Manual therapy and exercise for rotator cuff disease – Duke Center of Excellence in Manual and Manipulative Therapy

Author Names

Page, M.J. Green, S., McBain, B., Surace, S.J., Deitch, J., Lyttle, N., Mrocki, M.A., & Buchbinder, R.

Reviewer Name

Hannah Koch, SPT

Reviewer Affiliation(s)

Duke University

Paper Abstract

Background Management of rotator cuff disease often includes manual therapy and exercise, usually delivered together as components of a physical therapy intervention. This review is one of a series of reviews that form an update of the Cochrane review, ‘Physiotherapy interventions for shoulder pain’. Objectives To synthesise available evidence regarding the benefits and harms of manual therapy and exercise, alone or in combination, for the treatment of people with rotator cuff disease. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 3), Ovid MEDLINE (January 1966 to March 2015), Ovid EMBASE (January 1980 to March 2015), CINAHL Plus (EBSCO, January 1937 to March 2015), ClinicalTrials.gov and the WHO ICTRP clinical trials registries up to March 2015, unrestricted by language, and reviewed the reference lists of review articles and retrieved trials, to identify potentially relevant trials. Selection criteria We included randomised and quasi‐randomised trials, including adults with rotator cuff disease, and comparing any manual therapy or exercise intervention with placebo, no intervention, a different type of manual therapy or exercise or any other intervention (e.g. glucocorticoid injection). Interventions included mobilisation, manipulation and supervised or home exercises. Trials investigating the primary or add‐on effect of manual therapy and exercise were the main comparisons of interest. Main outcomes of interest were overall pain, function, pain on motion, patient‐reported global assessment of treatment success, quality of life and the number of participants experiencing adverse events. Data collection and analysis Two review authors independently selected trials for inclusion, extracted the data, performed a risk of bias assessment and assessed the quality of the body of evidence for the main outcomes using the GRADE approach. Main results We included 60 trials (3620 participants), although only 10 addressed the main comparisons of interest. Overall risk of bias was low in three, unclear in 14 and high in 43 trials. We were unable to perform any meta‐analyses because of clinical heterogeneity or incomplete outcome reporting. One trial compared manual therapy and exercise with placebo (inactive ultrasound therapy) in 120 participants with chronic rotator cuff disease (high quality evidence). At 22 weeks, the mean change in overall pain with placebo was 17.3 points on a 100‐point scale, and 24.8 points with manual therapy and exercise (adjusted mean difference (MD) 6.8 points, 95% confidence interval (CI) ‐0.70 to 14.30 points; absolute risk difference 7%, 1% fewer to 14% more). Mean change in function with placebo was 15.6 points on a 100‐point scale, and 22.4 points with manual therapy and exercise (adjusted MD 7.1 points, 95% CI 0.30 to 13.90 points; absolute risk difference 7%, 1% to 14% more). Fifty‐seven per cent (31/54) of participants reported treatment success with manual therapy and exercise compared with 41% (24/58) of participants receiving placebo (risk ratio (RR) 1.39, 95% CI 0.94 to 2.03; absolute risk difference 16% (2% fewer to 34% more). Thirty‐one per cent (17/55) of participants reported adverse events with manual therapy and exercise compared with 8% (5/61) of participants receiving placebo (RR 3.77, 95% CI 1.49 to 9.54; absolute risk difference 23% (9% to 37% more). However adverse events were mild (short‐term pain following treatment). Five trials (low quality evidence) found no important differences between manual therapy and exercise compared with glucocorticoid injection with respect to overall pain, function, active shoulder abduction and quality of life from four weeks up to 12 months. However, global treatment success was more common up to 11 weeks in people receiving glucocorticoid injection (low quality evidence). One trial (low quality evidence) showed no important differences between manual therapy and exercise and arthroscopic subacromial decompression with respect to overall pain, function, active range of motion and strength at six and 12 months, or global treatment success at four to eight years. One trial (low quality evidence) found that manual therapy and exercise may not be as effective as acupuncture plus dietary counselling and Phlogenzym supplement with respect to overall pain, function, active shoulder abduction and quality life at 12 weeks. We are uncertain whether manual therapy and exercise improves function more than oral non‐steroidal anti‐inflammatory drugs (NSAID), or whether combining manual therapy and exercise with glucocorticoid injection provides additional benefit in function over glucocorticoid injection alone, because of the very low quality evidence in these two trials. Fifty‐two trials investigated effects of manual therapy alone or exercise alone, and the evidence was mostly very low quality. There was little or no difference in patient‐important outcomes between manual therapy alone and placebo, no treatment, therapeutic ultrasound and kinesiotaping, although manual therapy alone was less effective than glucocorticoid injection. Exercise alone led to less improvement in overall pain, but not function, when compared with surgical repair for rotator cuff tear. There was little or no difference in patient‐important outcomes between exercise alone and placebo, radial extracorporeal shockwave treatment, glucocorticoid injection, arthroscopic subacromial decompression and functional brace. Further, manual therapy or exercise provided few or no additional benefits when combined with other physical therapy interventions, and one type of manual therapy or exercise was rarely more effective than another. Authors’ conclusions Despite identifying 60 eligible trials, only one trial compared a combination of manual therapy and exercise reflective of common current practice to placebo. We judged it to be of high quality and found no clinically important differences between groups in any outcome. Effects of manual therapy and exercise may be similar to those of glucocorticoid injection and arthroscopic subacromial decompression, but this is based on low quality evidence. Adverse events associated with manual therapy and exercise are relatively more frequent than placebo but mild in nature. Novel combinations of manual therapy and exercise should be compared with a realistic placebo in future trials. Further trials of manual therapy alone or exercise alone for rotator cuff disease should be based upon a strong rationale and consideration of whether or not they would alter the conclusions of this review.

NIH Risk of Bias Tool

Quality Assessment of Systematic Reviews and Meta-Analyses

Is the review based on a focused question that is adequately formulated and described?

Were eligibility criteria for included and excluded studies predefined and specified?

Did the literature search strategy use a comprehensive, systematic approach?

Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?

Were the included studies listed along with important characteristics and results of each study?

Was publication bias assessed?

Was heterogeneity assessed? (This question applies only to meta-analyses.)

Cannot Determine, Not Reported, Not Applicable

Key Finding #1

Research may indicate that glucocorticoid injection is more effective in the treatment of rotator cuff disease than manual therapy.

Key Finding #2

The current research on the effectiveness of manual therapy vs. placebo is inconclusive due to a lack of agreement between studies

Key Finding #3

Until further evidence confirms or refutes these results, practitioners should communicate the uncertainty of effect and consider other approaches or combinations of treatment.

Key Finding #4

Novel combinations of manual therapy and exercise should be compared with a realistic placebo in future trials.

Please provide your summary of the paper

The systematic review analyzed the results of 60 trials investigating the benefits and harms of manual therapy and exercise for rotator cuff disease. The intention of the review was to synthesize the available evidence for exercise and manual therapy, alone and in combination, to guide therapists in the treatment of rotator cuff disease. Due to clinical heterogeneity, it is difficult for conclusive statements to be made. Ten studies investigated the effects of manual therapy paired with exercise. Notably of these studies, one found an increase in overall change in pain levels, function, and self-reported treatment success to be greater in patients treated with manual therapy than those receiving a placebo. Fifty‐two trials investigated the effects of manual therapy alone or exercise alone and concluded there was no difference in patient‐important outcomes between manual therapy alone and placebo, no treatment, therapeutic ultrasound, and kinesiotaping. However, manual therapy alone was less effective than glucocorticoid injection. Further, manual therapy or exercise provided few or no additional benefits when combined with other physical therapy interventions, and one type of manual therapy or exercise was rarely more effective than another. Based on the available evidence, corticosteroid injections may be a more effective treatment option for the management of rotator cuff disease than manual therapy, however, further research is indicated. Therapists should inform their patients of the uncertainty of the effect of manual therapy on the management of rotator cuff disease when opting to utilize those techniques.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

This systematic review’s results may cause therapists to question if manual therapy for the treatment of rotator cuff disease is the best practice and worth utilizing. Furthermore, the review indicates that corticosteroid injections may be the most effective option, encouraging therapists to refer out. The systematic review encourages therapists to communicate with their patients the uncertainty of manual therapy in the treatment of rotator cuff disease, however, it does not discourage the utilization of such techniques. This contradiction demonstrates the need for standardization of research protocols to evaluate the effectiveness of manual therapy in the treatment of rotator cuff disease. This would enable therapists the opportunity to utilize research to guide their practice.