Author Names
Brantingham, J, Cassa, T, Bonnefin, D, Jensen, M, Globe, G, Hicks, M, Korporaal, C
Reviewer Name
Natalia Engel, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Objective: The purpose of this study was to conduct a systematic review on manual and manipulative therapy (MMT) for common shoulder pain and disorders. Methods: A search of the literature was conducted using the Cumulative Index of Nursing Allied Health Literature; PubMed; Manual, Alternative, and Natural Therapy Index System; Physiotherapy Evidence Database; and Index to Chiropractic Literature dating from January 1983 to July 7, 2010. Search limits included the English language and human studies along with MeSH terms such as manipulation, chiropractic, osteopathic, orthopedic, musculoskeletal, physical therapies, shoulder, etc. Inclusion criteria required a shoulder peripheral diagnosis and MMT with/without multimodal therapy. Exclusion criteria included pain referred from spinal sites without a peripheral shoulder diagnosis. Articles were assessed primarily using the Physiotherapy Evidence Database scale in conjunction with modified guidelines and systems. After synthesis and considered judgment scoring were complete, with subsequent participant review and agreement, evidence grades of A, B, C, and I were applied. Results: A total of 211 citations were retrieved, and 35 articles were deemed useful. There is fair evidence (B) for the treatment of a variety of common rotator cuff disorders, shoulder disorders, adhesive capsulitis, and soft tissue disorders using MMT to the shoulder, shoulder girdle, and/or the full kinetic chain (FKC) combined with or without exercise and/or multimodal therapy. There is limited (C) and insufficient (I) evidence for MMT treatment of minor neurogenic shoulder pain and shoulder osteoarthritis, respectively. Conclusions: This study found a level of B or fair evidence for MMT of the shoulder, shoulder girdle, and/or the FKC combined with multimodal or exercise therapy for rotator cuff injuries/disorders, disease, or dysfunction. There is a fair or B level of evidence for MMT of the shoulder/shoulder girdle and FKC combined with a multimodal treatment approach for shoulder complaints, dysfunction, disorders, and/or pain.
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
Multimodal treatment appears to be the most valuable approach for treating shoulder conditions, including manual therapy grades III-V when appropriate, in conjunction with exercise or rehabilitation therapy.
Key Finding #2
There is fair evidence for manual therapy of the shoulder/shoulder girdle and/or the full kinetic chain included in a multimodal approach for shoulder complaints, dysfunction, disorders and/or pain.
Key Finding #3
There is fait evidence for manual therapy with exercise that includes proprioceptive retraining for frozen shoulder or adhesive capsulitis.
Key Finding #4
There is fair evidence for using soft tissue or myofascial treatments for soft tissue disorders of the shoulder.
Please provide your summary of the paper
This article demonstrates the importance of using manual therapy for shoulder disorders in conjunction with exercise intervention. It is important to first evaluate the glenohumeral joint, acromioclavicular joint, scapulothoracic joint, the cervical spine, upper ribs, and the full kinetic chain (elbow/hand) to assess ROM, accessory glide, end-feel, and accessory motion deficits, and to rule out contraindications to manual therapy. Manual therapy can then be applied as an effective conjunctive therapy to rehabilitation exercises and interventions, with the greatest benefits seen in high velocity low amplitude thrust or grades III and IV mobilization. In treatment of shoulder injuries, it is important to address soft tissue, proprioceptive, and functional deficits and limitations along with joint restrictions/fixations in order to prescribe appropriate exercises and apply manual therapy to appropriately benefit the patient and to achieve the greatest outcome.
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 demonstrates the efficacy of manual therapy, but highlights that this efficacy is highest when it is implemented in conjunction with exercise interventions. Because of these results, it will be crucial when treating patients with shoulder disorders to not rely on manual therapy as the sole treatment option. Assessing the patient holistically at the shoulder joint and surrounding joints in order to uncover impairments, followed by ruling out red flags and contraindications for manual therapy, is a way to use evidence-based treatment to lead to enactment of a multimodal approach wherein exercise interventions and manual therapy are implemented based on the patient’s deficits and needs. Using this multimodal approach has the potential to reach the highest possible outcome for a patient with shoulder disorders.
