Graded Motor Imagery and Task-Oriented Exercise in Shoulder Impingement

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.

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

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.

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

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.

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

Shoulder laterality performance will be assessed using the 'Recognise™' application developed by the Neuro Orthopaedic Institute. The 'Recognise™ Shoulder' section of the app, specifically the 'Vanilla' mode, will be used. A total of 20 shoulder images will be presented for 5 seconds each. Participants will be asked to identify as quickly and accurately as possible whether the displayed image represents a right or left shoulder by pressing the corresponding button on the screen. The percentage of correct responses and reaction time will be recorded as outcome measures.

Movement imagery ability will be assessed using the Movement Imagery Questionnaire-3 (MIQ-3). The questionnaire consists of 12 items. Participants are asked to imagine four different movements using internal visual imagery, external visual imagery, and kinesthetic imagery. They rate the clarity or ease of imagining each movement on a 7-point ordinal scale (1 = very hard to feel/see, 7 = very easy to feel/see)

Kinesiophobia will be assessed using the Tampa Scale for Kinesiophobia (TSK), developed by Miller, Kori, and Todd. The scale consists of 17 items evaluating fear of injury, reinjury, fear-avoidance beliefs, and activity-related concerns. Each item is scored on a 4-point Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree). Higher scores indicate a higher level of kinesiophobia.

Patient satisfaction with treatment will be assessed using the Global Rating of Change (GRC) Scale. This scale is widely used in clinical research, particularly in musculoskeletal conditions. It is designed to measure a patient's perceived improvement or deterioration over time, either to determine the effectiveness of an intervention or to track clinical progress. The version used in this study consists of 5 levels and is scored between -2 and +2.