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

  1. Is the review based on a focused question that is adequately formulated and described?
  • Yes
  1. Were eligibility criteria for included and excluded studies predefined and specified?
  • Yes
  1. Did the literature search strategy use a comprehensive, systematic approach?
  • Yes
  1. Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?
  • Yes
  1. Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?
  1. Were the included studies listed along with important characteristics and results of each study?
  • Yes
  1. Was publication bias assessed?
  • Yes
  1. Was heterogeneity assessed? (This question applies only to meta-analyses.)
  • Yes

 

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.