Author Names
Mintken P E, McDevitt A W, Cleland J A, Boyles R E, Beardslee A R, Burns S A, Haberl M D, Hinrichs L A, Michener L A.
Reviewer Name
Razan Mazin Fayyad, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Background: Cervicothoracic manual therapy has been shown to improve pain and disability in individuals with shoulder pain, but the incremental effects of manual therapy in addition to exercise therapy have not been investigated in a randomized controlled trial. Objective: To compare the effects of cervicothoracic manual therapy and exercise therapy to those of exercise therapy alone in individuals with shoulder pain. Methods: Individuals (n = 140) with shoulder pain were randomly assigned to receive 2 sessions of cervicothoracic range-of-motion exercises plus 6 sessions of exercise therapy, or 2 sessions of high-dose cervicothoracic manual therapy and range-of-motion exercises plus 6 sessions of exercise therapy (manual therapy plus exercise). Pain and disability were assessed at baseline, 1 week, 4 weeks, and 6 months. The primary aim (treatment group by time) was examined using linear mixed-model analyses and the repeated measure of time for the Shoulder Pain and Disability Index (SPADI), the numeric pain-rating scale, and the shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH). Patient-perceived success was assessed and analyzed using the global rating of change (GROC) and the Patient Acceptable Symptom State (PASS), using chi-square tests of independence. Results: There were no significant 2-way interactions of group by time or main effects by group for pain or disability. Both groups improved significantly on the SPADI, numeric pain-rating scale, and QuickDASH. Secondary outcomes of success on the GROC and PASS significantly favored the manual therapy-plus-exercise group at 4 weeks (P = .03 and P<.01, respectively) and on the GROC at 6 months (P = .04). Conclusion: Adding 2 sessions of high-dose cervicothoracic manual therapy to an exercise program did not improve pain or disability in patients with shoulder pain, but did improve patient-perceived success at 4 weeks and 6 months and acceptability of symptoms at 4 weeks. More research is needed on the use of cervicothoracic manual therapy for treating shoulder pain.
NIH Risk of Bias Tool
Quality Assessment of Controlled Intervention Studies
- Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
- Yes
- Was the method of randomization adequate (i.e., use of randomly generated assignment)?
- Yes
- Was the treatment allocation concealed (so that assignments could not be predicted)?
- Yes
- Were study participants and providers blinded to treatment group assignment?
- Yes
- Were the people assessing the outcomes blinded to the participants’ group assignments?
- Yes
- Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
- Yes
- Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
- Yes
- Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
- No
- Was there high adherence to the intervention protocols for each treatment group?
- Yes
- Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
- Yes
- Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
- Yes
- Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
- Yes
- Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
- Yes
- Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
- Yes
Key Finding #1
The addition of cervicothoracic manual therapy to an evidence-based exercise program did not improve pain or disability in individuals with shoulder pain over exercise alone.
Key Finding #2
Both study groups had clinically significant improvements in pain and disability, despite the chronic nature of the symptoms.
Key Finding #3
A greater percentage of the individuals in the manual therapy-plus-exercise group experienced a successful outcome or acceptability of symptoms.
Please provide your summary of the paper
Shoulder pain is experienced by many individuals throughout their lifetime. Exercise has been used in the treatment of shoulder disorders. Many studies have shown the importance of exercise in the improvement of pain and disability in individuals with shoulder pain. In addition, multimodal care, which includes manual therapy and exercise, has also been reported to improve outcomes in individuals with shoulder pain. Generally speaking, treatment of shoulder pain has been mostly directed toward the glenohumeral joint. However, this doesn’t take into account the adjacent structures such as the cervicothoracic spine and adjacent ribs. To date, no studies have compared the effectiveness of a comprehensive stretching and strengthening program combined with cervicothoracic manual therapy to that of exercise alone. Therefore, this study aimed to examine the effects of cervicothoracic manual therapy plus exercise versus exercise alone in individuals with shoulder pain. 140 individuals were randomized to 2 sessions of cervicothoracic range-of-motion exercises plus 6 sessions of exercise therapy, or 2 sessions of high-dose cervicothoracic manual therapy and range-of-motion exercises plus 6 sessions of exercise therapy. Pain and disability were assessed as primary outcomes and patient-perceived success was assessed as a secondary outcome. Results showed no significant difference between the two groups in terms of primary outcomes. Both groups showed significant improvements in pain and disability. In terms of secondary outcomes, a greater percentage of the individuals in the manual therapy-plus-exercise group experienced a successful outcome or acceptability of symptoms. Overall, the study does not support the addition of cervicothoracic manual therapy to an exercise program to decrease pain and disability in individuals with shoulder pain, however, manual therapy may lead to greater rates of patient-perceived success.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
This study showed how the addition of high-dose cervicothoracic manual therapy and range-of-motion exercises to an exercise program does not have increased benefits over an exercise program alone. The paper goes on to discuss several limitations of the study, which include a higher-than-expected drop-out rate, the patient population in the study having chronic symptoms, an insufficient dosage and prescriptive manual therapy, and variation in the delivery of care by multiple therapists. With that, addressing these limitations and conducting more research on the use of cervicothoracic manual therapy for the treatment of shoulder pain is needed. Such studies would enhance our understanding and allow for the implementation of supported exercises in the clinic.
