular positioning, compounding the problem by promoting anterior tilt and internal rotation of the scapula, thereby narrowing the subacromial space.

The etiology of SAPS is multifactorial and can be broadly categorized into intrinsic and extrinsic factors. Intrinsic factors include age-related degenerative changes, decreased vascularity of the rotator cuff tendons, and genetic predisposition to tendon pathology. With aging, there is a natural decline in tendon elasticity and healing capacity, making individuals more prone to tendinopathy and tears. Extrinsic factors, on the other hand, involve mechanical compression and include anatomical variations such as acromial shape (e.g., hooked acromion), thickening of the coracoacromial ligament, and osteophyte formation at the acromioclavicular joint. Occupational and recreational activities that involve repetitive overhead movements, such as painting, swimming, or throwing sports, significantly increase the risk of developing SAPS. Additionally, lifestyle factors such as physical inactivity, obesity, and smoking may impair tissue healing and contribute to the progression of the condition.(7) Pain in SAPS is primarily nociceptive in nature, arising from inflamed and mechanically stressed tissues. However, chronic cases may also involve central sensitization, where the nervous system becomes hypersensitive, leading to amplified pain perception even in response to minimal stimuli. This chronic pain state often results in protective muscle guarding, reduced movement, and further functional decline, creating a vicious cycle of pain and disability. Range of motion is typically limited, particularly in shoulder abduction and external rotation, due to both pain inhibition and structural restrictions. Functional disability manifests as difficulty performing daily activities such as dressing, grooming, or lifting objects, significantly impacting quality of life.

In the context of rehabilitation, traditional in-person physiotherapy focuses on restoring normal biomechanics through strengthening, stretching, manual therapy, and patient education. However, with advancements in digital health, telerehabilitation has emerged as an effective alternative, especially in situations where access to in-person care is limited. Telerehabilitation involves the delivery of rehabilitation services through telecommunication technologies, allowing patients to perform guided exercises and receive feedback remotely. While telerehabilitation alone can improve pain and function through structured exercise programs and education, the addition of manual therapy techniques such as the Mulligan Concept may enhance outcomes. The Mulligan technique, particularly Mobilization with Movement (MWM), is based on the principle of correcting positional faults in joints through the application of sustained accessory glides combined with active physiological movement. In SAPS, this technique aims to restore normal arthrokinematics of the glenohumeral joint, reduce pain, and improve range of motion immediately.

The rationale behind combining telerehabilitation with Mulligan techniques lies in addressing both the mechanical and neuromuscular components of SAPS. While telerehabilitation can effectively target muscle strength, flexibility, and motor control through exercise, Mulligan techniques provide a hands-on approach to correct joint mechanics and reduce pain rapidly. Even in a remote setting, modified or self-applied Mulligan techniques can be taught to patients under virtual supervision, empowering them to actively participate in their treatment. This integrative approach may lead to superior improvements in pain reduction, range of motion, and functional outcomes compared to telerehabilitation alone. Moreover, patient adherence and engagement are often enhanced through interactive and personalized telerehabilitation platforms, which can further contribute to successful rehabilitation.

Pathophysiology of subacromial pain syndrome involves a complex interplay of degenerative tendon changes, mechanical compression, inflammation, and neuromuscular dysfunction, while its etiology encompasses a wide range of intrinsic and extrinsic factors. The condition leads to significant pain, restricted range of motion, and functional impairment. Understanding these underlying mechanisms is essential for designing effective treatment strategies. The integration of telerehabilitation with manual therapy approaches like the Mulligan technique represents a modern, patient-centered approach that addresses both structural and functional aspects of the condition, offering promising outcomes in the management of SAPS.

The Mulligan concept that was introduced by Brian Mulligan is a manual therapy method combining a sustained accessory joint mobilization with an active movement performed by the patient. The idea is to correct "positional faults" in joints which might be causing the pain or movement restriction. When this method is used on the shoulder joint, MWM is aimed at restoring better glenohumeral mechanics by allowing pain-free movement with therapist guidance and active participation of the patient. Some recent research has also supported its value in lowering pain severity, improving subacromial space and increasing ROM and overall functional performance in SAPS patients.

Along with the improvements seen in manual therapy, rise of tele-rehabilitation has changed the usual practice of physiotherapy in the last few years. Tele-rehab uses digital communication tools for providing rehab services from a distance and helps people who have issues with access, cost or travelling long distances for treatment. After the COVID- 19 time, telehealth-based rehab became very common and many patients with musculoskeletal issues, including shoulder problems, started using it quite comfortably. A recent systematic review and meta-analysis shows that telerehabilitation can reduce pain and improve shoulder ROM and function, especially when the program continues for around 12 weeks or more . But the level of improvement may vary depending on how well the patient follows the plan, technology they have and also the quality of communication between therapist and patient.

Integrating the Mulligan technique into a tele-rehabilitation setup might actually be a major step forward in managing SAPS and many clinicians are now considering it more seriously. Even though Mulligan mobilization normally needs direct therapist contact, some modified virtual protocols can still guide the patient to do self-assisted mobilization while the therapist supervises the movements through online tools. This kind of setup combines the clinical benefit of MWM with the practical accessibility that telemedicine already offers. It not only deals with the usual logistical problems of in-person therapy but also gives patients a bit more control over their own progress through self- management and real-time feedback.

Several studies have already shown that MWM works well for improving pain and ROM when compared to standard rehab alone and mostly the patients actually felt quicker relief. In one randomized controlled trial, Mulligan MWM turned out to be more effective in early phase of SAPS rehab giving faster pain reduction and better joint function. Also a systematic review has pointed out that when MWM is combined with exercise therapy improvements of pain and function are noticeably better in short term than exercise alone. And in shoulder impingement syndrome Mulligan mobilization was also reported to increase subacromial space and improve proprioception, showing that its benefits are not only mechanical but also somehow neuromuscular.

Tele-rehabilitation on the other hand has shown almost similar effectiveness compared to usual face-to-face therapy for non-operative shoulder conditions and the difference among groups was not very large. Patients who recieved tele-guided rehab reported nearly same improvements in SPADI scores and ROM as those who came for traditional in-person sessions , but adherence and motivation were identified as very important factors for better results . By using features like interactive video sessions, simple wearable motion sensors and feedback-based reminders tele-rehabilitation can make sure that patients are doing movements more accurately and staying involved. So when Mulligan mobilization principles are added into this tele-rehab structure outcomes for SAPS patients can possibly become even better than either method alone(8).

The pain-relieving effect of MWM comes from both mechanical correction and some neurophysiological changes. The sustained glide given during active movement stimulate mechanoreceptors and decrease nociceptive signals which helps shoulder move with less pain. This neurophysiological effect may also support central motor control and eventually improving long-term shoulder function. And tele-rehabilitation naturally adds to this by allowing frequent monitoring, easier adjustments in treatment and more regular therapist-patient interaction which may further enhance recovery in many patient , even when sessions are performed at home enviroment.

The importance of the present study is that it tries to validate a new, more accessible and still evidence-based model of therapy for SAPS. As many healthcare systems are now focusing on digital health transformation,se hybrid physiotherapy approaches that mix manual therapy ideas with telehealth delivery are slowly becoming a new area in musculoskeletal rehab. If this method proves effective, tele-rehabilitation with Mulligan techniques could even change usual standard practice for shoulder pain syndromes by offering a cost-effective, scalable and more patient-centered treatment option.

The possible usefulness of these results goes beyond SAPS alone and may be helpful for other musculoskeletal problems where pain, ROM and functional ability are connected. Clinicians might adapt this combined method for rotator cuff tendinopathy, frozen shoulder or even for post-operative shoulder stiffness. Moreover, this approach fits well with international priorities that support remote access to healthcare, patient empowerment and better continuity of care, especially in areas where resources or specialist services are limited.

This study aims to compare effects of tele-rehabilitation with and also without Mulligan techniques on pain levels, ROM and functional limitations in SAPS patients. By evaluating these factors thoroughly, study hopes to find out whether adding Mulligan mobilization into a tele-rehab program gives extra therapeutic benefits over usual tele- guided exercise plans. The results are expected to provide meaningful evidence that can help optimize physiotherapy management for SAPS and improve patient recovery through more innovative rehabilitation models.

Inclusion Criteria:

• Individuals aged 25 to 55 years
• Clinically diagnosed with subacromial pain syndrome or subacromial impingement confirmed through orthopedic assessment
• Duration of symptoms at least three months

Exclusion Criteria:

• History of shoulder fracture dislocation or surgical intervention
• Neurological disorders affecting shoulder function such as cervical radiculopathy

"IPD will not be shared due to participant confidentiality, ethical restrictions, and lack of consent for public data sharing."

Outcome assessors will be blinded to group allocation to minimize assessment bias. Due to the nature of the intervention (tele-rehabilitation and self-administered exercises), participants and intervention providers will not be blinded.