Shoulder

The Immediate Effects of Acromioclavicular Joint Mobilization on Shoulder Range of Motion: A Quasi-Experimental Study

Author Names

Keramat, K. U. & Habib, A.

Reviewer Name

Emily LaPlante, LAT, ATC, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Introduction: The shoulder movement is dependent upon the integrated motion of many joints including Acromio-Clavicular Joint (ACJ). Chronic shoulder pathologies are likely to stiffen the
ACJ and mobilization may reverse the effects. The current study aimed to study the effects of mobilization of ACJ on the shoulder ROM in healthy asymptomatic participants with restricted
shoulder ROM.

Material & Methods: This single-subject quasi-experimental study recruited 30 healthy subjects with an equal proportion of males and females who had restrictions in the ROM. The mean age
(SD) of the participant was 22.60 (±1.16 years), height 5.52 (±0.21) meter, weight 63.30 (±12.78) kg and Body Mass Index 22.22 (±3.84) kg/m2. Outcome measuring tools were shoulder range of
motion (abduction, flexion, internal rotation, external rotation) and functional movements of reaching up behind the back and reaching down behind the neck. Acromioclavicular joint
mobilization pre-intervention and post-intervention measurements of all variables were compared.

Results: The measurement of functional movements and all the ROM improved significantly from their baseline measurements following the ACJ mobilization. The mean change (±SD) in
RBTB was 2.94 (±2.05), RBTN was 3.20 (±1.50), flexion was 6.53(±6.03), abduction was 8.83(±7.72), internal rotation was 7.60(±5.71), external rotation was 3.5(±5.80). The change was
marked in RBTN (19.5%) and RBTB (17.9%).

Conclusion: ACJ mobilization acutely improves the shoulder range of motion in healthy subjects. ACJ is therefore recommended for trials on prevention and rehabilitation of the shoulder.

Key Words: prevention of shoulder injury, sports physiotherapy, shoulder injury, shoulder rehabilitation

NIH Risk of Bias Tool:

Quality Assessment Tool for Before-After (Pre-Post) Studies with No Control Group

1. Was the study question or objective clearly stated?
-Yes
2. Were the eligibility/ selection criteria for the study population prespecified and clearly described
-Yes
3. Were the participants in the study representative of those who would be eligible for the test/ intervention in the general or clinical population of interest?
-No
4. Were all eligible participants that met the prespecified entry criteria enrolled?
-Yes
5. Was the sample size sufficiently large to provide confidence in the findings?
-No
6. Was the test/ service/ intervention clearly described and delivered consistently across the study population?
-Yes
7. Were the outcome measures prespecified, clearly defined, valid, reliable and assessed consistently across all study participants?
-Yes
8. Were the people assessing the outcomes blinded to the participants’ exposures/ interventions?
-No
9. Was the loss to follow up after baseline 20% or less? Were those lost to follow up accounted for in the analysis?
-Yes
10. Did the statistical methods examine changes in outcome measures from before to after the intervention? Were statistical tests done that provided p values for the pre-to-post changes?
-Yes
11. Were the outcome measures of interest taken multiple times before the intervention and multiple times after the intervention?
-No
12. If the intervention was conducted at a group level, did the statistical analysis take into account the use of individual level data to determine effects at the group level?
-Cannot determine, not reported, not applicable

Key Finding #1

Statistically significant change (P< 0.05) occurred in all ranges of motion. (specifically internal and external rotation)

Key Finding #2

ACJ mobilizations can effectively address limitations in functional movements of reaching up behind the back and reaching down behind the neck.

Please provide your summary of the paper

A pretest-posttest design was used to test the effect of ACJ mobilization on shoulder range of motion – particularly with internal and external rotation. A total of 30 participants were
recruited with 10 male and 10 female participants all who were undergraduate students of a DPT program. Participants were asked to use their dominant arm to reach up and behind the
back and to reach down behind the neck with non-dominant hand. The distance between the hands in fists was measured, three measurements were taken and averaged. In addition,
internal and external rotation of the dominant side were both measured in the supine position and the average of 2 trials was taken. Following pretest measurement – ACJ mobilization was
applied by a physiotherapist for a total of 5-10 oscillations per minute and at least 3 times. The force was applied in an anterior to posterior direction and held for 10 seconds. Following the
ACJ mobilization, the participants were retested. Statistically significant change (P< 0.05) occurred in all ranges of motion.

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

Based on the results of the study, it is possible for ACJ mobilizations to address limitations in functional movements of the shoulder including reaching up behind the back and reaching
down behind the neck. In addition, significant change was seen with internal and externation rotation at the shoulder. All participants were asymptomatic and had no history of shoulder
injury. Further studies look at a wider patient population including varying activity levels, shoulder pain or previous injury.

The Effectiveness of Manual Therapy in Supraspinatus Tendinopathy

Author Names

Gamze Senbursa, Gül Baltaci, and Ö. Ahmet Atay

Reviewer Name

Adrienne Maniktala LAT, ATC, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objectives: The aim of this randomized controlled study was to assess the efficacy of manual therapy in the treatment of patients with symptomatic supraspinatus tendinopathy. Methods: Seventy-seven patients (age range, 30 to 55 years) with supraspinatus tendinopathy, were randomly assigned to one of the three treatment groups: a supervised exercise program (Group 1), a supervised exercise program combined with joint and soft tissue mobilization (Group 2), or a home-based rehabilitation program (Group 3). All patients had rehabilitation for 12 weeks. Pain level was evaluated with a visual analogue scale (VAS) and the range of motion (ROM) was measured with a goniometer. The Modified American Shoulder and Elbow Surgery (MASES) score was used in functional assessment. Flexion, abduction, internal and external rotation strengths were measured with a manual muscle test. All patients were evaluated before, and at the 4th and 12th week of the rehabilitation. Results: All groups experienced significant decrease in pain and an increase in shoulder muscle strength and function by both the 4th and 12th weeks of treatment (p0.05). However, the greatest improvement in functionality was found in Group 2. Conclusion: Supervised exercise, supervised and manual therapy, and home-based exercise are all effective and promising methods in the rehabilitation of the patients with subacromial impingement syndrome. The addition of an initial manual therapy may improve the results of the rehabilitation with exercise.

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

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Was the treatment allocation concealed (so that assignments could not be predicted)?

Were study participants and providers blinded to treatment group assignment?

Were the people assessing the outcomes blinded to the participants’ group assignments?

Cannot Determine, Not Reported, or Not Applicable

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Cannot Determine, Not Reported, or Not Applicable

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Cannot Determine, Not Reported, or Not Applicable

Was there high adherence to the intervention protocols for each treatment group?

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

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?

Cannot Determine, Not Reported, or Not Applicable

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Key Finding #1

There was no noted significant difference in the 3 groups amongst pain, shoulder range of motion, or rotator cuff muscle strength, but there was faster improvement in night pain and pain with movement in Group 2 than other groups.

Key Finding #2

The rate of positive special tests (impingement, tendon tenderness, and instability) decreased with treatment.

Key Finding #3

The manual therapy group (Group 2) demonstrated the best results at the week 12 follow-up, compared to the other groups.

Key Finding #4

All 3 groups showed a significant different in their MASES (modified American Shoulder and Elbow Surgeons’ questionnaire) score at 4 weeks but there was no difference at the 12-week follow-up.

Please provide your summary of the paper

The authors of this study chose to compare manual therapy, mobilizations and exercise in supraspinatus tendinopathies to increase literature on the subject and determine which may be more beneficial. The three different groups consisted of; a supervised exercise group that included glenohumeral and scapulothoracic exercises 3 times a week (Group 1), a manual therapy and exercise group that included joint and soft tissue mobilizations along with the exercises from the first group 3 times a week (Group 2), and a home-based exercise group (Group 3). The study determined that manual therapy, mobilizations and exercise can be equally beneficial to improve rotator cuff strength, increase range of motion and decrease pain.

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

The information in this study can be correlated to clinical practice because the implementation of these components can help to decrease treatment time and are all considered cost efficient. The authors suggest 3 weeks of manual therapy when treating supraspinatus tendinopathies.

The Effectiveness of Manual Therapy in the Management of Musculoskeletal Disorders of the Shoulder: A Systematic Review

Author Names

Cecilia Ho, C., Sole, G., Munn, J.

Reviewer Name

Giulia Marsella, Student Physical Therapist

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract
A systematic review of randomized controlled trials (RCTs) was conducted to determine the effectiveness of manual therapy (MT) techniques for the management of musculoskeletal
disorders of the shoulder. Seven electronic databases were searched up to January 2007, and reference lists of retrieved articles and relevant MT journals were screened. Fourteen RCTs met
the inclusion criteria and their methodological qualities were assessed using the PEDro scale. Results were analyzed within diagnostic subgroups (adhesive capsulitis (AC), shoulder impingement syndrome [SIS], non-specific shoulder pain/dysfunction) and a qualitative analysis using levels of evidence to define treatment effectiveness was applied. For SIS, there was no clear evidence to suggest additional benefits of MT to other interventions. MT was not shown to be more effective than other conservative interventions for AC, however, massage and Mobilizations-with-ovement may be useful in comparison to no treatment for short-term outcomes for shoulder dysfunction.

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?
-Yes
Were eligibility criteria for included and excluded studies predefined and specified?
-Yes
Did the literature search strategy use a comprehensive, systematic approach?
-Yes
Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?
-Yes
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?
-Yes
Was publication bias assessed?
-Yes
Was heterogeneity assessed? (This question applies only to meta-analyses.)
-Cannot Determine, Not Reported, Not Applicable

Key Finding #1
Due to the heterogeneity of musculoskeletal impairments, outcomes, and interventions of manual therapy among the 14 randomized control trials, only a systematic review and no meta- analysis was conducted.

Key Finding #2
There is moderate quality evidence that manual therapy is not more effective in comparison to other interventions for patients with impingement syndrome, adhesive capsulitis, and unspecific shoulder pain.

Key Finding #3
“Mobilization-with-Movement” or soft-tissue massage was shown to be beneficial for the management of musculoskeletal shoulder disorders in comparison to no treatment.

Please provide your summary of the paper
This systematic review aims to examine the effectiveness of manual therapy for the treatment of musculoskeletal shoulder pathologies. 14 randomized-controlled studies included in this review were of humans with adhesive capsulitis, shoulder impingement syndrome, and non-specific shoulder pain. Manual therapy, which was defined as “manipulation, passive joint or soft-tissue mobilization techniques or massage” were examined upon the outcomes of pain, functional outcomes, range of motion, patient satisfaction, or recovery rate. The average number of intervention sessions across studies was 11 (ranged from 3 to 20). 12 out of the 14 studies evaluated intermediate effects, while 2 of the studies evaluated long-term effects. Overall, this review found inconsistent evidence for the effectiveness of manual therapy for shoulder disorders. Exercise in combination with manual therapy was not more effective than exercise alone for the treatment of shoulder impingement. Manual therapy showed no significance differences in improved pain, range of motion and function for patients with adhesive capsulitis, however with this patient population there is moderate evidence that high grade manual therapy is more beneficial than low grade manual therapy for function and range of motion in the long term. There is moderate quality evidence that manual therapy is no more effective than other interventions for the treatment of nonspecific shoulder pain for improving pain and function in the short term. The research quality of this systematic review was high with the largest bias introduced being non-blinding (100% of studies did not blind the therapists and 86% of the studies did not blind subjects). The average methodological quality was defined as high with a mean PEDro score being ≥ 6 (greater than 5 is considered high quality).

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

This systemic review examined a broad definition of manual therapy and a variety of outcome measures and interventions. Due to the heterogeneity of variables, there is a greater opportunity for inconsistent findings, which is the case for this review. Largely, manual therapy is not supported over other therapeutic interventions. At the same time, there appears to be short-term benefit of soft tissue massage for musculoskeletal shoulder pathologies when compared to no treatment and long-term benefit of high-grade manual therapy for the management of adhesive capsulitis. Due to moderate quality evidence indicating that manual therapy is no more beneficial than other intervention, manual therapy may not be the most effective way to manage patients with musculoskeletal shoulder disorders unless if utilized in the two capacities previously stated. Because these findings indicate that manual therapy may be comparable to other physical therapy interventions, utilizing manual therapy over other interventions is up to the physical therapist’s clinical judgement on an individual patient basis.

Efficacy of Mobilization With Movement (MWM) for Shoulder Conditions: A Systematic Review and Meta-Analysis

Author Names

Satpute, K., Reid, S., Mitchell, T., Mackay, G., Hall, T.

Reviewer Name

Marc Moreno-Takegami, Duke Doctor of Physical Therapy Student

Reviewer Affiliation(s)

Doctor of Physical Therapy student at Duke University

Paper Abstract

Objective To assess the effects of mobilization with movement (MWM) on pain, range of motion (ROM), and disability in the management of shoulder musculoskeletal disorders. Methods Six databases and Scopus, were searched for randomized control trials. The ROB 2.0 tool was used to determine risk-of-bias and GRADE used for quality of evidence. Meta-analyses were performed for the sub-category of frozen shoulder and shoulder pain with movement dysfunction to evaluate the effect of MWM in isolation or in addition to exercise therapy and/or electrotherapy when compared with other conservative interventions. Results Out of 25 studies, 21 were included in eight separate meta-analyses for pain, ROM, and disability in the two sub-categories. For frozen shoulder, the addition of MWM significantly improved pain (SMD −1.23, 95% CI −1.96, −0.51)), flexion ROM (MD −11.73, 95% CI −17.83, −5.64), abduction ROM (mean difference −13.14, 95% CI −19.42, −6.87), and disability (SMD −1.50, 95% CI (−2.30, −0.7). For shoulder pain with movement dysfunction, the addition of MWM significantly improved pain (SMD −1.07, 95% CI −1.87, −0.26), flexion ROM (mean difference −18.48, 95% CI- 32.43, −4.54), abduction ROM (MD −32.46, 95% CI – 69.76, 4.84), and disability (SMD −0.88, 95% CI −2.18, 0.43). The majority of studies were found to have a high risk of bias. Discussion MWM is associated with improved pain, mobility, and function in patients with a range of shoulder musculoskeletal disorders and the effects clinically meaningful. However, these findings need to be interpreted with caution due to the high levels of heterogeneity and risk of bias. Level of Evidence Treatment, level 1a. KEYWORDS: Mulligan’s mobilization with movement, manual therapy, systematic review, shoulder dysfunction

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.)

Key Finding #1

MWM demonstrated statistically significant and clinically relevant benefits in patients with stage-II frozen shoulder when compared to exercise, passive manual therapy or electrotherapy.

Key Finding #2

Similarly, for patients with shoulder pain and movement dysfunction, MWM demonstrated statistically significant and clinically relevant benefits when compared to exercise alone, electrotherapy, or sham interventions.

Key Finding #3

In addition to ROM, MWM conferred a statically significant improvement in pain intensity over a control condition in both frozen shoulder and shoulder pain and movement dysfunction subcategories.

Please provide your summary of the paper

The objective of this systematic review and meta-analysis was to assess the effects of mobilization with movement on pain, range of motion, and disability in the management of shoulder musculoskeletal disorders. A literature search was conducted in six databases and identified a total of 1956 studies, of which 31 potentially eligible studies were identified and eventually 25 were included based on the inclusion and exclusion criteria. A Meta-analysis was also carried out on the results from 21 studies using the post-intervention scores for experimental and control groups. The findings revealed that MWM in isolation or in addition to exercise therapy and/or electrotherapy is superior in improving pain, ROM, and disability in patients with shoulder dysfunction when compared with either exercise therapy and electrotherapy alone or another type of manual therapy. However, the authors acknowledge that caution is required in the interpretation of these findings due to the high levels of heterogeneity and risk of bias.

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 provided a lot of evidence for the benefits of manual therapy, specifically MWM, in specific shoulder pathologies. For instance, in patients with frozen shoulder, improvement in pain was statistically significant and favored MWM even when the control group included other passive joint mobilization techniques or sham interventions, suggesting that pain relief with MWM may be due to neurophysiological effects as opposed to biomechanical effects of stretching. In my own practice, I hope I can present treatments like MWM to patients who have frozen shoulder or other related pathologies as a viable and effective option for treating whatever they may have. I also hope I can synthesize the evidence from studies such as these in order to demonstrate the research behind these interventions in a way that is digestible and easy for the patient to understand. If the patient has belief and trust in the treatment, I believe that gives the patient the confidence needed in order to get the most out of each session and physical therapy in general.

Combined Use of Diadynamic Currents and Manual Therapy on Myofascial Trigger Points in Patients With Shoulder Impingement Syndrome: A Randomized Controlled Trial

Author Names

Gomes, C., Dibai-Filho, A., Politti, F., Gonzalez, T., Biasotto-Gonzalez, D.

Reviewer Name

Nikol Papa

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objective: The purpose of this study was to evaluate the effect of combined manual therapy (MT) and diadynamic (DD) currents on myofascial trigger points of the upper trapezius muscle in individuals with a diagnosis of unilateral shoulder impingement syndrome. Methods: A randomized clinical trial was conducted involving 60 individuals with shoulder impingement syndrome who were allocated to the following 3 groups: (1) MT and DD currents (MTDD), (2) MT alone, and (3) DD currents alone. The participants were submitted to 16 treatment sessions over an 8-week period and were evaluated using the Numerical Rating Pain Scale as well as the pain and disability subscales of the Shoulder Pain and Disability Index. Results: Differences in Numerical Rating Pain Scale scores (secondary outcome) between MTDD and MT groups (mean difference 2.25 points, 95% confidence interval 1.07-3.42) and between MTDD and DD groups (mean difference 2.30 points, 95% confidence interval 1.42-3.17) were clinically relevant. No clinical gains were observed in the comparisons between groups of Shoulder Pain and Disability Index scores. Conclusion: The combination of MT and DD currents on myofascial trigger points was more effective at reducing pain intensity but not disability than each therapy performed individually for patients with unilateral shoulder impingement syndrome.

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

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Was the treatment allocation concealed (so that assignments could not be predicted)?

Were study participants and providers blinded to treatment group assignment?

Were the people assessing the outcomes blinded to the participants’ group assignments?

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Was there high adherence to the intervention protocols for each treatment group?

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

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?

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Key Finding #1

The intervention group that received both manual therapy and diadynamic (DD) currents experienced significant reductions in pain intensity compared to control groups

Key Finding #2

The intervention group that received both manual therapy and diadynamic (DD) currents did not see significant reductions in disability compared to control groups

Please provide your summary of the paper

The purpose of the present study was to evaluate the effects of manual therapy and DD currents on myofascial trigger points of the upper trapezius muscle in individuals with a diagnosis of unilateral shoulder impingement syndrome. The primary outcome of interest was the impact of this approach on disability and the secondary outcome focused on pain intensity.

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

It may be beneficial to use combined both MT and DD for patients experiencing acute pain who are prone to flare-ups if they are in too much discomfort to fully engage in therapeutic exercises during the visit but the benefit is mild at best. This article put all participants under the general umbrella of shoulder impingement syndrome which is not ideal as this could include patients with either primary or secondary shoulder impingement. One issue of creating a large generalized group is that the individual presentations of each of these subsets of shoulder impingement require different treatment approaches at baseline. Therefore, this approach may favor one type of impingement over another but there is no way to determine that.

Guided Exercises With or Without Joint Mobilization or No Treatment in Patients With Subacromial Pain Syndrome: A Clinical Trial

Author Names

Eliason A., Harringe, M., Engstrom, B., & Werner, S.

Reviewer Name

Jaime Pardee

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background Graded resistance training is the recommended treatment for patients with subacromial pain syndrome. It is debated whether adding joint mobilization will improve the outcome. The aim of this study was to evaluate the clinical outcome of guided exercises with or without joint mobilization, compared with controls who did not receive any treatment. Methods A 3-armed controlled trial in a primary care setting. A total of 120 patients, with clinically diagnosed subacromial pain syndrome, were randomized into guided exercise groups with and without additional joint mobilization, and a control group that did not receive any treatment. Data were analysed at baseline, 6 weeks, 12 weeks and 6 months. Primary outcome was the Constant-Murley score, and secondary outcomes were pain and active range of motion. Results Shoulder function improved in all groups, as measured with the Constant-Murley score. At 12 weeks and 6 months the exercise groups improved significantly compared with the control group (p ≤ 0.05). Add-on joint mobilization resulted in decreased pain in active range of motion at 6 and 12 weeks compared with guided exercise or no treatment (p ≤ 0.05). Range of motion increased over time in all 3 groups. Conclusion In patients with subacromial pain syndrome guided exercises improved shoulder function compared with no treatment. Add-on joint mobilization decreased pain in the short-term compared with exercise alone or no treatment.

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

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Was the treatment allocation concealed (so that assignments could not be predicted)?

Cannot Determine, Not Reported, or Not Applicable

Were study participants and providers blinded to treatment group assignment?

Were the people assessing the outcomes blinded to the participants’ group assignments?

Cannot Determine, Not Reported, or Not Applicable

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Was there high adherence to the intervention protocols for each treatment group?

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Cannot Determine, Not Reported, or Not Applicable

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

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?

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Key Finding #1

Shoulder function improved for all groups over 12 weeks and the 2 intervention groups were significantly improved compared to the control group. The 2 intervention groups reached a clinically important change of 17 points or more at the 12 week follow up.

Key Finding #2

The sub score of pain in the intervention groups were significantly improve compared to the control group at 6 and 12 weeks as well as at 6 months post.

Key Finding #3

Found a short term effect on pain reduction with add-on joint mobilization compared with exercises alone or no treatment.

Please provide your summary of the paper

This study sought to determine treatment efficacy in patients with shoulder pain treated with a combination of mobilizations and guided training or guided training alone. The results were compared to a control group that received no treatment. The study was a randomized controlled trial with a total of 120 patients aged between 20-59 years. The results showed that in the short term, joint mobilizations decreased pain and may serve as a substitute for non-steroidal anti-inflammatory drugs (NSAIDs) or other painkillers at the start of treatment.

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

The randomized control trial showed that joint mobilizations can have an analgesic effect on those with shoulder pain. Although this effect is short-term, it can greatly benefit a patient with high irritability, especially at the start of the treatment. This study showed that all the intervention groups showed improvements in shoulder function and pain when compared to the control group. The results highlight the importance of physical therapy for shoulder pain. The added impact of joint mobilizations, especially early in rehabilitation, impacts pain reduction.

Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement Syndrome

Author Names

Bang MD, Deyle GD

Reviewer Name

Margaret Pohl, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Study Design A prospective randomized clinical trial. Objective To compare the effectiveness of 2 physical therapy treatment approaches for impingement syndrome of the shoulder. Background Manual physical therapy combined with exercise is a commonly applied but currently unproven clinical treatment for impingement syndrome of the shoulder. Methods and Measures Thirty men and 22 women (age 43 years ± 9.1) diagnosed with shoulder impingement syndrome were randomly assigned to 1 of 2 treatment groups. The exercise group performed supervised flexibility and strengthening exercises. The manual therapy group performed the same program and received manual physical therapy treatment. Both groups received the selected intervention 6 times over a 3-week period. The testers, who were blinded to group assignment, measured strength, pain, and function before treatment and after 6 physical therapy visits. Strength was a composite score of isometric strength tests for internal rotation, external rotation, and abduction. Rain was a composite score of visual analog scale measures during resisted break tests, active abduction, and functional activities. Function was measured with a functional assessment questionnaire. The visual analog scale used to measure pain with functional activities and the functional assessment questionnaire were also measured 2 months after the initiation of treatment. Results Subjects in both groups experienced significant decreases in pain and increases in function, but there was significantly more improvement in the manual therapy group compared to the exercise group. For example, pain in the manual therapy group was reduced from a pretreatment mean (±SD) of 575.8 (±220.0) to a posttreatment mean of 174.4 (±183.1). In contrast, pain in the exercise group was reduced from a pretreatment mean of 557.1 (±237.2) to a posttreatment mean of 360.6 (±272.3). Strength in the manual therapy group improved significantly while strength in the exercise group did not. Conclusion Manual physical therapy applied by experienced physical therapists combined with supervised exercise in a brief clinical trial is better than exercise alone for increasing strength, decreasing pain, and improving function in patients with shoulder impingement syndrome. J Orthop Sports Phys Ther 2000;30:126–137.

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

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Was the treatment allocation concealed (so that assignments could not be predicted)?

Were study participants and providers blinded to treatment group assignment?

Were the people assessing the outcomes blinded to the participants’ group assignments?

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Was there high adherence to the intervention protocols for each treatment group?

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

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?

Cannot Determine, Not Reported, or Not Applicable

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Key Finding #1

Overall, both groups, those who performed exercises, and those who received manual therapy in addition to performing exercises, saw meaningful decreases in pain and increases in functional ability. However, the manual therapy group saw significantly more improvement than the exercise group.

Key Finding #2

The manual therapy and exercise group saw significant strength increases, while the exercise only group did not.

Please provide your summary of the paper

This study looked to compare the effectiveness of manual therapy with exercise compared to exercise alone as treatment approaches for impingement syndrome in the shoulder. 52 participants were randomly assigned to one of two treatment groups, the exercise group or the manual therapy group. The exercise group performed supervised flexibility and strengthening exercises while the manual therapy group performed the same exercises, with the addition of manual therapy treatment performed by a skilled physical therapist. Both groups were treated 6 times over a 3-week period and the participant’s strength, pain, and function were measured prior to and following skilled interventions. As a result, both groups experienced pain decreases and functional increases, but the manual therapy group’s improvements were significantly greater. Additionally, the manual therapy group experienced increases in strength while the exercise group did not. Overall, this study shows that manual therapy with exercise is a beneficial intervention for individuals with shoulder impingement syndrome and has greater impacts on strength, function and pain than exercises alone.

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

The findings of this study should be taken into consideration when treating patients with impingement syndrome in the shoulder. When seeing a patient with this diagnosis, exercise is helpful but manual therapy will provide more significant pain and functional benefits to the patient. In clinical practice, time in the clinic can best be used by performing manual therapy techniques and educating patients on proper exercise forms and frequency, to give them the ability to properly perform their home exercise programs and see meaningful changes.

The Effect of Anterior Versus Posterior Glide Joint Mobilization on External Rotation Range of Motion in Patients With Shoulder Adhesive Capsulitis

Author Names

Johnson, A. J., Godges, J. J., Zimmerman, G. J., & Ounanian, L. L

Reviewer Name

Marie-Adelaide Robinson, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Study Design: Randomized clinical trial. Objective: To compare the effectiveness of anterior versus posterior glide mobilization techniques for improving shoulder external rotation range of motion (ROM) in patients with adhesive capsulitis. Background: Physical therapists use joint mobilization techniques to treat motion impairments in patients with adhesive capsulitis. However, opinions of the value of anterior versus posterior mobilization procedures to improve external rotation ROM differ. Methods and Measures: Twenty consecutive subjects with a primary diagnosis of shoulder adhesive capsulitis and exhibiting a specific external rotation ROM deficit were randomly assigned to 1 of 2 treatment groups. All subjects received 6 therapy sessions consisting of application of therapeutic ultrasound, joint mobilization, and upper-body ergometer exercise. Treatment differed between groups in the direction of the mobilization technique performed. Shoulder external rotation ROM measured initially and after each treatment session was compared within and between groups and analyzed using a 2-way ANOVA, followed by paired and independent t tests. Results: There was no significant difference in shoulder external rotation ROM between groups prior to initiating the treatment program. A significant difference between groups (P = .001) was present by the third treatment. The individuals in the anterior mobilization group had a mean improvement in external rotation ROM of 3.0° (SD, 10.8°; P = .40), whereas the individuals in the posterior mobilization group had a mean improvement of 31.3° (SD, 7.4°; P<.001). Conclusions: A posteriorly directed joint mobilization technique was more effective than an anteriorly directed mobilization technique for improving external rotation ROM in subjects with adhesive capsulitis. Both groups had a significant decrease in 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

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Was the treatment allocation concealed (so that assignments could not be predicted)?

Cannot Determine, Not Reported, or Not Applicable

Were study participants and providers blinded to treatment group assignment?

Were the people assessing the outcomes blinded to the participants’ group assignments?

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Cannot Determine, Not Reported, or Not Applicable

Was there high adherence to the intervention protocols for each treatment group?

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

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?

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Cannot Determine, Not Reported, or Not Applicable

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Key Finding #1

The use of a posterior GH glide proved more effective to increase shoulder external rotation ROM in patients with adhesive capsulitis than an anterior GH glide.

Key Finding #2

The joint capsule plays an important role in the translation of the humeral head during movement.

Key Finding #3

In contrary to the convex-concave rules, tension in the capsular tissues controls the translatory movements of the humeral head, as tension increases the more the arm is elevated, it causes a reduction in posterior and inferior translation of the humeral head.

Key Finding #4

A tight rotator cuff interval found in adhesive capsulitis limits ROM and can produced unwanted anterosuperior translation, which diminishes posterior translation of the humeral head.

Please provide your summary of the paper

This study shows that posterior mobilizations (PM) of the GH joint had more effect in increasing external rotation of the shoulder than anterior mobilizations (AM) in patients with adhesive capsulitis. Each patient underwent thermal ultrasound to alter the viscoelastic properties of the capsule to maximize the intervention followed by immediate anterior or posterior sustained mobilization for 15 minutes at a grade 3 stretch mobilization, each held for a minute long. Each patient was put at their end range of abduction and ER before lateral traction and the mobilization was applied. Following treatment, each patient exercised on an upper body ergometer in the forward position only for 3 minutes in their pain-free range to limit soreness. After 6 sessions, the patients that underwent AM, 2 lost ER ROM, 1 had no change, and 7 improved. In contrast, all patients increased ROM in ER with posterior mobilizations. It is important to note that the improvements in ROM in the AM group did not exceed 18 degrees, whereas in the PM group, the improvements were in the 22-45 degree range. Overall, the findings of this study provide a different perspective on mobilizations to increase ER in patients with adhesive capsulitis. The concave-convex rules are based on joint geometry, therefore, as the GH is concave and the humeral head is convex, an anterior mobilization would theoretically be more beneficial to increase external rotation.

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

Overall, the findings prove that contrary to concave-convex rules of the glenohumeral joint, posterior mobilizations had better outcomes in increasing external rotation in patients with adhesive capsulitis. This finding will be important in the treatment of patients that are limited in external rotation due to adhesive capsulitis. Knowing where the capsule has the most tension is key. The more the arm is elevated, the tension in the capsule increases, therefore, decreased the posterior and inferior translation of the humeral head. Furthermore, a tight rotator cuff interval can place the humeral head in a more anterosuperior position, diminishing the posterior translation.

The Immediate Effects of Muscle Energy Technique on Posterior Shoulder Tightness: A Randomized Controlled Trial

Author Names

Moore, S. D., Laudner, K. G., Mcloda, T. A., & Shaffer, M. A

Reviewer Name

Marie-Adelaide Robinson, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Study Design: Randomized controlled trial. Objective: To compare a muscle energy technique (MET) for the glenohumeral joint (GHJ) horizontal abductors and an MET for the GHJ external rotators to improve GHJ range of motion (ROM) in baseball players. Background: Overhead athletes often exhibit loss of GHJ ROM in internal rotation, which has been associated with shoulder pathology. Current stretching protocols aimed at improving flexibility of the posterior shoulder have resulted in inconsistent outcomes. Although utilization of MET has been hypothesized to lengthen tissue, there are limited empirical data describing the effectiveness of such stretches for treating posterior shoulder tightness. Methods: Sixty-one Division I baseball players were randomly assigned to 1 of 3 groups: MET for the GHJ horizontal abductors (n = 19), MET for the GHJ external rotators (n = 22), and control (n = 20). We measured preintervention and postintervention GHJ horizontal adduction and internal rotation ROM, and conducted analyses of covariance, followed by Tukey honestly significant difference post hoc analysis for significant group-by-time interactions (P<.05). Results: The group treated with the MET for the horizontal abductors had a significantly greater increase in GHJ horizontal adduction ROM postintervention (mean ± SD, 6.8° ± 10.5°) compared to the control group (−1.1° ± 6.8°) (P = .011) and a greater increase in internal rotation ROM postintervention (4.2° ± 5.3°) compared to the group treated with the MET for the external rotators (0.2° ± 6.3°) (P = .020) and the control group (−0.2° ± 4.0°) (P = .029). No significant differences among groups were found for any other variables (P>.05). Conclusion: A single application of an MET for the GHJ horizontal abductors provides immediate improvements in both GHJ horizontal adduction and internal rotation ROM in asymptomatic collegiate baseball players. Application of MET for the horizontal abductors may be useful to gain ROM in overhead athletes.

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

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Was the treatment allocation concealed (so that assignments could not be predicted)?

Were study participants and providers blinded to treatment group assignment?

Were the people assessing the outcomes blinded to the participants’ group assignments?

Cannot Determine, Not Reported, or Not Applicable

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Was there high adherence to the intervention protocols for each treatment group?

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Cannot Determine, Not Reported, or Not Applicable

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

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?

Cannot Determine, Not Reported, or Not Applicable

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Key Finding #1

Following one application of MET of the horizontal abductors, collegiate asymptomatic baseball players had immediate improvement in glenohumeral internal rotation and horizontal adduction range of motion in the dominant arm.

Key Finding #2

Acute application of MET on glenohumeral joint posterior shoulder ROM can help prevent shoulder injuries related to GIRD and posterior shoulder tightness.

Please provide your summary of the paper

This study showed that a single application of a muscle energy technique of the horizontal abductors improved glenohumeral (GH) internal rotation and horizontal adduction range of motion in the dominant arm of asymptomatic collegiate baseball players. Each player was randomly assigned a group and the researcher measuring range of motion was blinded to the groupings, however the provider performing the MET was not blinded. Limitations of the study included the frequency of sessions and lack of post intervention follow up to see if continued MET would provide more permanent benefits. As this study based its findings on a singular session of MET, it is unclear if continued use of MET will provide long-term benefits or just an acute outcome. The study referenced that stretching of the GH joint internal rotators in overhead athletes proved successful in regaining and maintaining increased ROM, however the specific techniques of stretching the posterior capsule remain inconsistent. I believe this study did an adequate job trying to isolate the posterior capsule in the GH when conducting the MET to provide more specific data to supplement existing research.

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

Overall, the findings of the study provide physical therapists or athletic trainers another technique to help overhead athletes increase internal rotation and horizontal adduction range of motion. Like the study mentioned, there are techniques such as the sleeper stretch that can aid in increasing range of motion. However, I believe this specific technique of MET isolates the posterior shoulder and can target the internal rotators and horizontal adductor muscles with greater efficiency to improve range of motion.

Manual Therapy and Exercise for Adhesive Capsulitis (Frozen Shoulder)

Author Names

Page, M., Green, S., Kramer, S., Johnston, R., McBain, B., Chau, M., Buchbinder, R.

Reviewer Name

Megan Saunders

Reviewer Affiliations

Duke university school of medicine, doctor of physical therapy division

Paper Abstract

Background: Adhesive capsulitis (also termed frozen shoulder) is commonly treated by 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 synthesize available evidence regarding the benefits and harms of manual therapy and exercise, alone or in combination, for the treatment of patients with adhesive capsulitis. Search methods: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL Plus, ClinicalTrials.gov and the WHO ICTRP clinical trials registries up to May 2013, unrestricted by language, and reviewed the reference lists of review articles and retrieved trials, to identify potentially relevant trials. Selection criteria: We included randomized controlled trials (RCTs) and quasi-randomized trials, including adults with adhesive capsulitis, and comparing any manual therapy or exercise intervention versus placebo, no intervention, a different type of manual therapy or exercise or any other intervention. Interventions included mobilization, manipulation and supervised or home exercise, delivered alone or in combination. Trials investigating the primary or adjunct effect of a combination of manual therapy and exercise were the main comparisons of interest. Main outcomes of interest were participant-reported pain relief of 30% or greater, overall pain (mean or mean change), function, global assessment of treatment success, active shoulder abduction, 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 32 trials (1836 participants). No trial compared a combination of manual therapy and exercise versus placebo or no intervention. Seven trials compared a combination of manual therapy and exercise versus other interventions but were clinically heterogeneous, so opportunities for meta-analysis were limited. The overall impression gained from these trials is that the few outcome differences between interventions that were clinically important were detected only up to seven weeks. Evidence of moderate quality shows that a combination of manual therapy and exercise for six weeks probably results in less improvement at seven weeks but a similar number of adverse events compared with glucocorticoid injection. The mean change in pain with glucocorticoid injection was 58 points on a 100-point scale, and 32 points with manual therapy and exercise (mean difference (MD) 26 points, 95% confidence interval (CI) 15 points to 37 points; one RCT, 107 participants), for an absolute difference of 26% (15% to 37%). Mean change in function with glucocorticoid injection was 39 points on a 100-point scale, and 14 points with manual therapy and exercise (MD 25 points, 95% CI 35 points to 15 points; one RCT, 107 participants), for an absolute difference of 25% (15% to 35%). Forty-six per cent (26/56) of participants reported treatment success with manual therapy and exercise compared with 77% (40/52) of participants receiving glucocorticoid injection (risk ratio (RR) 0.6, 95% CI 0.44 to 0.83; one RCT, 108 participants), with an absolute risk difference of 30% (13% to 48%). The number reporting adverse events did not differ between groups: 56% (32/57) reported events with manual therapy and exercise, and 53% (30/57) with glucocorticoid injection (RR 1.07, 95% CI 0.76 to 1.49; one RCT, 114 participants), with an absolute risk difference of 4% (-15% to 22%). Group differences in improvement in overall pain and function at six months and 12 months were not clinically important. We are uncertain of the effect of other combinations of manual therapy and exercise, as most evidence is of low quality. Meta-analysis of two trials (86 participants) suggested no clinically important differences between a combination of manual therapy, exercise, and electrotherapy for four weeks and placebo injection compared with glucocorticoid injection alone or placebo injection alone in terms of overall pain, function, active range of motion and quality of life at six weeks, six months and 12 months (though the 95% CI suggested function may be better with glucocorticoid injection at six weeks). The same two trials found that adding a combination of manual therapy, exercise and electrotherapy for four weeks to glucocorticoid injection did not confer clinically important benefits over glucocorticoid injection alone at each time point. Based on one high quality trial (148 participants), following arthrographic joint distension with glucocorticoid and saline, a combination of manual therapy and supervised exercise for six weeks conferred similar effects to those of sham ultrasound in terms of overall pain, function and quality of life at six weeks and at six months, but provided greater patient-reported treatment success and active shoulder abduction at six weeks. One trial (119 participants) found that a combination of manual therapy, exercise, electrotherapy and oral non-steroidal anti-inflammatory drug (NSAID) for three weeks did not confer clinically important benefits over oral NSAID alone in terms of function and patient-reported treatment success at three weeks. On the basis of 25 clinically heterogeneous trials, we are uncertain of the effect of manual therapy or exercise when not delivered together, or one type of manual therapy or exercise versus another, as most reported differences between groups were not clinically or statistically significant, and the evidence is mostly of low quality. Authors’ conclusions: The best available data show that a combination of manual therapy and exercise may not be as effective as glucocorticoid injection in the short-term. It is unclear whether a combination of manual therapy, exercise and electrotherapy is an effective adjunct to glucocorticoid injection or oral NSAID. Following arthrographic joint distension with glucocorticoid and saline, manual therapy and exercise may confer effects similar to those of sham ultrasound in terms of overall pain, function and quality of life, but may provide greater patient-reported treatment success and active range of motion. High-quality RCTs are needed to establish the benefits and harms of manual therapy and exercise interventions that reflect actual practice, compared with placebo, no intervention and active interventions with evidence of benefit (e.g. glucocorticoid injection).

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.)

Key Finding #1

Participants who had manual therapy and exercise did not improve pain scores or function as much as participants who had a glucocorticoid injections at 7 weeks.

Key Finding #2

When comparing a combination of manual therapy, exercise, and electrotherapy for 4 weeks and a placebo injection compared to a glucocorticoid injection alone or a placebo injection alone, there was no clinically important differences in terms of pain, function, active range of motion, or quality of life at 6 weeks and 12 months in a meta-analysis of two trails.

Key Finding #3

A combination of manual therapy and exercise for 6 weeks following arthrographic joint distension with glucocorticoid and saline had similar results to sham ultrasound in regards to pain, function, and quality of life. However, manual therapy and exercise showed better patient reported outcomes and active shoulder abduction at 6 weeks in this high quality trial (148 participants).

Key Finding #4

One study (119 participants) showed that a combination of manual therapy, exercise, electrotherapy, and oral NSAIDS did not show statistically significant results when compared to NSAIDs alone in regards to function and patient reported outcomes.

Please provide your summary of the paper

The authors of the systematic review found that in the short term, manual therapy and exercise may not be as effective as glucocorticoid injections for adhesive capsulitis. In addition, the heterogeneous trails investigated were of low quality and did not demonstrate individual effects of manual therapy or exercise, or competing types of manual therapy interventions.

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

Because this systematic review is largely focused on short term outcomes, it does not indicate how participants would respond over time to manual therapy and exercise vs. a glucocorticoid injection when treating adhesive capsulitis. Although injections may improve pain and ROM in the short term, a ceiling effect may occur. This review may sway patients to seek short-term pain relief rather than treating the root of the problem with consistent exercise. Furthermore, as the authors of the review stated, no trials compared a combination of manual therapy and exercise versus placebo or no intervention, making it difficult to interpret the benefits of physical therapy intervention. Further studies should investigate treatments compared to placebo for adhesive capsulitis, as well as compare outcomes of varying manual therapy techniques.

Effects of Exercise Therapy Plus Manual Therapy on Muscle Activity, Latency Timing, and SPADI Score in Shoulder Impingement Syndrome

Author Names

Sharma, S; Hussein, M; Sharma, S

Reviewer Name

Dylan Scott, DPT

Reviewer Affiliation(s)

Duke University

Paper Abstract

Abstract Purpose The study aimed to compare the effects of exercise therapy plus manual therapy (ET plus MT) and exercise therapy (ET) alone on muscle activity, muscle onset latency timing and shoulder pain and disability index-Hindi (SPADI-H) score in athletes with shoulder impingement syndrome (SIS). Materials and method Overhead male athletes diagnosed with SIS were randomly allocated into ET plus MT group(n = 40) and ET group(n = 40). Muscle activity, muscle onset latency timings and SPADI-H score were assessed. Both the groups performed 8 weeks of intervention and were evaluated at baseline, 4th and 8th weeks. Result ET plus MT group was more effective in increasing muscle activity, optimising latency timings and decreasing SPADI score when compared to ET group alone(p < 0.05). After treatment muscle activity and SPADI-H improved in both groups (p < 0.05). Conclusion ET plus MT was superior for improving muscle activity, muscle onset latency timing and SPADI score compared to ET alone.

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

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Was the treatment allocation concealed (so that assignments could not be predicted)?

Were study participants and providers blinded to treatment group assignment?

Were the people assessing the outcomes blinded to the participants’ group assignments?

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Was there high adherence to the intervention protocols for each treatment group?

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

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?

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Key Finding #1

The combination of exercise therapy and manual therapy reduced pain and improved function in patients with shoulder impingement syndrome, as measured by the Shoulder Pain and Disability Index (SPADI).

Key Finding #2

Patients who received the combination of exercise therapy and manual therapy showed significant improvement in muscle activity and latency timing compared to the exercise therapy alone group.

Key Finding #3

The group performing combined ET plus MT showed greater reduction with percentage of change in the range of around 30.13%, then the other groups 4.24%, according to the SPADI.

Key Finding #4

The significant change in the timing of the scapular muscles (MOLT) was also found, with the maximum change being recorded for UT and MT muscles.

Please provide your summary of the paper

The study investigated the effects of exercise therapy plus manual therapy on muscle activity, latency timing, and Shoulder Pain and Disability Index (SPADI) score in patients with shoulder impingement syndrome. 46 participants were randomized into two groups, with one group receiving exercise therapy plus manual therapy and the other group receiving only exercise therapy. The exercise therapy consisted of stretching, range of motion exercises, and strengthening exercises, while the manual therapy involved joint mobilization, massage, and soft tissue mobilization. The study found that the exercise therapy plus manual therapy group had significantly improved muscle activity and latency timing compared to the exercise therapy-only group. Furthermore, the exercise therapy plus manual therapy group had a greater reduction in SPADI score compared to the exercise therapy-only group. These findings suggest that adding manual therapy to exercise therapy may have additional benefits for patients with shoulder impingement syndrome.

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

The results suggest that a combination of exercise therapy and manual therapy can significantly reduce pain and disability, as well as improve muscle activity and timing in patients with shoulder impingement syndrome. Exercises targeting scapular stabilization, rotator cuff strengthening, and mobility can be utilized to improve muscle activity and timing. Additionally, manual therapy techniques such as joint mobilization and soft tissue massage can be used to address any joint restrictions or muscle imbalances.

Efficacy of Different Types of Mobilization Techniques in Patients With Primary Adhesive Capsulitis of the Shoulder: A Systematic Review

Author Names

Noten, S. et al

Reviewer Name

Emily Stadnick, 2nd year SPT at Duke

Reviewer Affiliation(s)

Duke University School of Medicine- DPT program

Paper Abstract

Abstract Objective: To systematically review the literature for efficacy of isolated articular mobilization techniques in patients with primary adhesive capsulitis (AC) of the shoulder. Data Sources: PubMed and Web of Science were searched for relevant studies published before November 2014. Additional references were identified by manual screening of the reference lists. Study Selection: All English language randomized controlled trials evaluating the efficacy of mobilization techniques on range of motion (ROM) and pain in adult patients with primary AC of the shoulder were included in this systematic review. Twelve randomized controlled trials involving 810 patients were included. Data Extraction: Two reviewers independently screened the articles, scored methodologic quality, and extracted data for analysis. The review was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. All studies were assessed in duplicate for risk of bias using the Physiotherapy Evidence Database Scale for randomized controlled trials. Data Synthesis: The efficacy of 7 different types of mobilization techniques was evaluated. Angular mobilization (nZ2), Cyriax approach (nZ1), and Maitland technique (nZ6) showed improvement in pain score and ROM. With respect to translational mobilizations (nZ1), posterior glides are preferred to restore external rotation. Spine mobilizations combined with glenohumeral stretching and both angular and translational mobilization (nZ1) had a superior effect on active ROM compared with sham ultrasound. High-intensity mobilization (nZ1) showed less improvement in the Constant Murley Score than a neglect group. Finally, positive long-term effects of the Mulligan technique (nZ1) were found on both pain and ROM. Conclusions: Overall, mobilization techniques have beneficial effects in patients with primary AC of the shoulder. Because of preliminary evidence for many mobilization techniques, the Maitland technique and combined mobilizations seem recommended at the moment. Archives of Physical Medicine and Rehabilitation 2016;97:815-25

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

The literature in this systematic review demonstrated that overall, mobilization techniques can provide beneficial effects in patients with primary AC of the shoulder.

Key Finding #2

Spine mobilzations and the Maitland technique combined with stretching of the glenohumeral joint and both angular and translational mobilizations seem to be the current recommendation from this systematic review.

Please provide your summary of the paper

The goal of this paper was to systematically review studies involving patients with primary adhesive capsulitis of the shoulder to determine the efficacy of isolated articular mobilization techniques on this population. 7 different techniques and mobilizations were examined using the 12 randomized controlled trials that qualified to be included in the review. Results showed that mobilization techniques can benefit patients with primary AC of the shoulder, and the Maitland technique in addition to combined mobilizations is the current recommendation from this paper. The Maitland technique was shown to have beneficial effects on pain and ROM for patients with primary adhesive capsulitis. Although Maitland proved beneficial, some studies included in this review had limitations including not blinding participants or therapists, variable length, duration, and severity of the injury, and decreased sample size making the information determined from this review less generalizable.

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

More studies need to be done to conclude the efficacy of other mobilization techniques aside from Maitland. Additionally, a larger sample size and more homogenous criteria of the stage of injury need to be examined to determine the effects of all manual therapy techniques on ROM and pain for various stages of primary shoulder AC.

Subacromial Impingement Syndrome—Effectiveness of Physiotherapy and Manual Therapy

Author Names

Gebremariam, L; Hay, E; van der Sanske, R; Rinkel, W; Koes, B; Huisstede, B

Reviewer Name

Chance Thomas Thorkelson SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy

Paper Abstract

Background The subacromial impingement syndrome (SIS) includes the rotator cuff syndrome, tendonitis and bursitis of the shoulder. Treatment includes surgical and non-surgical modalities. Non-surgical treatment is used to reduce pain, to decrease the subacromial inflammation, to heal the compromised rotator cuff and to restore satisfactory function of the shoulder. To select the most appropriate non-surgical intervention and to identify gaps in scientific knowledge, we explored the effectiveness of the interventions used, concentrating on the effectiveness of physiotherapy and manual therapy. Methods The Cochrane Library, PubMed, EMBASE, PEDro and CINAHL were searched for relevant systematic reviews and randomised clinical trials (RCTs). Two reviewers independently extracted data and assessed the methodological quality. A best-evidence synthesis was used to summarise the results. Results Two reviews and 10 RCTs were included. One RCT studied manual therapy as an add-on therapy to self-training. All other studies studied the effect of physiotherapy: effectiveness of exercise therapy, mobilisation as an add-on therapy to exercises, ultrasound, laser and pulsed electromagnetic field. Moderate evidence was found for the effectiveness of hyperthermia compared to exercise therapy or ultrasound in the short term. Hyperthermia and exercise therapy were more effective in comparison to controls or placebo in the short term (moderate evidence). For the effectiveness of hyperthermia, no midterm or long-term results were studied. In the midterm, exercise therapy gave the best results (moderate evidence) compared to placebo or controls. For other interventions, conflicting, limited or no evidence was found. Conclusions Some physiotherapeutic treatments seem to be promising (moderate evidence) to treat SIS, but more research is needed before firm conclusions can be drawn.

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.)

Key Finding #1

The article found that mobilization as an add-on treatment to exercise was significantly better at decreasing pain and improving composite strength. Another RCT found similar benefits in reducing pain but no significant difference in ROM.

Key Finding #2

The evidence for manual therapy was limited in this patient population and needs further research to better understand the role it can have on recovery. Clearer research was found in support for exercise therapy.

Key Finding #3

An article looked at the effectiveness of manual therapy compared to self-training and saw a significant decrease in pain after 12 weeks, but limited evidence was shown in the short term.

Please provide your summary of the paper

This article gathered relevant research that compared the benefits of non-surgical interventions on subacromial impingement syndrome (SIS) to surgical procedures. Two reviewers sifted through the relevant literature and used a best-evidence synthesis to summarize the results. Two reviews and ten RCTs met the inclusion criteria. The nature of the different articles included looked at interventions such as US, laser, Exercise, and manual therapy techniques. The article found the most supported intervention to be hyperthermia and manual therapy techniques possessed limited evidence. The article discussed some of the limitations this review possesses such as smaller scale studies, and potential bias in assigning studies a title of high-quality. The emphasis was placed in a need for a more large-scale study to better understand proper clinical decision making.

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

The scarcity of research pertaining to a major diagnosis of the shoulder highlights further needs in pushing our profession to find best practices that will help our patients. The two articles that referenced manual therapy found benefits in reducing the subject’s level of pain. This finding has great benefit for PT as we work to find stronger research to support the need for these treatments physiologically. With a decreased reporting of pain patients will be more likely to return to previous levels of function, adhere to training programs, and work at improving noted impairments. Manual therapy can be a means of facilitating further intervention progression as well as avoid the decision to participate in surgical interventions and their risk factors. PTs can look to implement manual techniques to aid patients in overcoming the barrier of pain and ultimately participate in interventions such as functional training.

Effect of Manual Physiotherapy in Homogeneous Individuals With Subacromial Shoulder Impingement: A Randomized Controlled Trial

Author Names

Land, H., Gordan, S., Watt, K.

Reviewer Name

Luke Vitale, SPT, CSCS

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objective: To compare the effect of specific interventions aimed at (1) the upper thoracic spine (passive mobilization) and (2) the posterior shoulder (massage, passive mobilization, and stretching) to (3) an active control intervention in a homogeneous group with extrinsic subacromial shoulder impingement (SSI). Study Design: Single‐centre, prospective, double‐blinded, randomized controlled trial. Method: Eligible individuals with clearly defined extrinsic SSI were randomized to each group. Treatment duration was 12 consecutive weeks consisting of nine treatments over 6 weeks, followed by 6 weeks when one home exercise was performed daily. Outcomes included (1) active thoracic flexion/extension range of motion, (2) passive glenohumeral internal rotation and posterior shoulder range, (3) pain rating, and (4) shoulder pain and function disability index. Data were analyzed at baseline, 6 and 12 weeks. Shoulder pain and function disability index scores were investigated via email 6 months after commencement of treatment. Results: Twenty participants completed treatment in each group. No differences were identified between groups at baseline. Upper thoracic and posterior shoulder interventions, with a targeted home exercise, both significantly decreased pain and increased function scores and increased posterior shoulder range compared with active control at 12 weeks, and 6 months following cessation of the trial. Conclusion: Manual therapy treatment that addresses these extrinsic factors, of thoracic spine or posterior shoulder tightness, decreases the signs and symptoms of SSI. The trial is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR; 12615001303538). Keywords: manual therapy, randomized controlled trial, subacromial shoulder impingement, treatment

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

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Cannot Determine, Not Reported, or Not Applicable

Was the treatment allocation concealed (so that assignments could not be predicted)?

Were study participants and providers blinded to treatment group assignment?

Were the people assessing the outcomes blinded to the participants’ group assignments?

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Cannot Determine, Not Reported, or Not Applicable

Was there high adherence to the intervention protocols for each treatment group?

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

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?

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Key Finding #1

Post-hoc analysis found a significant improvement in SPADI scores, passive IR, and posterior shoulder range in the thoracic and shoulder directed intervention groups compared to the active control group from baseline to week 6.

Key Finding #2

No differences in the above outcomes were seen between the shoulder treatment and thoracic treatment groups.

Key Finding #3

Improvements in SPADI scores in the intervention groups were above the MCID and maintained at 12 weeks and 6 months out from baseline. No significant improvement was seen between 6 and 12 weeks however.

Please provide your summary of the paper

Land et al. conducted a randomized control trial to assess the effect of: a) passive mobilization of the upper thoracic spine, b) massage, passive mobilization, and stretching of the soft tissues of the posterior shoulder, and c) an active control group, on pain, ROM, and function in a homogenous group of subjects with subacromial shoulder impingement. Participants were randomized into three groups. The control group received ultrasound for 6 weeks. The first intervention group received treatment directed at the thoracic spine for 6 weeks along with a daily HEP that was performed for 12 weeks. The second intervention group received intervention to the posterior shoulder soft tissues along with a daily home stretch that was performed for 12 weeks. Individuals included in this study were between the ages of 40-60 years, tested positive to 3/5 special tests (one positive test had to be Hawkins-Kennedy and/or Neer’s), and had an insidious onset of catching or aching pain to antero-lateral-superior shoulder without joint stiffness. The authors found significant improvements in passive IR, posterior shoulder range, and SPADI scores in both intervention groups when compared to the active control group. Passive IR and SPADI scores met the MCID in the intervention groups. It should be noted, however, that all groups (including control) experienced a statistically significant improvement in these measures between baseline and 6 weeks. SPADI scores maintained a significant increase between 12 weeks and 6 months when compared to the control group.

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 presents data that supports the use of manual therapy and exercise in patients with subacromial shoulder impingement diagnoses. Further, the data shows that both intervention directed to the thoracic spine, and intervention directed at the posterior shoulder were equally effective (no significant difference between the two). The control group in this trial only received ultrasound for 6 weeks and then a daily home stretch for the remaining 6 weeks, which doesn’t give us a great comparison to other non-manual therapy treatments for subacromial shoulder impingement. Also, with the age of participants ranging from 40-60 years old, we cannot apply these results to a younger patient population. This paper makes a good case for implementing manual therapy techniques to either the thoracic spine or posterior shoulder when treating shoulder impingement, however, further studies comparing manual therapy + exercise to exercise alone, in various age groups, may provide useful information to discern how exercise alone stands up to manual therapy + exercise.

Scapular Kinematics Pre- and Post–Thoracic Thrust Manipulation in Individuals With and Without Shoulder Impingement Symptoms: A Randomized Controlled Study

Author Names

Haik, M., Alburquerque-Sendin, F., Silva, C., Siqueira-Junior, A., Ribeiro, I., Camargo, P.

Reviewer Name

Luke Vitale, SPT, CSCS

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Study design: Randomized controlled trial with immediate follow-up. Objectives: To evaluate the immediate effects of a low-amplitude, high-velocity thrust thoracic spine manipulation (TSM) on pain and scapular kinematics during elevation and lowering of the arm in individuals with shoulder impingement syndrome (SIS). The secondary objective was to evaluate the immediate effects of TSM on scapular kinematics during elevation and lowering of the arm in individuals without symptoms. Background: Considering the regional interdependence among the shoulder and the thoracic and cervical spines, TSM may improve pain and function in individuals with SIS. Comparing individuals with SIS to those without shoulder pathology may provide information on the effects of TSM specifically in those with SIS. Methods: Fifty subjects (mean ± SD age, 31.8 ± 10.9 years) with SIS and 47 subjects (age, 25.8 ± 5.0 years) asymptomatic for shoulder dysfunction were randomly assigned to 1 of 2 interventions: TSM or a sham intervention. Scapular kinematics were analyzed during elevation and lowering of the arm in the sagittal plane, and a numeric pain rating scale was used to assess shoulder pain during arm movement at preintervention and postintervention. Results: For those in the SIS group, shoulder pain was reduced immediately after TSM and the sham intervention (mean ± SD preintervention, 2.9 ± 2.5; postintervention, 2.3 ± 2.5; P<.01; moderate effect size [Cohen d = 0.2]). Scapular internal rotation increased 0.5° ± 0.02° (P = .04; small effect size [Cohen d<0.1]) during elevation of the arm after TSM and sham intervention in the SIS group only. Subjects with and without SIS who received TSM and asymptomatic subjects who received the sham intervention had a significant increase (1.6° ± 2.7°) in scapular upward rotation postintervention (P<.05; small effect size [Cohen d<0.2]), which was not considered clinically significant. Scapular anterior tilt increased 1.0° ± 4.8° during elevation and lowering of the arm postmanipulation (P<.05; small effect size [Cohen d<0.2]) in the asymptomatic subjects who received TSM. Conclusion: Shoulder pain in individuals with SIS immediately decreased after a TSM. The observed changes in scapular kinematics following TSM were not considered clinically important. Keywords: manipulation; manual therapy; rehabilitation; spine.

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

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Was the treatment allocation concealed (so that assignments could not be predicted)?

Were study participants and providers blinded to treatment group assignment?

Were the people assessing the outcomes blinded to the participants’ group assignments?

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Cannot Determine, Not Reported, or Not Applicable

Was there high adherence to the intervention protocols for each treatment group?

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Cannot Determine, Not Reported, or Not Applicable

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

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?

Cannot Determine, Not Reported, or Not Applicable

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Key Finding #1

In subjects with shoulder impingement syndrome (SIS), shoulder pain was reduced immediately following thoracic manipulation and a sham treatment which mimicked the set-up of thoracic manipulation but did not provide the HVLA thrust.

Key Finding #2

SIS groups experienced a significant decrease in pain of 0.6 points on the NPRS, however, this does not meet the MCID of 2 points proposed by Farrar et al., 2001.

Key Finding #3

The mean change in NPRS for the manipulation and sham groups were 25.5% and 10.3%, respectively. These changes represent the MCID for patients with chronic pain as suggested by Dworkin et al., 2009.

Key Finding #4

There were significant, yet clinically non-relevant changes in scapular kinematics in the SIS thoracic manipulation and sham groups.

Please provide your summary of the paper

This study was an RCT that investigated the effects of thoracic spine manipulation on shoulder pain and scapular kinematics in subjects with shoulder impingement syndrome (SIS). They hypothesized that thoracic spine manipulation (TSM) would reduce pain in subjects with SIS, and alter scapular kinematics in both asymptomatic subjects, and those with SIS. They randomly assigned 97 subjects into four groups; SIS+TM, SIS+Sham, Asymptomatic+TSM, and Asymptomatic+Sham. Electromagnetic sensors were placed on specific bony landmarks of the spine, scapula, and humerus in order to accurately assess kinematics before and after. Sensors were not removed or adjusted between trials, and the manipulation/sham was completed in a way that did not disturb the sensors. Both SIS groups saw a statistically significant decrease in pain of 0.6 points on the NPRS following either TSM or sham treatment. These changes, however, do not meet the MCID of 2 points. When assessing who reported decreased pain following intervention, 60% reported changes following TSM whereas 36% reported changes following sham treatment. Statistically significant changes in scapular kinematics were also found, however, they were not clinically relevant.

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

This paper shows that thoracic manipulation may significantly alter pain in subjects with shoulder impingement syndrome. However, they also found that a sham manipulation (no actual HVLA thrust) also significantly decreases pain following application. When looking at point change on the NPRS, the changes were not clinically relevant, however when looking at mean % change, they were above the MCID for chronic pain. Another consideration is that group means may potentially hide some subjects that responded in a statistically AND clinically significant way to TSM for SIS. Any changes that were seen in scapular kinematics did not appear to be clinically meaningful. These findings suggest that TSM is potentially beneficial for transient pain relief in those with shoulder impingement syndrome. However, they also point to the fact that whether an HVLA thrust manipulation is performed or not may not be important, and changes in pain result independently of a thrust. As always, patient values/expectations are very important to consider. If a patient is hesitant to receive a HVLA thrust, then they may reap the same benefits from the grade III/IV mobilization that occurs before a thrust. Counter to that, if a patient believes that manipulations will be beneficial, then transient pain relief may be amplified. It is important to note that this study did not follow-up over time, so conclusions cannot be drawn regarding how long this pain relief was experienced.

Effectiveness of Glenohumeral Joint Mobilization on Range of Motion and Pain in Patients With Rotator Cuff Disorders: A Systematic Review and Meta- Analysis

Article Full Title

Effectiveness of Glenohumeral Joint Mobilization on Range of Motion and Pain in Patients With Rotator Cuff Disorders: A Systematic Review and Meta- Analysis

Author Names

Héctor Gutiérrez-Espinoza, Iván Cuyul-Vásquez, Cristian Olguin-Huerta, Marcelo Baldeón-Villavicencio, Felipe Araya-Quintanilla

Reviewer Name

Yanfei Li, PT, DPT, CSCS

Reviewer Affiliation(s)

Hybrid Orthopedic Physical Therapy Residency Program, Duke University Physical Therapy Division

Paper Abstract

The purpose of this study was to determine the effectiveness of glenohumeral joint mobilization (JM) on range of motion and pain intensity in patients with rotator cuff (RC) disorders. Methods An electronic search was performed in the MEDLINE, CENTRAL, Embase, PEDro, LILACS, CINAHL, SPORTDiscus, and Web of Science databases. The eligibility criteria for selecting studies included randomized clinical trials that investigated the effect of glenohumeral JM techniques with or without other therapeutic interventions on range of motion, pain intensity, and shoulder function in patients older than 18 years with RC disorders. Two authors independently performed the search, study selection, and data extraction, and assessed risk of bias. Grades of Recommendation Assessment, Development and Evaluation ratings were used to evaluate the quality of evidence in this study. Results Twenty-four trials met the eligibility criteria, and 15 studies were included in the quantitative synthesis. At 4 to 6 weeks, for glenohumeral JM with other manual therapy techniques vs other treatments, the mean difference (MD) for shoulder flexion was −3.42° (P = .006), abduction 1.54° (P = .76), external rotation 0.65° (P = .85), and Shoulder and Pain Disability Index score 5.19 points (P = .5), and standard MD for pain intensity was 0.16 (P = .5). At 4 to 5 weeks, for the addition of glenohumeral JM to an exercise program vs exercise program alone, the MD for the visual analog scale was 0.13 cm (P = .51) and the Shoulder and Pain Disability Index score was −4.04 points (P = .01). Conclusion Compared with other treatments or an exercise program alone, the addition of glenohumeral JM with or without other manual therapy techniques does not provide significant clinical benefit with respect to shoulder function, range of motion, or pain intensity in patients with RC disorders. The quality of evidence was very low to high according to Grades of Recommendation Assessment, Development and Evaluation ratings.

Quality Assessment of Systematic Reviews and Meta-Analyses

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

Was publication bias assessed?

Yes

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

Yes

Key Finding #1

Minimal Impact on Range of Motion Compared to other treatments, at 4–6 weeks, GH joint mobilization with other manual therapy resulted in GH joint AROM improvements: Flexion: -3.42° (P = .006) In favor of GH Joint mobilization. Moderate heterogeneity, low quality of evidence Abduction: 1.54° (P = .76) Substantial heterogeneity, very low quality of evidence External Rotation: 0.65° (P = .85) Substantial heterogeneity, very low quality of evidence.

Key Finding #2

There was no statistically significant difference in the overall pooled SMD estimate for pain intensity between glenohumeral JM with other manual therapy techniques compared with other treatments (SMD = 0.16, 95% CI = -0.31 to 0.63, P = .5) with substantial heterogeneity (I2 = 84%, P< 0.05)

Key Finding #3

There was no statistically significant difference in the overall pooled MD estimate for the SPADI questionnaire between glenohumeral JM with other manual therapy techniques compared with other treatments (MD = 5.19 points, 95% CI = -9.82 to 20.19, P = .5), with considerable heterogeneity (I2 = 96%, P <0.05). There was very low quality of evidence according to the GRADE rating.

Please provide your summary of the paper

This systematic review and meta-analysis assessed the effectiveness of glenohumeral joint mobilization (JM) in rotator cuff disorders. A total of 24 studies (15 included in the meta-analysis) evaluated JM’s impact on range of motion, pain intensity, and shoulder function. The results indicate that glenohumeral JM, with or without other manual therapy techniques, does not provide significant clinical benefits compared to standard treatments like exercise or other treatments. Currently, the treatment of RC disorders should be individualized based on a variety of patient-related factors, including activity level, degree of impairment, comorbidities, patient expectations, and, age. Due to the large number and variability of interventions and co- interventions in the groups in the included trials, it was very difficult to pool data in a point estimate and thus to be able to establish the specific effects of glenohumeral JM techniques in patients with RC disorders. The study calls for higher-quality randomized controlled trials (RCTs) to further investigate the specific effects and dosage-response relationships of JM.

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 suggests that compared with an exercise program alone or other treatments, the addition of glenohumeral JM with or without other manual therapy techniques does not provide a significant clinical benefit with respect to shoulder function, range of motion, or pain intensity in patients with RC disorders. However, due to substantial heterogeneity, subgroup analyses based on the type or dose of glenohumeral JM technique or the type of RC disorder are not able to be performed. During clinical practice, we need to tailor our treatment plan to the individual in front of us, such as considering the extent of injury, symptom behaviors, patient’s goals and expectations, concomitant impairments, etc. There are some studies included in this paper that suggest short-term pain reduction after JM. More high-quality RCTs are needed to: Determine the optimal dose and frequency of JM. Identify subgroups of patients who might benefit from JM. Explore neurophysiological mechanisms influencing JM’s effects.

Spinal Manipulation and Electrical Dry Needling in Patients with Subacromial Pain Syndrome: A Multicenter Randomized Clinical Trial

Article Full Title

Spinal Manipulation and Electrical Dry Needling in Patients with Subacromial Pain Syndrome: A Multicenter Randomized Clinical Trial

Author Names

Dunning, J., Butts, R., Fernandez-de-las-Penas, C., Walsh, S., Goult, C., Gillett, B., Arias-Buria, J., Garcia, J., Young, I.

Reviewer Name

Jake Isaac, DPT

Reviewer Affiliation(s)

X3 Performance and Physical Therapy, Duke University Hybrid Orthopedic Residency

Paper Abstract

Abstract Objectives To compare the effects of spinal thrust manipulation and electrical dry needling (TMEDN group) to those of nonthrust peripheral joint/soft tissue mobilization, exercise, and interferential current (NTMEX group) on pain and disability in patients with subacromial pain syndrome (SAPS). Design Randomized, single-blinded, multicenter parallel-group trial. Methods Patients with SAPS were randomized into the TMEDN group (n = 73) or the NTMEX group (n = 72). Primary outcomes included the Shoulder Pain and Disability Index and the numeric pain-rating scale. Secondary outcomes included the global rating of change scale (GROC) and medication intake. The treatment period was 6 weeks, with follow-ups at 2 weeks, 4 weeks, and 3 months. Results At 3 months, the TMEDN group experienced greater reductions in shoulder pain and disability (P<.001) compared to the NTMEX group. Effect sizes were large in favor of the TMEDN group. At 3 months, a greater proportion of patients within the TMEDN group achieved a successful outcome (GROC score of 5 or greater) and stopped taking medication (P<.001). Conclusion Cervicothoracic and upper-rib thrust manipulation combined with electrical dry needling resulted in greater reductions in pain, disability, and medication intake than nonthrust peripheral joint/soft tissue mobilization, exercise, and interferential current in patients with SAPS. The effects were maintained at 3 months. J Orthop Sports Phys Ther 2021;51(2):72–81. Epub 28 Aug 2020. doi:10.2519/jospt.2021.9785

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? No

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? Yes

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

Patients receiving cervicothoracic and upper-rib thrust manipulation plus electrical dry needling experienced greater reductions in pain and shoulder disability after 3 months compared to the group receiving exercise, peripheral non-thrust peripheral joint/soft tissue mobilizations and IFC.

Key Finding #2

Patients in the spinal manipulation and dry needling group were more likely to discontinue medication at the 3-month mark compared to those in the comparison group.

Please provide your summary of the paper

This study aimed to evaluate the effectiveness of combining cervicothoracic and upper-rib thrust manipulation and electrical dry needling in those with Subacromial Pain Syndrome. The randomized, single-blinded, multicenter clinical trial involved 145 individuals diagnosed with SAPS who were placed into two treatment groups. One group received cervicothoracic and upper-rib thrust manipulation combined with electrical dry needling (TMEDN Group). The comparison group received nonthrust peripheral joint/soft tissue mobilization, exercise, and interferential current (NTMEX Group). Primary outcomes of the study were the Shoulder Pain and Disability Index and the numeric pain-rating scale. Secondary outcomes included the global rating of change scale and medication intake. Treatments were administered twice per week over a 6-week period, with follow-up assessments at 2 weeks, 4 weeks, and 3 months. Results demonstrated significantly greater reductions in shoulder pain and disability at the 3-month mark in the TMEDN group compared to the NTMEX group. Additionally, a higher proportion of patients in the TMEDN group discontinued medication use and reported a successful outcome as indicated by a GROC score of 5 or greater. These findings suggest that the combination of cervicothoracic and upper-rib thrust manipulation with electrical dry needling can be effective in the treatment of individuals with SAPS.

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

This paper demonstrates the effectiveness of the combination of spinal thrust manipulation and electrical dry needling in reducing shoulder pain and disability in those with SAPS. Previous research has demonstrated the effectiveness of exercise as a treatment for those with SAPS, and this paper indicates that spinal manipulation and electrical dry needling used in conjunction also prove to be an effective treatment for this condition. Perhaps the combination of spinal manipulation, electrical dry needling, and exercise could elevate the effectiveness of treatment in this patient population resulting in superior outcomes.

One-Year Outcome of Subacromial Corticosteroid Injection Compared With Manual Physical Therapy for the Management of the Unilateral Shoulder Impingement Syndrome

Article Full Title
One-Year Outcome of Subacromial Corticosteroid Injection Compared With Manual Physical Therapy for the Management of the Unilateral Shoulder Impingement Syndrome

Author Names
Daniel I. Rhon, PT, DPT, DSc; Robert B. Boyles, PT, DSc; and Joshua A. Cleland, PT, PhD

Reviewer Name
Hana Alvey, SPT, CSCS, CPT

Reviewer Affiliation(s)
Duke University School of Medicine

Paper Abstract
Background: Corticosteroid injections (CSIs) and physical therapy are used to treat patients with the shoulder impingement syndrome (SIS) but have never been directly compared.
Objective: To compare the effectiveness of 2 common nonsurgical treatments for SIS.
Design: Randomized, single-blind, comparative-effectiveness, parallel-group trial. (ClinicalTrials.gov: NCT01190891)
Setting: Military hospital–based outpatient clinic in the United States.
Patients: 104 patients aged 18 to 65 years with unilateral SIS between June 2010 and March 2012.
Intervention: Random assignment into 2 groups: 40-mg triamcinolone acetonide subacromial CSI versus 6 sessions of manual physical therapy.
Measurements: The primary outcome was change in Shoulder Pain and Disability Index scores at 1 year. Secondary outcomes included the Global Rating of Change scores, the Numeric Pain Rating Scale scores, and 1-year health care use.
Results: Both groups demonstrated approximately 50% improvement in Shoulder Pain and Disability Index scores maintained through 1 year; however, the mean difference between groups was not significant (1.5% [95% CI, 6.3% to 9.4%]). Both groups showed improvements in Global Rating of Change scale and pain rating scores, but between-group differences in scores for the Global Rating of Change scale (0 [CI, 2 to 1]) and pain rating (0.4 [CI, 0.5 to 1.2]) were not significant. During the 1-year follow-up, patients receiving CSI had more SIS-related visits to their primary care provider (60% vs. 37%) and required additional steroid injections (38% vs. 20%), and 19% needed physical therapy. Transient pain from the CSI was the only adverse event reported.
Limitation: The study occurred at 1 center with patients referred to physical therapy.
Conclusion: Both groups experienced significant improvement. The manual physical therapy group used less 1-year SIS-related health care resources than the CSI group.
Primary Funding Source: Cardon Rehabilitation Products through the American Academy of Orthopaedic Manual Physical Therapists.

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?
NO
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?
YES
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)?
NO
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
Both the Corticosteriod Injection (CSI) group and the Manual Physical Therapy (MPT) group maintained 50% improvements in their SPADI scores through the the 1 year follow up.

Key Finding #2
There was no significant difference in Shoulder Pain and Disability Index (SPADI) scores or the Global Rating of Change (GRC) scores between the CSI and MPT groups.

Key Finding #3
The MPT group ended up utlizing less subacromial impingement syndrome health care services and resources than the CSI group, like making fewer visits to see their primary care physician for shoulder pain.

Please provide your summary of the paper:
Subacromial Impingement Syndrome (SIS) is a condition where there is pain or discomfort in the shoulder due to impingement of the rotator cuff tendons as they pass under the acromion during certain movements. Knowing that corticosteroid injections and manual physical therapy both have positive effects on SIS, this research study’s aim is to compare the two interventions and see which leads to better outcomes for patients with SIS. Through randomization, one group received the steroid injections, and the other group received manual therapy. The CSI group could receive as many as 3 steroid injections in the one year period, and the manual therapy group received treatment 2 days a week for 3 weeks, along with a HEP. Outcome measures like the SPADI, GRC, and NPRS were measured at baseline, 1 month, 3 month, 6 months, and 1 year. The study concluded that there were clinically significant improvements for both groups’ outcomes measures, though there were no significant differences between the CSI and MPT groups. However, the MPT group utilized less health care resources than the CSI over the 1 year period.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
This paper shows that SIS can be successfully managed and treated with both corticosteroid injections and manual therapy. In light of this information, patients have more than one option for treatment, which is beneficial for treating unique individuals who will respond differently to different treatments. If manual therapy does not benefit them or provide the results they are looking for, they can try corticosteroid injections, or vice versa. These treatments can also be used in conjunction with each other. Since manual therapy is a conservative approach when treating SIS, there are few, if any, contraindications, posing little risks to patients and presenting itself as a great treatment option for various conditions.

The Effect of Muscle-Biased Manual Therapy on Shoulder Kinematics, Muscle Performance, Functional Impairment, and Pain in Patients with Frozen Shoulder

Article Full Title

The Effect of Muscle-Biased Manual Therapy on Shoulder Kinematics, Muscle Performance, Functional Impairment, and Pain in Patients with Frozen Shoulder

Author Names

Chun-Kai Tang, Yi-Fen Shih, & Chun-Shou Lee

Reviewer Name

Devon Anthony

Reviewer A5iliation(s)

Duke University Doctor of Physical Therapy

Paper Abstract

Background: Frozen shoulder (FS) is characterized by restricted active and passive shoulder mobility and pain.

Purpose: Compare the effect of muscle-biased manual therapy (MM) and regular physical therapy (RPT) in patients with FS.

Study design: Pretest-post-test control group study design.

Methods: We recruited 34 patients with FS and compared the effect of 12-session MM and RPT. The outcome measures were scapular kinematics and muscle activation, scapular alignment, shoulder range of motion, and pain intensity. Two-way analysis of variance was used to examine the intervention effect with α = 0.05.

Results: Both programs resulted in similar improvements in pain and shoulder function.

Compared to the RPT, MM resulted in increased posterior tilt (MM: 7.04°-16.09°, RPT: 2.50° to -4.37°; p = 0.002; ES = 0.261) and lower trapezius activation (MM: 260.61%470.90%, RPT: 322.64%-313.33%; p = 0.033; ES = 0.134) during scaption, and increased posterior tilt (MM: 0.70°-15.16°, RPT: -9.66° to -6.44°; p = 0.007; ES = 0.205) during the hand-to-neck task. The MM group also showed increased GH backward elevation (MM: 37.18°-42.79°, RPT: 43.64°-40.83°; p = 0.004, ES = 0.237) and scapular downward rotation (MM: -2.48° to 6.80°, RPT: 1.93°-1.44°; p < 0.001; ES = 0.404) during the thumb-to-waist task, enhanced shoulder abduction (MM: 84.6°-102.3°, RPT: 85.1°-92.9°; p = 0.02; ES = 0.153), and improved scapular alignment (MM: 10.4-9.65 cm, RPT: 9.41-9.56 cm; p = 0.02; ES = 0.114).

Conclusions: MM was superior to the RPT regarding scapular neuromuscular performance. Clinicians should consider adding muscle-biased treatment when treating FS.

Quality Assessment of Case-Control Studies

Was the research question or objective in this paper clearly stated and appropriate?
1. Yes
Was the study population clearly specified and defined?
1. Yes
Did the authors include a sample size justification?
1. Yes
Were controls selected or recruited from the same or similar population that gave rise to the cases (including the same timeframe)?
1. Yes
Were the definitions, inclusion and exclusion criteria, algorithms or processes used to identify or select cases and controls valid, reliable, and implemented consistently across all study participants?
1. Yes
Were the cases clearly defined and di5erentiated from controls?
1. Yes
If less than 100 percent of eligible cases and/or controls were selected for the study, were the cases and/or controls randomly selected from those eligible? a. N/A
Was there use of concurrent controls?
1. Yes
Were the investigators able to confirm that the exposure/risk occurred prior to the development of the condition or event that defined a participant as a case? a. N/A
Were the measures of exposure/risk clearly defined, valid, reliable, and implemented consistently (including the same time period) across all study participants?
1. N/A
Were the assessors of exposure/risk blinded to the case or control status of participants?
1. N/A
Were key potential confounding variables measured and adjusted statistically in the analyses? If matching was used, did the investigators account for matching during study analysis?
1. No

Key Finding #1

Over the course of a 12-week plan of care, patients that participated in a musclebiased manual therapy (MM) program showed greater improvement of scapular posterior tilt, scapular downward rotation, and glenohumeral extension

Key Finding #2

Patients that underwent the MM program demonstrated greater lower trap activation post-treatment, but did not demonstrate significant di&erences in muscle activation otherwise

Key Finding #3

The modified slide test detected improved scapular control and may be appropriate to utilize as a clinical assessment tool for improvements in frozen shoulder.

Key Finding #4

Traditional physical therapy approaches and MM techniques are both appropriate to reduce pain intensity, improve general shoulder mobility, and decrease level of functional limitation

Please provide your summary of the paper

Frozen shoulder is a diagnosis that is commonly seen in physical therapy clinics, especially among older adults. The authors of this paper aim to address gaps in research literature regarding long-term e&ects of 6 weeks of muscle-biased manual therapy (MM) on the clinical presentation of frozen shoulder, specifically in ROM, pain, muscle activation, and functional impairment. Using a pre-test/post-test control group study, the authors designed a 6-week plan of care and evaluated 2 groups of at least 17 study participants, who were identified based on physician referral. The muscle-biased manual therapy consisted of 15 minutes of hot pack use, followed by lengthening and compressive forces applied to the pectoral and shoulder girdle musculature, most similar to a muscle release. The control group received the same hot pack therapy, followed by end range GH joint distraction and A/P glide mobilizations. The treatment sessions for both groups were 45 minutes, with a total of 12 sessions in 6-8 weeks. Halfway through their treatment plans (34 weeks) each group switched their assigned intervention so that the control group received 3 weeks of the experimental treatment and vice versa. At the conclusion of the study, the authors found that the MM groups showed significantly more improvement in scapular and glenohumeral motions during various functional tasks. The MM group also showed a significant di&erence in upper trap activation during scaption as well as overall abduction ROM. The authors found data to support the common finding that mobility deficits in patients with frozen shoulder can be a&ected by muscular and capsular interventions, however they found that MM techniques resulted in improvements at an earlier point in the plan of care than in the respective control group.

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

This article provides strong evidence that muscle-biased manual therapy is an e&ective intervention in the treatment of frozen shoulder. More specifically, the MM technique can be used to improve scapular and glenohumeral motion during functional movements in a slightly quicker timeframe than traditional joint/capsular approaches. The MM approach was also found to lead to clinically significant improvements in pain and functional, further supporting their use. The authors note some limitations of the study, primarily due to sample selection, as patients were recruited from physician referral in the hospital setting. While these limitations may be significant in more chronic or long-term cases of frozen shoulder, they do not discount the value of the authors’ findings and treatment approach. As is the case with anything, the limitations of the study warrant careful consideration to each individual patient and should serve as a starting point for clinical decision making, not an end-all-be-all.

Treatment of Individuals with Chronic Bicipital Tendinopathy using Dry Needling, Eccentric Concentric Exercise and Stretching: a Case Series

Article Full Title

Treatment of Individuals with Chronic Bicipital Tendinopathy using Dry Needling, Eccentric Concentric Exercise and Stretching: a Case Series

Author Names

Amy W. McDevitt, PT, DPT; Suzanne J. Snodgrass, PT, PhD; Joshua A. Cleland, PT, PhD; Mary Becky R Leibold, PT, DPT; Lindsay A. Krause, PT, DPT & Paul E. Mintken, PT, DPT

Reviewer Name

Devon Anthony

Reviewer Affiliation(s)

Duke University Doctor of Physical Therapy

Paper Abstract

Objectives: To describe the outcomes of 10 patients with chronic biceps tendinopathy treated by physical therapy with the novel approach of dry needling (DN), eccentric-concentric exercise (ECE), and stretching of the long head of the biceps tendon (LHBT).

Methods: Ten individuals reporting chronic anterior shoulder symptoms (> 3 months), pain with palpation of the LHBT, and positive results on a combination of tests including active shoulder flexion, Speed’s, Hawkins Kennedy, Neer, and Yergason’s tests participated in this case series. Validated self-reported outcome measures including the mean numeric pain rating scale (NPRS) and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) were taken at baseline. Participants were treated with two to eight sessions of DN to the LHBT and an ECE program and stretching of the biceps muscle. At discharge, patients completed the global rating of change (GROC), QuickDASH and NPRS.

Results: Patients had an improved mean NPRS of 3.9 (SD, 1.3; p < 0.001), QuickDASH of 19.01% (SD, 10.8; p < 0.02) and GROC +5.4 (SD, 1.3). Conclusion: Findings from this case series suggest that DN and ECE may be beneficial for the management of patients with chronic LHBT tendinopathy. Further research on the efficacy of this novel treatment approach is warranted.

Quality Assessment Tool for Case Series Studies

Was the study question or objective clearly stated?
1. Yes
Was the study population clearly and fully described, including a case definition?
1. Yes
Were the cases consecutive?
1. No
Were the subjects comparable?
1. Yes
Was the intervention clearly described?
1. Yes
Were the outcome measures clearly defined, valid, reliable, and implemented consistently across all study participants?
1. No
Was the length of follow-up adequate?
1. No
Were the statistical methods well-described?
1. Yes
Were the results well-described?
1. Yes

Key Finding #1

A combination of Dry Needling, eccentric-concentric exercise, and stretching improves pain and disability in individuals with chronic LHBT bicipital tendinopathy in 2 – 8 visits.

Key Finding #2

This treatment approach may also supplement manual therapy and strengthening in rotator cuV/scapular pathologies

Key Finding #3

Even though conservative management of shoulder pain often takes a multimodal approach to the entire shoulder region, physical therapists are often unable to definitively screen and diagnose bicipital tendinopathy, as demonstrated by a 5.3% accuracy of palpation of the LHBT. This demonstrates an area for future research and development of more statistically sound screening tools.

Please provide your summary of the paper

Driven by the common prevalence of shoulder pain and the relatively low rates of recovery, this paper explores the response of 10 individuals with a primary complaint of chronic anterior shoulder pain (> 3 months) to a treatment plan consisting of a mix of dry needling (DN), eccentric-concentric exercises (ECE), and stretching. The authors of this case series focus specifically on LBHT tendinopathy, which they note to be a commonly chronic and difficultly treated condition. Using the QuickDASH, NPRS, strength testing, and ROM/muscle length measurements, the authors followed the outcomes of study participants over the course of 2 – 8 treatment sessions. At the conclusion of these sessions, all participants demonstrated improved scores QuickDASH and NPRS beyond the MCID. The authors do not note any significant differences in ROM, strength, or muscle length referencing multiple limitations of the study, including, but not limited to variation among therapists (4 therapists performed interventions across the 10 patients), diagnostic difficulty for LHBT tendinopathy, and an absence of long-term follow up with patients.

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

This case series provides a somewhat novel approach to tendinopathy and does a great job referencing pervious literature to support the hypotheses and clinical reasoning behind the multi-modal approach taken in this case series. As the authors note, further research is needed to establish a stronger relationship between the DN/ECE/Stretching approach and outcomes, but this certainly provides a significant foundation to base further clinical decision making, especially in the acute treatment of tendinopathy. The resources cited in this paper would also serve as a strong collective for clinicians looking for research to support dry needling or ECE independently. I would be interested to see if these findings can be replicated in other body regions (i.e. Achillies tendinopathy, patellar tendinopathy, lateral epicondylitis, etc…)

Effectiveness of trigger point manual therapy for rotator cuff related shoulder pain: a systemic review and meta-analysis

Cierra Berry, SPT, ERA-C

Duke University Department of Physical Therapy

Research Article Title: “Effectiveness of trigger point manual therapy for rotator cuff related shoulder pain: a systemic review and meta-analysis”

Authors (Last, First Initial): Dongye Zeng, et.al.

Abstract:

Purpose: To evaluate the effectiveness of trigger point manual therapy (TPMT) in treating rotator cuff related shoulder pain (RCRSP).

Methods: Randomized controlled trials that compared the effects of TPMT with no or other conservative treatments in patients with RCRSP were included. Primary outcomes were shoulder pain intensity and function. Secondary outcomes were pressure pain threshold (PPT) and number of myofascial trigger points (MTrPs). The Cochrane Risk of Bias 2.0 tool, PEDro scale and GRADE approach were employed.

Results: Ten studies were included in this systematic review and seven in the meta-analysis. Very low to low quality of evidence showed no statistically significant difference between TPMT and other conservative treatments in rest and activity pain reduction in the short term (3 days to 12 weeks), and the difference in shoulder function was statistically significant in favor of TPMT. Furthermore, TPMT was found to be effective in the improvement of PPT and the inactivation of active MTrPs in the short term.

Conclusion: TPMT may be equally effective as other passive treatments for the pain reduction in patients with RCRSP in the short term, and slightly more effective for functional improvement. TPMT seems to be effective to treat the active MTrPs in RCRSP.

Registration number: CRD42023409101.

Keywords: Shoulder pain; conservative treatment; manual therapy; physical therapy; trigger points.

Quality Assessment for Systematic Reviews and Meta-Analyses: (yes/no/cannot determine, not reported, n/a)

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

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

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

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

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

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

Was publication bias assessed? Yes

Was heterogeneity assessed? (only applies to meta-analyses) Yes

Key Findings:

Effects on pressure pain threshold

“Significant improvement post-treatment was observed in all the TPMT groups and two studies identified a significant advantage of TPMT in the between group comparisons.”

Effects on number of myofascial trigger points

“Three studies identified greater improvement in the TPMT group compared with the comparison group after treatment.”

Effects on shoulder function

“Subgroup analysis showed that TPMT has a moderate effect compared to sham or no treatment based on low quality evidence.”

Effects on activity pain intensity

“Subgroup analyses showed no significant difference between TPMT and other conservative treatments which included manual therapy and exercise.”

Summary

This study aimed to compare the effectiveness of trigger point manual therapy as a therapeutic intervention for rotator cuff related shoulder pain. In the context of the study, trigger point manual therapy included: includes trigger point pressure release, myofascial release, positional release methods, muscle energy technique, transverse friction massage, and integrated neuromuscular inhibition technique. These interventions were compared to sham/no treatment or other conservative treatments (ie. Exercise therapy, manual therapy, physical modalities and education. Research reviewed randomized controlled trials to be included in their inclusion criteria and based on the included studies, 381 participants were a part of the study. During their analysis, they noted the effectiveness of trigger point manual therapy on the following outcomes, shoulder function, rest pain intensity, pressure pain threshold and the number of myofascial trigger points. The results depicted low quality evidence on the effectiveness of trigger point manual therapy on activity pain intensity. In addition, subgroup analyses showed trigger point manual therapy had a moderate effect on shoulder function when compared to sham/no treatment, after treatment, three studies showed greater improvement in trigger point manual therapy group on the number of myofascial trigger points, and pain improved post-treatment in the trigger therapy groups when compared.

Clinical Interpretation. Include how this study may impact clinical practice and how the results can be implemented.

This study can be used by clinicians to support their clinical reasoning for providing trigger point manual therapy in the short term. If a patient with rotator cuff related shoulder pain is limited by their chronic pain, this intervention has the ability to decrease their pain and willingness to move. The results also showed to have a moderate effect on the rest pain intensity when participants were not given a treatment. However, this study has low evidence to support the effects of trigger point manual therapy on activity pain intensity. In addition, the clinician can use conservative interventions as an alternative method since, when compared to trigger point manual therapy, they were equally effective.

Effect of manual physiotherapy in homogeneous individuals with subacromial shoulder impingement: A randomized controlled trial

Article Full Title: Effect of manual physiotherapy in homogeneous individuals with subacromial shoulder impingement: A randomized controlled trial

Author Names: Helen Land, Susan Gordon, Kerrianne Watt

Reviewer Name: Megan Broomfield, SPT

Reviewer Affiliation(s): Duke University Doctor of Physical Therapy Program, SPT

Paper Abstract:

Objective: To compare the effect of specific interventions aimed at (1) the upper thoracic spine (passive mobilization) and (2) the posterior shoulder (massage, passive mobilization, and stretching) to (3) an active control intervention in a homogeneous group with extrinsic subacromial shoulder impingement (SSI).

Study Design: Single‐centre, prospective, double‐blinded, randomized controlled trial.

Method: Eligible individuals with clearly defined extrinsic SSI were randomized to each group. Treatment duration was 12 consecutive weeks consisting of nine treat-ments over 6 weeks, followed by 6 weeks when one home exercise was performed daily. Outcomes included (1) active thoracic flexion/extension range of motion, (2)passive glenohumeral internal rotation and posterior shoulder range, (3) pain rating,and (4) shoulder pain and function disability index. Data were analysed at baseline, 6 and 12 weeks. Shoulder pain and function disability index scores were investigated via email 6 months after commencement of treatment.

Results: Twenty participants completed treatment in each group. No differences were identified between groups at baseline. Upper thoracic and posterior shoulder interventions, with a targeted home exercise, both significantly decreased pain and increased function scores and increased posterior shoulder range compared with active control at 12 weeks, and 6 months following cessation of the trial.

Conclusion: Manual therapy treatment that addresses these extrinsic factors, of tho-racic spine or posterior shoulder tightness, decreases the signs and symptoms of SSI.The trial is registered with the Australian New Zealand Clinical Trials Registry(ANZCTR; 12615001303538).

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? Yes
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?

Key Finding #1

Passive IR significantly improved in the groups receiving upper thoracic treatment compared with the active control group and also in the posterior shoulder treatment compared with the active control group.

Key Finding #2

Posterior shoulder range improved in the groups receiving upper thoracic treatment compared with the active control group and also in the posterior shoulder treatment compared with the active control group.

Key Finding #3

Shoulder pain and disability index (SPADI) scores improved in the groups receiving upper thoracic treatment compared with the active control group and also in the posterior shoulder treatment compared with the active control group.

Key Finding #4

Both manual therapy interventions had a similar positive effect on reducing pain, showing no difference between the two interventions’ effects on improving function and increasing posterior shoulder range after 6 weeks in patients with SSI.

Please provide your summary of the paper

In this double‐blinded RCT, researchers aimed to compare the effects of different interventions on pain, function, and range of motion on patients with subacromial shoulder impingement (SSI). These interventions included: upper thoracic manual therapy; posterior shoulder massage, manual therapy, and stretching; and a control group. Specific manual therapy interventions are detailed in pictures and text within the posted study. Researchers hypothesized there would be an improvement in the studied factors in the groups who received the manual therapy interventions compared to the control group. Participants were randomized into either a control group, a group which received treatment to the upper thoracic region for 6 weeks plus a daily thoracic home exercise program for 12 weeks, a group which received treatment to the soft tissue of the posterior shoulder for 6 weeks plus a daily home posterior shoulder stretch for 12 weeks, and a control group who received ultrasound for 6 weeks. 60 total participants underwent an initial 3‐week period where they received treatment twice a week, and then once a week for the next 3 weeks. After 6 weeks, manual therapy was ended and participants were told to continue with their home exercise program. Outcome measures assessed were the numeric pain rating scale, shoulder pain and disability index, passive internal rotation range, posterior shoulder range, upper thoracic resting posture, and range of motion at baseline and weeks 6 and 12. Shoulder pain and disability index scores were followed up with at 6 months. Results found an improvement in function and passive internal rotation range in both groups. However, the range of upper thoracic flexion/extension and thoracic resting angle was not found to significantly change in any of the groups. Limitations of this study include a lack of sensitivity of the upper thoracic measurement, volunteer bias, generally small sample size, previous treatment experiences that were not accounted for, and the need for an altered active control group mid-study. When compared to a control group, manual therapy was found to increase function scores posterior shoulder range and decrease pain compared to an active control group.

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

From this article, we can affirm the interventions’ efficacy of decreasing pain and increasing function. Although the reasoning of why manual therapy affects the factors studied needed to have further research, this RCT gives evidence for the beneficial use of manual therapy in this population. Through decreasing upper thoracic and posterior shoulder tightness with the use of manual therapy, clinicians can decrease the symptoms of SSI. Some limitations included volunteer bias and a small group of included volunteers, and further research is needed to address these limitations through the use of a larger sample size to capture more volunteers and decrease availability bias of participant recruitment. This study impacts clinical practice by providing further evidence for the efficacy of using manual therapy for patients with SSI, and gives examples of researched interventions to effectively utilize in the clinic. This article can be clinically applied through the use of manual therapy interventions for patients with SSI to increase function and decrease pain effectively and at a low cost.

Comparing the Efficacy of Manual Therapy and Exercise to Synchronized Telerehabilitation with Self-Manual Therapy and Exercise in Treating Subacromial Pain Syndrome: A Randomized Controlled Trial

Article Full Title: Comparing the Efficacy of Manual Therapy and Exercise to Synchronized Telerehabilitation with Self-Manual Therapy and Exercise in Treating Subacromial Pain Syndrome: A Randomized Controlled Trial

Author Names: Erman Berk Çelik and Aysenur Tuncer 

Reviewer Name: Abbie Bushinski, SPT

Reviewer Affiliation(s): Duke University Doctor of Physical Therapy Division

Paper Abstract:

This study aimed to investigate the efficacy of manual therapy and exercise versus synchronized telerehabilitation with self-manual therapy and exercise in treating Subacromial Pain Syndrome (SAPS). Sixty individuals diagnosed with SPS, aged 18–50 years, were randomly assigned to home exercise (HE), manual therapy (MT), and telerehabilitation (TR) groups. Treatment protocols were administered over 8 weeks and included specific exercises and therapy interventions. Outcome measures included the Visual Pain Scale (VAS), shoulder range of motion (ROM) via goniometric measurements, Quick Disability Arm-Shoulder-Hand Problems Survey (Q-DASH), and patient satisfaction. Results revealed that both MT and TR groups exhibited reduced pain, increased ROM, lower Q-DASH scores, and higher patient satisfaction than the HE group. However, no significant differences were found between the MT and TR groups regarding pain levels, ROM, Q-DASH scores, or patient satisfaction. The study concludes that both telerehabilitation and manual therapy effectively alleviate pain and are well-received by patients with SPS. Additionally, manual therapy demonstrates superiority in enhancing functional levels compared to exercise-based interventions (Registration: NCT05200130).

Keywords: subacromial pain syndrome; manual therapy; telerehabilitation

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?

Were the people assessing the outcomes blinded to the participants’ group assignments?

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?

Not reported

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Not reported

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?

Not reported

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: There was a reduction in pain for participants in the manual therapy and telerehabilitation groups compared to the home exercise group.

Key Finding #2: Shoulder ROM increased in participants in the manual therapy and telerehabilitation groups compared to the home exercise group.

Key Finding #3: Quick Disability Arm-Shoulder-Hand Problems Survey (Q-DASH) scores were lower for participants in the manual therapy group at 8 and 12 weeks compared to the home exercise and telerehabilitation groups.

Key Finding #4: Treatment satisfaction was reported to be higher for participants in the manual therapy and telerehabilitation groups compared to the home exercise group.

Please provide your summary of the paper

This randomized control trial hypothesized that both manual therapy and telerehabilitation would be effective in reducing pain and improving shoulder function in patients with subacromial pain syndrome (SAPS). The RCT consisted of 3 groups: the home exercise group, the manual therapy and exercise group, and the telerehabilitation self-mobilization and exercise group. There was a total of 60 participants (20 per group). The inclusion criteria consisted of participants being 18-50 years old, with shoulder pain for more than 6 weeks. Other clinical tests were also utilized as inclusion criteria as participants needed to have at least 2/3 positive tests to be included in the study. These clinical tests were the Hawkins-Kennedy Test, Painful Arc Test, and Infraspinatus Resistance Test. Participants were excluded from the study if they had other conditions affecting the neck, shoulder, or back, had previous treatment for their shoulder pain, a positive drop arm test, or a BMI >30 kg/m2. All participants were given an exercise routine consisting of rotator cuff strengthening exercises, scapular stabilization strengthening exercises, and shoulder stretches. The manual therapy group received glenohumeral inferior, anterior, and posterior glides in addition to their prescribed exercise routine. Manual therapy was performed 2x per week for 5×10 seconds. The telerehabilitation group received education on glenohumeral inferior, anterior, and posterior self-mobilization techniques in addition to their prescribed exercises. Self-mobilizations were performed 5×10 seconds, 2x a week via telehealth. Shoulder function and pain were assessed using the Visual Pain Scale (VAS), shoulder range of motion (ROM), Quick Disability Arm-Shoulder-Hand Problems Survey (Q-DASH), and patient satisfaction ratings. Overall, they determined that the manual therapy and telerehabilitation groups had the greatest impact on patients’ pain and ROM compared to the home exercise group. Additionally, the manual therapy and telerehabilitation groups improved overall shoulder function with a slightly higher improvement found in participants in the manual therapy group. Patient satisfaction was also found to be higher in the manual therapy and telerehabilitation groups than in the home exercise group. Therefore, the RCT concluded that manual therapy plus exercise and telerehabilitation-supported exercise and self-mobilizations were effective forms of treatment in patients with subacromial pain syndrome.

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

Based on the conclusions of the RCT, manual therapy and strengthening exercises are safe and effective in treating shoulder pain, ROM, and overall function for patients with SAPS. Although the study concluded positive results future research should be conducted with larger sample sizes and should consider the ease of technology, patient preferences, and technological issues. Additionally, this RCT concluded that telerehabilitation sessions with guided self-mobilizations are effective in treating SAPS and that telerehabilitation may be an effective way to deliver care in the future.

The effect of Mulligan and Maitland techniques on pain, functionality, proprioception, and quality of life in individuals with rotator cuff lesions

Article Full Title: The effect of Mulligan and Maitland techniques on pain, functionality, proprioception, and quality of life in individuals with rotator cuff lesions

Author Names: Celik, Tarik, Burak Menek

Reviewer Name: Natanael Casiano

Reviewer Affiliation(s): SPT

Paper Abstract

Background: Rotator cuff disease treatment typically involves manual therapy and exercise as part of physical therapy. Purpose: This study aims to investigate the effects of Mulligan and Maitland mobilization methods on pain, functionality, quality of life, and proprioception in individuals with rotator cuff lesions. Study Design: This was a single-blinded randomized clinical trial. Methods: The study included 45 individuals with rotator cuff lesions. Participants were randomly divided into three groups: conventional exercise, Maitland mobilization, and Mulligan mobilization. All participants were assessed pretreatment and post treatment using the Visual Analog Scale, Disabilities of the Arm, Shoulder, and Hand, Rotator Cuff Quality of Life, range of motion (ROM), and proprioception. Results: All parameters, except proprioception, improved significantly in all three groups post treatment (p < 0.05). Mulligan group (MG) and Maitland mobilization group (MMG) had higher improvements to the conventional exercise group (CG) in terms of flexion ROM (p = 0.05, effect size = 0.22), abduction ROM (p = 0.02, effect size = 0.26), Disabilities of the Arm, Shoulder, and Hand (p < 0.001, effect size = 0.56). Also, the MG group had greater improvements to the MMG and CG groups in terms of Rotator Cuff Quality of Life/ symptoms (p < 0.001, effect size = 0.43), job (p < 0.001, effect size = 0.61), lifestyle (p < 0.001, effect size = 0.42), emotional parameters (p < 0.001, effect size = 0.29). MG was more effective than the MMG in Visual Analog Scale activity (p < 0.001, effect size = 0.32), external rotation (p = 0.012, effect size = 0.19), and abduction ROM (p = 0.002, effect size = 0.26). However, no improvement in proprioception was observed across all groups (p > 0.05). Conclusions: This study concluded that, in addition to conventional treatment, both Mulligan and Maitland mobilization therapy effectively improve range of motion, functionality, and quality of life.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

1. Was the study described as randomized, a randomized trial, a randomized
clinical trial, or an RCT

– Yes
2. Was the method of randomization adequate (i.e., use of randomly
generated assignment)?

– Yes
3. Was the treatment allocation concealed (so that assignments could not be
predicted)?

– No
4. Were study participants and providers blinded to treatment group
assignment?

– No
5. Were the people assessing the outcomes blinded to the participants’ group
assignments?

– Yes
6. Were the groups similar at baseline on important characteristics that could
affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

– Yes
7. Was the overall drop-out rate from the study at endpoint 20% or lower of
the number allocated to treatment?

– No

Was the differential drop-out rate (between treatment groups) at endpoint
15 percentage points or lower?

– No
9. Was there high adherence to the intervention protocols for each treatment
group?

– Yes
10. Were other interventions avoided or similar in the groups (e.g., similar
background treatments)?

– Yes
11. Were outcomes assessed using valid and reliable measures, implemented
consistently across all study participants?

– Yes
12. 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
13. Were outcomes reported or subgroups analyzed prespecified (i.e.,
identified before analyses were conducted)?

– Yes
14. Were all randomized participants analyzed in the group to which they were
– Yes

Key Finding #1: None of the techniques used in the study made significant improvements in proprioception.

Key Finding #2: Each intervention improved all but one patient parameters, however, manual therapy methods like Mulligan and Maitland led to better outcomes than relying on exercises alone.

Key Finding #3: Mulligan mobilization provided the greater improvements in quality of life, external rotation, abduction ROM, and VAS activity parameters compared to Maitland and conventional exercises

Please provide your summary of the paper:

This study investigates the impact of Mulligan and Maitland mobilization techniques on people with rotator cuff lesions, comparing them to conventional exercise programs and examining their effects on pain relief, range of motion, functionality, proprioception, and overall quality of life. The study involved 45 participants who were divided into three groups: one for each mobilization technique and a control group receiving conventional therapy. Results showed that both Mulligan and Maitland techniques significantly improved pain, ROM, functionality, and quality of life. However, Mulligan mobilization appeared to be more effective than Maitland in certain parameters. None of the groups or approaches led to significant improvements in proprioception.

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 highlights the effectiveness of manual therapy in treating rotator cuff injuries. Mulligan mobilization showed to be the most effective technique for improving measures such as some ranges of motion and quality of life, which can promote better patient recovery outcomes. However, since neither technique improved proprioception, additional interventions may be necessary to address that aspect. In clinical practice, clinicians can use these findings to develop more personalized treatment plans that prioritizes more effective manual therapy techniques to improve patient outcomes while being mindful of the limitations of these interventions and adjusting treatment plans accordingly.

Effectiveness of formal physical therapy following total shoulder arthroplasty: A systematic review

Article Full Title: Effectiveness of formal physical therapy following total shoulder arthroplasty: A systematic review

Reviewer Name: Li Chen

Study Design: randomized controlled trials

Abstract:

Background Physical therapy is considered routine practice following total shoulder arthroplasty. To date, current regimens are based on clinical opinion, with evidence-based recommendations. The aim of this systematic review was to evaluate the effectiveness of total shoulder arthroplasty physical therapy programmes with a view to inform current clinical practice, as well as to develop a platform upon which future research might be conducted. Methods An electronic search of MEDLINE, EMBASE, CINAHL and Cochrane Library to March 2018 was complemented by hand and citation-searching. Studies were selected in relation to pre-defined criteria. A narrative synthesis was undertaken. Results A total of 506 papers were identified in the electronic database search, with only one study showing moderate evidence of early physical therapy promoting a more rapid return of short-term improvement in function and pain. No studies evaluated the effectiveness of physical therapy programmes in reverse total shoulder arthroplasty procedures. Discussion Restoring range of motion and strength following total shoulder arthroplasty is considered important for patients to obtain a good outcome post-surgery and, when applied early, may offer more rapid recovery. Given the rising incidence of total shoulder arthroplasties, especially reverse total shoulder arthroplasty, there is an urgent need for high-quality, adequately powered randomised controlled trials to determine the effectiveness of rehabilitation programmes following these surgeries.

NIH Risk of Bias Score: 6

Key Findings of the Study:

Moderate evidence that early initiation of ROM exercises, starting from 1 to 4 weeks post-surgery, led to faster improvements in pain and function within the first 8 weeks after TSA. This early intervention was more effective compared to a delayed approach (starting from 4 weeks post-surgery).

Despite the short-term improvements, no significant differences were observed in pain, function, or ROM between the early and delayed rehabilitation groups at 3, 6, or 12 months post-surgery. This suggests that while early rehabilitation may provide quicker recovery, it does not influence the long-term functional outcomes.

The review highlighted a lack of robust, high-quality research on post-operative rehabilitation following TSA, with only one high-quality RCT meeting the inclusion criteria. This indicates a significant gap in evidence, especially when compared to the extensive research available for other joint replacements like hip and knee arthroplasties.

Reviewer Summary:

This systematic review sheds light on the importance of early post-operative rehabilitation for total shoulder arthroplasty. Initiating physical therapy early in the recovery process provides short-term benefits, such as improved pain management and functional recovery within the first 8 weeks. This is consistent with clinical practices that emphasize early mobilization to prevent stiffness and accelerate recovery.

However, despite these early gains, the study highlights a key observation: no significant long-term benefits were found from early rehabilitation, as outcomes like pain, function, and ROM were comparable between early and delayed rehabilitation groups at 3, 6, and 12 months. This nuance is crucial for clinical decision-making, as it suggests that while early therapy might expedite recovery, the long-term success of TSA rehabilitation may depend on other factors beyond the timing of interventions.

A major limitation of the review is the lack of high-quality evidence in this area, with only one high-quality RCT meeting the inclusion criteria. This gap in research is concerning, especially as TSA and reverse TSA become more prevalent.

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