Shoulder

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

Article: Bang MD, Deyle GD. Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients with Shoulder Impingement Syndrome. Journal of Orthopaedic & Sports physical therapy.

Full Text

Study Design: Prospective Randomized Controlled Trial Abstract: The purpose of this study was to investigate the comparative effectiveness of exercise with and without manual therapy (MT) to treat shoulder impingement syndrome (SIS). The randomized controlled trial included patients (30 men, 22 women, age 43 years +- 9 years) that were diagnosed with SIS. The patients were randomly assigned to 1 of 2 treatment groups. One group received exercises only for the shoulder girdle and/or cervical spine, and the other group received the same exercises and MT. Groups received treatment 6 times over a 3-week period in 30 min sessions. The main outcome measures were pain, strength, and function. Pain was a composite score measured using the visual analog scale during break tests, resisted abduction, and functional tests. Function was measured with a functional assessment questionnaire, and strength was a composite score of isometric strength tests for internal rotation, external rotation, and abduction. Outcomes were taken prior to treatment and during treatment, and pain and function were measured two months after treatment. Two patients dropped out of the trial before it ended. The results showed significant improvements in pain and function in both groups, but the MT group showed more improvement compared to the exercise group.

NIH Risk of Bias Score: 9/14 Key Findings of the Study:

1. Shoulder strengthening and passive stretching can decrease shoulder pain and improve function in patients with SIS.

2. Combining shoulder strengthening exercises and stretching with MT will improve patient outcomes with SIS.

3. Outcomes were measured using a functional assessment questionnaire, which was developed in 1993 by looking at the Oswestry Disability Index, but not a validated outcome measure.

Reviewer Summary: The results showed that manual therapy can be beneficial when coupled with a shoulder strengthening program to improve pain and function in SIS patients. The study used dynamometers to measure isometric strength in each patient, but the pain and function outcomes were not validated and lack reliability. The patients in the exercise group completed the exercises under the supervision of a PT, while the MT and exercise group received MT from the therapists and completed the exercises at home. The MT group had more significant decreases in pain, and improvements in strength and function, but this could be due to the perception that MT appears like more individualized care than just exercises. Perhaps not all of the MT group performed the exercises at home, and their strength improved due to a decrease in pain from not using their shoulder musculature as often as the exercise group. While there are some gaps in the study, it appears that MT can be beneficial for SIS patients, especially when coupled with an individualized exercise program.

Effectiveness of Conservative Interventions Including Exercise, Manual Therapy, and Medical Management in Adults With Shoulder Impingement: A Systematic Review and Meta-Analysis of RCTs

Author Names

Steuri, R; Sattelmayer, M; Elsig, S; Kolly, C; Tal, A; Taeymans, J; Hilfiker, R

Reviewer Name

Semat Adekoya, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

[Objective] To investigate the effectiveness of conservative interventions for pain, function and range of motion in adults with shoulder impingement. [Design] Systematic review and meta-analysis of randomised trials. [Data sources] Medline, CENTRAL, CINAHL, Embase and PEDro were searched from inception to January 2017. [Study selection criteria] Randomised controlled trials including participants with shoulder impingement and evaluating at least one conservative intervention against sham or other treatments. [Results] For pain, exercise was superior to non-exercise control interventions (standardised mean difference (SMD) −0.94, 95% CI −1.69 to −0.19). Specific exercises were superior to generic exercises (SMD −0.65, 95% CI −0.99 to −0.32). Corticosteroid injections were superior to no treatment (SMD −0.65, 95% CI −1.04 to −0.26), and ultrasound guided injections were superior to non-guided injections (SMD −0.51, 95% CI −0.89 to −0.13). Nonsteroidal anti-inflammatory drugs (NSAIDS) had a small to moderate SMD of −0.29 (95% CI −0.53 to −0.05) compared with placebo. Manual therapy was superior to placebo (SMD −0.35, 95% CI −0.69 to −0.01). When combined with exercise, manual therapy was superior to exercise alone, but only at the shortest follow-up (SMD −0.32, 95% CI −0.62 to −0.01). Laser was superior to sham laser (SMD −0.88, 95% CI −1.48 to −0.27). Extracorporeal shockwave therapy (ECSWT) was superior to sham (−0.39, 95% CI −0.78 to –0.01) and tape was superior to sham (−0.64, 95% CI −1.16 to −0.12), with small to moderate SMDs. [Conclusion] Although there was only very low quality evidence, exercise should be considered for patients with shoulder impingement symptoms and tape, ECSWT, laser or manual therapy might be added. NSAIDS and corticosteroids are superior to placebo, but it is unclear how these treatments compare to exercise.

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

Manual therapy was superior compared to placebo when studying the effectiveness of pain reduction.

Key Finding #2

Manual therapy plus exercise was superior compared to exercise alone, but only at the shortest follow up time frame.

Please provide your summary of the paper

This paper examined the impacts of many different conservative approaches to treating patients with shoulder impingement syndrome (SIS). Conservative approaches included manual therapy, exercise, corticosteroid injections, non-steroidal anti-inflammatory drugs (NSAIDS), laser, and extracorporeal shockwave therapy. Results demonstrated that conservative treatment generally improves outcomes compared to sham or placebo, with some improvement effects larger than others. Manual therapy yielded superior compared to placebo, with manual therapy paired with exercise even more impactful than exercise alone.

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 displayed a wide array of conservative interventions and their impacts. Understanding how manual therapy can be paired with exercise, most notably specific exercise rather than general, can yield improvements in patients with shoulder impingement syndrome. SIS is the third most common musculoskeletal presentation following back and neck disorders, with prevalence especially noted in women and those aged 45-64 years of age. Untreated SIS can lead to increases in pain and disability as well as decrease the quality of life and healthy sleeping patterns. This can lead both directly and indirectly to further joint destruction, ultimately warranting a total joint reconstruction. Although the results of this study yielded lower quality evidence, with all of the traffic light classifications defined as “orange” (uncertain effect), the results are promising and show impacts compared to passive interventions.

Manual Therapy Associated With Upper Limb Exercises vs. Exercises Alone for Shoulder Rehabilitation in Postoperative Breast Cancer

Author Names

Pace do Amaral, M. T., Freire de Oliveira, M. M., Ferreira, N.deO., Guimarães, R. V., Sarian, L. O., & Gurgel, M. S.

Reviewer Name

Morgan Baxter, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Our objective was to evaluate the effectiveness of manual therapy (MT) associated with upper limb (UL) exercises in women with impaired shoulder range of motion (ROM) after axillary lymph node dissection (ALND) for breast cancer. A randomized, prospective, blinded clinical trial with 131 women with a ROM <- 100° for shoulder flexion and/or abduction on the first day postoperatively were evaluated. Sixty-six women were allocated to group exercises and 65 underwent the exercises followed by MT. Shoulder ROM was measured by goniometry, and function was evaluated by the Modified-University of California at Los Angeles Shoulder Rating Scale–the UCLA Scale, in the 1st, 6th, 12th, and 18th month after surgery. The chi-square test was used for the relationship between clinical characteristics and oncological treatment between groups, and ANOVA for repeat measures was used. No difference in recovery of shoulder ROM as well as UL function was observed between groups. Improvement in ROM was gradual from the 1st to the 18th month, and the function achieving a good classification at 18th month. MT associated with exercises did not enhance the results obtained with exercises alone for shoulder ROM and ipsilateral UL function.

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

1 month of guided exercise with home exercise instruction is sufficient to create lasting improvement in ROM and shoulder function 18 months following axillary lymph node dissection.

Key Finding #2

Manual therapy with exercise or exercise alone creates the same change in shoulder ROM and function over the 18 months following axillary lymph node dissection.

Please provide your summary of the paper

Patients with less than 100* of shoulder flexion or abduction immediately following axillary lymph node dissection as part of breast cancer treatment were split into 2 treatment groups, one with manual therapy as part of treatment and one without. Members of both groups preformed exercises starting post-op day 1, and they continued in an outpatient group exercise program for 1 month which included 45 minute sessions 3 times a week. In addition to the group exercise, the manual therapy group received 2, 20 minute sessions of manual therapy each week that included glenohumeral and scapular mobilization, as well as massage. If after 1 month of treatment the patient still had ROM or functional limitations, they were referred to continue PT on their own and were removed from the study. Outcomes of ROM and function were assessed with goniometry and the Modified-UCLA Shoulder Rating Scale before surgery, post-op day 1, and post-op months 1, 6, 12, and 18. Over the course of the 18 months, each group showed improvement from post-surgery day 1 through 18 months in terms of ROM and function, however there was no significant difference in improvement between the exercise with manual therapy group and the exercise only group.

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

While there was no significant improvement in the manual therapy group versus the exercise only group, this does not necessarily mean that manual therapy is not effective for breast cancer patients following axillary lymph node dissection. Since both exercise only and manual therapy in conjunction with exercise resulted in the same ROM and functional gains, the use of manual therapy can be left up to clinician and patient preference. Some patients like there to be hands on work done during their physical therapy appointments. In cases like this, manual therapy could be a good treatment option. Additionally, this study specified the exact manual therapy techniques that needed to be implemented in each 20 minute manual session. It is possible that there could have been better outcomes in individual patients if the manual techniques were specific to each patient and modified based on patient response. One major limitation to this study was the high loss to follow up, since all patients who still had functional or ROM deficits after 1 month were referred out to other physical therapy and removed from the study. Therefore, these results only document the success of those patients who responded well in the first month post-op. Overall, while this study did not show manual in conjunction with exercise to be more effective for treating decreased shoulder ROM and function than exercise alone, manual therapy still appears affective as an adjunct to exercise.

Does Adding Mobilization to Stretching Improve Outcomes for People With Frozen Shoulder? A Randomized Controlled Clinical Trial

Author Names

Çelik, D., & Kaya Mutlu, E.

Reviewer Name

Morgan Baxter, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objective: To assess the effectiveness of joint mobilization combined with stretching exercises in patients with frozen shoulder. Design: A randomized controlled clinical pilot trial. Setting: Department of Orthopedics and Traumatology. Subjects: Thirty patients with frozen shoulder. Intervention: All participants were randomly assigned to one of two treatment groups: joint mobilization and stretching versus stretching exercises alone. Both groups performed a home exercise program and were treated for six weeks (18 sessions). Main measures: The primary outcome measures for functional assessment were the Disabilities of the Arm, Shoulder and Hand score and the Constant score. The secondary outcome measures were pain level, as evaluated with a visual analog scale, and range of motion, as measured using a conventional goniometer. Patients were assessed before treatment, at the end of the treatment, and after one year as follow-up. Results: Two-by-two repeated-measures ANOVA with Bonferroni corrections revealed significant increases in abduction (91.9° [CI: 86.1-96.7] to 172.8° [CI: 169.7-175.5]), external rotation (28.1° [CI: 22.2-34.2] to 77.7° [CI: 70.3-83.0]) and Constant score (39.1 [CI: 35.3-42.6] to 80.5 [75.3-86.6]) at the one-year follow-up in the joint mobilization combined with stretching exercise group, whereas the group performing stretching exercise alone did not show such changes. Conclusion: In the treatment of patients with frozen shoulder, joint mobilization combined with stretching exercises is better than stretching exercise alone in terms of external rotation, abduction range of motion and function score.

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

6 weeks of stretching alone is enough to create change in function, pain, and range of motion (flexion, abduction, ER/IR) in patients with frozen shoulder.

Key Finding #2

Including mobilization with stretching creates significantly greater improvements in function and range of motion (abduction and ER) than stretching alone in patients with frozen shoulder.

Please provide your summary of the paper

People who had at least 3 months of pain and range of motion (ROM) restricted to less than 50% of their uninvolved shoulder in flexion, abduction, and external rotation (ER) were split into a stretching group or a stretching and joint mobilization group. This study assessed the effect of stretching and mobilization versus stretching alone on shoulder function, pain, and range of motion at 6 weeks and 1 year following the start of the treatment in patients with frozen shoulder. Both groups received 3, 20 minute stretching sessions with a physical therapist each week for 6 weeks. These sessions used cyclic stretching with 20 seconds of stretching followed by 10 seconds of rest repeated 10x for flexion, abduction, ER, and internal rotation (IR). The mobilization group also received 3, 30 minute mobilization sessions each week for 6 weeks. These sessions included 1-2 minutes of glenohumeral distraction and anterior, posterior, and inferior glides repeated 3-4x. During the first 2 weeks of treatment grade I-II mobilizations were used in resting position, but in subsequent weeks grade III-IV mobilizations were used in positions of restriction. Both groups were also instructed to perform a home exercise program 2x a day for a year which included 10 reps of 9 shoulder exercises. The scores from the Disabilities of the Arm, Shoulder, and Hand and Constant outcome measures were used to measure shoulder function. Function, pain, and ROM (flexion, abduction, ER/IR) improved at 6 weeks and 1 year in both the mobilization and stretching group and the stretching only group. However, the mobilization group showed a significantly greater improvement in shoulder abduction, ER, and function score based on the Constant score compared to the stretching only group. All outcomes improved in both groups between the 6 week and 1 year mark.

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

This study showed that stretching alone can have positive impacts on ROM, function, and pain. However, including mobilization techniques created significantly greater improvements in shoulder flexion, abduction, and function based on the Constant score at 6 weeks and 1 year. This serves as good evidence for incorporating glenohumeral mobilizations during physical therapy sessions to create greater improvements. This study also shows the impact of a home exercise program, since both groups of patients improved in all areas between 6 weeks and 1 year. Because they were not receiving PT at this time, these changes could be attributed to the home exercise program. A major strength of this article was the in depth description of the mobilizations, stretching program, and home exercise program. This makes it so clinicians can easily repeat these techniques and interventions on future patients.

Soft Tissue Mobilization and Stretching for Shoulder in CrossFitters: A Randomized Pilot Study

Author Names

Jusdado-Garcia, M & Cuesta-Barriuso, R

Reviewer Name

Megan Benzie, SPT, B.S.

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

The shoulder in CrossFit should have a balance between mobility and stability. Glenohumeral internal rotation deficit and posterior shoulder stiffness are risk factors for overhead shoulder injury. Objective. To determine the effectiveness of instrument-assisted soft tissue mobilization and horizontal adduction stretch in CrossFit practitioners’ shoulders. Methods: Twenty-one regular CrossFitters were allocated to experimental (stretching with isometric contraction and instrument-assisted soft tissue mobilization) or control groups (instrument-assisted soft tissue mobilization). Each session lasted 5 min, 2 days a week, over a period of 4 weeks. Shoulder internal rotation and horizontal adduction (digital inclinometer), as well as posterior shoulder stretch perception (Park scale), were evaluated. Shapiro–Wilk test was used to analyze the distribution of the sample. Parametric Student’s t-test was used to obtain the intragroup differences. The inter- and intra-rater differences were calculated using a repeated measures analysis of variance (ANOVA). Results. Average age was 30.81 years (SD: 5.35), with an average height of 178 (SD: 7.93) cm and average weight of 82.69 (SD: 10.82) kg. Changes were found in the experimental group following intervention (p < 0.05), and when comparing baseline and follow-up assessments (p < 0.05) in all variables. Significant differences were found in the control group following intervention (p < 0.05), in right horizontal adduction and left internal rotation. When comparing the perception of internal rotation and horizontal adduction in both groups, significant differences were found. Conclusions. Instrument-assisted soft tissue mobilization can improve shoulder horizontal adduction and internal rotation. An instrument-assisted soft tissue mobilization technique yields the same results alone as those achieved in combination with post-isometric stretch with shoulder adduction.

NIH Risk of Bias Tool

Quality Assessment of Case-Control Studies

Was the research question or objective in this paper clearly stated and appropriate?

Was the study population clearly specified and defined?

Did the authors include a sample size justification?

Were controls selected or recruited from the same or similar population that gave rise to the cases (including the same timeframe)?

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?

Were the cases clearly defined and differentiated from controls?

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?

Was there use of concurrent controls?

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?

Were the measures of exposure/risk clearly defined, valid, reliable, and implemented consistently (including the same time period) across all study participants?

Were the assessors of exposure/risk blinded to the case or control status of participants?

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?

Key Finding #1

Athletes training CrossFit more than four days a week without regular “physiotherapeutic care” were associated with higher musculoskeletal injury rates, with a high incidence in shoulder injuries specifically.

Key Finding #2

Glenohumeral joint stability depends, in large part, on active stability. The muscle fatigue that is caused by typical CrossFit workouts can have a detrimental effect on the amount of stability the joint can provide. This fatigue increases the likelihood of injury.

Key Finding #3

This study is limited in that the control group received soft tissue mobilizations, which the experimental group received instrument assisted soft tissue techniques and post isometric holds. With two variables being changed, it is impossible to determine if it was the instrument assisted device or the isometric holds that made the impact on the range of motion.

Key Finding #4

This study had significantly more males than females (19:2), which may indicate that the results are not transferable to all patients.

Please provide your summary of the paper

This randomized, single blind pilot study looked at the effect of either soft tissue mobilizations alone or instrument-assisted soft tissue techniques in addition to post-isometric horizontal adduction stretches on CrossFit athlete’s shoulder internal rotation, horizontal adduction, and the perception of the stretching of the back of the shoulder with each. The study excluded participants who had a shoulder injury in the past three months or had a shoulder surgery in the last six months. Due to this, these results are not as applicable to the injured population. The interventions were provided twice a week for four weeks. The soft tissue mobilizations were applied for 20 seconds in the parallel direction and 20 seconds in the perpendicular direction on the posterior shoulder. Most studies agree that three sets of 30 seconds are most beneficial for manual therapy techniques, so this may have impacted their results. However, this study did note that for instrument assisted techniques, they were able to use less time, 40 seconds compared to the typical 90 seconds, per stretch and yield the same result. The instrument assisted group achieved significant (p < 0.05) improvements in all variables measured and continued at the four week follow up mark. The control group also showed improvements (p < 0.05) in right horizontal adduction and left internal rotation. This study was limited in that there was a small sample size and participants were excluded if they experienced current or recent shoulder pain, which limits its ability to be applied to the clinical population. Additionally, this study did not look at if these positive effects last longer than four weeks after the final intervention session.

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 does suggest that manual therapy, specifically instrument assisted soft tissue work, may benefit CrossFit athletes in shoulder range of motion. This may help clinicians in decision making for a plan of care. However, this study was limited by protocol itself being not specific, short treatment times, and small subject groups. More research needs to be done on the injured shoulder for CrossFitters, in addition to the long term affects and maintenance of shoulder range of motion with treatments.

Acute Effects of Muscle Energy Technique and Joint Mobilization on Shoulder Tightness in Youth Throwing Athletes: A Randomized Controlled Trial

Author Names: Reed M., Begalle R., Laudner K.

Reviewer Name: Kendall Bietsch, SPT

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

Paper Abstract: Background: Posterior shoulder tightness (PST), defined as limited glenohumeral (GH) horizontal adduction and internal rotation motion, is a common occurrence in overhead athletes, particularly baseball and softball players, as a result of the extreme forces on the GH joint and the high number of throwing repetitions. Despite clinical evidence suggesting the use of joint mobilizations and muscle energy techniques (MET) for treating PST, there currently are no data examining the overall effectiveness of joint mobilizations and MET to determine optimal treatment for posterior shoulder tightness. Purpose: To compare the acute effectiveness of MET and joint mobilizations for reducing posterior shoulder tightness, as measured by passive GH horizontal adduction and internal rotation ROM, among high school baseball and softball players. Study Design: Randomized controlled study. Methods: Forty-two asymptomatic high school baseball and softball players were randomly assigned to one of three groups (14 MET, 14 joint mobilization, 14 control). Glenohumeral passive adduction and internal rotation ROM were measured in all participants in a pre-test post-test fashion. Between testing, the joint mobilization group received one application of GH posterior joint mobilizations. The MET group received one cycle of MET applied to the GH horizontal abductors. The control group received no intervention. Posttests measures were completed immediately following intervention or a similar amount of time resting for the control group and then again 15 minutes later. Results: One-way analyses of covariance showed that the MET group had significantly more horizontal adduction ROM post-treatment compared to the control group (p = 0.04). No significant differences existed between groups in horizontal adduction (p > 0.16) or internal rotation (p>.28) or at the 15-minute posttests (p > 0.70). Conclusion: The results of this study indicate the application of MET to the horizontal abductors provides acute improvements to GH horizontal adduction ROM in high school baseball and softball players, while joint mobilizations provide no improvements. Level of Evidence: 1

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)?: No

Were study participants and providers blinded to treatment group assignment?: No

Were the people assessing the outcomes blinded to the participants’ group assignments?: No

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)?: Cannot Determine, Not Reported, or Not Applicable

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?: No

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: In asymptomatic high school baseball and softball players, a single application of muscle energy techniques (MET) on the shoulder horizontal abductors produced significant increases in horizontal adduction ROM.

Key Finding #2: The effects of the MET treatment were acute/transient, with the improvements in glenohumeral ROM and posterior shoulder tightness (PST) lasting fewer than 15 minutes. However, this study suggests that athletes may see more prolonged results when performing MET immediately prior to participating in sport activity.

Key Finding #3: Utilizing MET on the horizontal abductors may assist in treating adolescent baseball and softball players with PST due to muscular limitations (versus capsular limitations).

Reviewer Paper Summary: This randomized controlled trial compared the effectiveness between joint mobilizations versus muscle energy techniques (MET) for treating posterior shoulder tightness (PST) in youth baseball and softball players. Effectiveness was measured by analyzing the degree of change between pretest and post-test passive glenohumeral (GH) adduction and internal rotation across 3 groups: the joint mobilization, MET, and control groups. The intervention in the joint mobilization group (n=14) consisted of fifteen, one-second, grade III posterior glenohumeral mobilizations with a one-second rest period between oscillations (total treatment time: 30 seconds). The MET group’s intervention (n=14) involved four application cycles of the following: a three-second passive stretch of the shoulder horizontal abductors followed by a 5-second period of active horizontal abduction into manual resistance at 25% of their maximal capacity. The control group (n=14) remained in a supine position for 60 seconds between the pretest and post-test ROM measurements. Compared to the control group, the single application of MET on the shoulder horizontal abductors produced significant, transient increases in horizontal adduction ROM in asymptomatic high school baseball and softball players. There were no significant differences between joint mobilizations and MET, or joint mobilizations and the control group. The authors therefore suggest that MET may be beneficial in assisting the prevention and treatment of shoulder injuries associated with PST. Future research is recommended to study how to achieve longer-lasting results of MET.

Reviewer Clinical Interpretation of this paper: This study shows that utilizing MET significantly improves shoulder horizontal adduction ROM compared to joint mobilizations in youth baseball and softball athletes with PST. However, the paper states that these changes are transient and do not last longer than 15 minutes. Considering the acuity of these changes, it may be helpful to couple shoulder horizontal abduction MET with immediate therapeutic exercise in a PT treatment session for a patient with PST. Following MET immediately with therapeutic PT exercises may allow the athlete to work more optimally in the newly acquired shoulder ranges of motion, and therefore improve PST outcomes. Implementing a combined approach of MET + therapeutic exercise to prevent or treat PST may lead to more effective PST treatment outcomes, compared to using exercise alone, MET alone, or using joint mobilization. This may be useful for clinicians to consider when creating a plan of care for youth baseball and softball players with posterior shoulder tightness.

Efficacy of Standardized Manual Therapy and Home Exercise Programme for Chronic Rotator Cuff Disease: Randomised Placebo-Controlled Trial

Author Names

Bennell, K., Wee, E., Coburn, S., Green, S., Harris, A., Staples, M., Forbes, A., Buchbinder, R.

Reviewer Name

Ericka Boeger, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objective: To investigate the efficacy of a programme of manual therapy and exercise treatment compared with placebo treatment delivered by physiotherapists for people with chronic rotator cuff disease.

Design: Randomised, participant and single assessor blinded, placebo-controlled trial.

Setting: Metropolitan region of Melbourne, Victoria, Australia.

Participants: 120 participants with chronic (>3 months) rotator cuff disease recruited through medical practitioners and from the community.

Interventions: The active treatment comprised a manual therapy and home exercise programme; the placebo treatment comprised inactive ultrasound therapy and application of an inert gel. Participants in both groups received 10 sessions of individual standardised treatment over 10 weeks. For the following 12 weeks, the active group continued the home exercise programme and the placebo group received no treatment.

Main outcome measures: The primary outcomes were pain and function measured by the shoulder pain and disability index, average pain on movement measured on an 11 point numerical rating scale, and participants’ perceived global rating of overall change.

Results: 112 (93%) participants completed the 22 week trial. At 11 weeks no difference was found between groups for change in shoulder pain and disability index (3.6, 95% confidence interval -2.1 to 9.4) or change in pain (0.7, -0.1 to 1.5); both groups showed significant improvements. More participants in the active group reported a successful outcome (defined as “much better”), although the difference was not statistically significant: 42% (24/57) of active participants and 30% (18/61) of placebo participants (relative risk 1.43, 0.87 to 2.34). The active group showed a significantly greater improvement in shoulder pain and disability index than did the placebo group at 22 weeks (between group difference 7.1, 0.3 to 13.9), although no significant difference existed between groups for change in pain (0.9, -0.03 to 1.7) or for the percentage of participants reporting a successful treatment outcome (relative risk 1.39, 0.94 to 2.03). Several secondary outcomes favoured the active group, including shoulder pain and disability index function score, muscle strength, interference with activity, and quality of life.

Conclusion: A standardised programme of manual therapy and home exercise did not confer additional immediate benefits for pain and function compared with a realistic placebo treatment that controlled for therapists’ contact in middle aged to older adults with chronic rotator cuff disease. However, greater improvements were apparent at follow-up, particularly in shoulder function and strength, suggesting that benefits with active treatment take longer to manifest.

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 treatment and placebo group demonstrated significant improvements at 11 weeks. There was no significant between group differences for shoulder pain, disability index score, and pain on movement. However, the active group demonstrated improvements in strength for self-reported and objective measures at the 11-week follow-up.

Key Finding #2

At the 22-week follow-up, the treatment group demonstrated significantly greater improvement in shoulder pain and disability index than the placebo group. They also had greater improvements in muscle strength, interference with ADLs, and health related quality of life.

Key Finding #3

The benefits of exercise and manual therapy for chronic rotator cuff disease are not immediate and become apparent over time.

Please provide your summary of the paper

This purpose of this paper was to determine whether a 10-week home exercise program and manual therapy from a physical therapist improved shoulder pain and function more than placebo treatment for patients with chronic (>3 months) rotator cuff disease.

There were 112 participants diagnosed with chronic rotator cuff disease who attended 10 physical therapy sessions over 10 weeks and the follow-up appointments at week 11 and 22. Participants were assigned to a home exercise program and manual therapy group or a placebo group who received a sham ultrasound therapy and non-therapeutic gel to the shoulder region for 10 minutes, with no exercises or manual therapy. The treatment group received interventions aimed at improving dynamic scapular control, strengthening scapular stabilizer and rotator cuff muscles, improving shoulder and thoracic posture, and increasing range of motion for thoracic extension. Soft tissue massage, passive mobilization of glenohumeral joint, scapular retraining and postural taping, spinal mobilization, and home exercises were provided to the treatment group. Both groups completed the 10 week session, then were instructed to continue their daily routine for an additional 12 weeks (HEP for treatment group, nothing for placebo group). Adherence to HEP in the treat group was tacked using a book log.

The primary outcomes were shoulder pain (NPRS) and disability index (SPADI). They also measured average pain with movement, interference with ADLs, patient perceived amount of weakness and stiffness, and health related quality of life. Isometric shoulder strength (abduction, IR, ER) was also assessed.

The results demonstrated that at the 11-week follow-up (immediately after intervention), both groups had similar results for pain and function. However, at the 22-week follow-up, the treatment group had greater improvements in pain, function, strength, interference with activities, and quality of life. These results signify that exercise and manual therapy benefits may take several weeks before patients feel the effects.

The authors discussed how these results may be due to the fact that symptoms of chronic rotator cuff disease change over time and patients often seek care when symptoms are the worst. The placebo effect was also discussed and how 90% of participants expected a moderate to large benefit from active treatment (positive expectation is associated with improved outcomes). They mentioned the need for further research on individualized chronic rotator cuff protocols and on benefits of different physical therapy routines combined with drug treatments.

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 impacts clinical practice because it indicates that exercise and manual therapy take time for the benefits to accumulate. It is important to educate patients with chronic rotator cuff disease on this because it is vital to stay consistent with PT exercise protocol. When in consistent pain (mild or moderate), it can be easy to feel disappointed and quit when something isn’t working. However, this study demonstrates the importance of continuing exercise and manual therapy for long term reductions in pain and improvements in function and strength. It is important to note that the treatment group received a standardized program, which may not have been specific to the patient’s presentation, dysfunction, and pain. In practice, it is important to create an intervention plan that is specific to that patient and their impairments. The authors mention that physical therapy interventions may be best at improving function, and not necessarily pain. If pain is the primary impairment, treatments that reduce pain (i.e. cortisone injections) should be used. If pain and loss of function are the impairments, then pain-relieving drugs and manual therapy / exercise should be utilized.

Effects of Two Different Mobilization Techniques on Pain, Range of Motion, and Functional Disability in Patients With Adhesive Capsulitis: A Comparative Study

Author Names

Agarwal, S., Raza, S., Moiz, J. A., Anwer, S., & Alghadir, A. H.

Reviewer Name

Meera V. Bucklin, SPT

Reviewer Affiliation(s)

Duke University student of Physical Therapy

Paper Abstract

This study aimed to compare the effects of two different mobilization techniques in the management of patients with adhesive capsulitis. Thirty non-diabetic men and women with adhesive capsulitis were randomly allocated to the reverse distraction group (n=15) or Kaltenborn group (n=15). The reverse distraction technique and Kaltenborn’s caudal and posterior glides (grades III and IV) were applied 10–15 times along with conventional physical therapy for 18 treatment sessions in 6 weeks. The pain was measured with a visual analog scale, abduction, and external rotation range of motion with goniometry, hand behind back reach with inch tape, and functional disability with the Flexilevel scale of shoulder function before and after the treatment. Although all the variables improved significantly in both groups after 18 intervention sessions, reverse distraction was significantly better than Kaltenborn’s caudal and posterior glides in decreasing pain and improving abduction range of motion and functional scores. This study supports the clinical use of reverse distraction as an alternative to conventional mobilization techniques to decrease pain and improve range of motion and functional scores in patients with adhesive capsulitis.

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 reverse distraction technique has a greater decrease in pain compared to the Kaltenborn mobilization technique by a significant amount (p<0.001). Both groups had significant decreases in pain by the end of 18 treatment sessions over 6 weeks.

Key Finding #2

This is the first study of this kind that compare the two techniques in patients with adhesive capsulitis. Some studies have shown the effectiveness of a reverse distraction technique in conjunction with other mobilizations or the effectiveness of reverse distraction in increasing mobility or reducing pain

Key Finding #3

There are no studies to support and explain why the reverse distraction is a better mobilization technique than the Kaltenborn. Further research is needed to explain the findings of this study.

Key Finding #4

This study states that because of capsular restrictions pain association a glenohumeral joint mobilization that is applied before a scapular mobilization can cause further pain. The study notes the need for improvement in adjoining joint mobility before getting the best effects for GH mobilization.

Please provide your summary of the paper

This study found significantly better outcomes in patients with nondiabetic adhesive capsulitis with a reverse distraction technique compared to a Kaltenborn end range lateral and posterior glides with lateral distraction. This comparative study randomly assigned 15 patients fitting inclusion criteria to either group and had a dropout rate of 1 participant per assignment leaving 28 participants total in the study. Patients were treated with their respective intervention for 3 sessions a week for 6 weeks, with a total of 18 visits. Changes in pain, ROM, and functional ability were measured before and after each intervention. The study found that active and passive abduction increased significantly in both treatment groups and pain levels decreased in both treatment groups. The reverse distraction technique had a more significant decrease in pain than the Kaltenborn. Decreases in pain are attributed to several mechanisms such as stimulation of Golgi tendons and type II mechanoreceptors, inhibition of type IV nociceptors, and reflex inhibition. There are no other studies to explain why the reverse distraction technique is better than the Kaltenborn, and further research is needed to support this study’s findings.

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 offers good evidence to support the implementation of two different manual techniques but lacks a comparison to treatment without manual therapy. While both groups had good outcomes the standardized other treatments for adhesive capsulitis with PROM, AROM, and strengthening could contribute to the progression of the client through treatment and pain. The impact on my clinical practice this article made has been my appreciation of the variety of manual therapy techniques there are- I think I was unaware of all the different techniques available for mobilization and how nuanced each can be to the point of comparative studies and significant differences in pain outcomes. I believe this study can impact how I practice knowing the research behind each individual manual technique I can best discern what technique I can use to implement with different diagnoses. In my practice there are good changes I will see a patient with adhesive capsulitis who would benefit in pain and ROM outcomes with manual techniques and knowing which one has the best outcomes can help me discern what to choose as my treatment for the best outcomes for my patients.

The Efficacy of Manual Therapy for Rotator Cuff Tendinopathy: A Systematic Review and Meta-Analysis

Author Names

Desjardins-Charbonneau, A., Roy, J S., Dionne, C., Frémont, P., Macdermid, J., Desmeules, F.

Reviewer Name

Alyssa Bush, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

The objective of this study was to evaluate the efficacy of manual therapy (MT) for patients with rotator cuff (RC) tendinopathy. Rotator cuff tendinopathy is a highly prevalent musculoskeletal disorder, for which MT is a common intervention used by physical therapists. However, evidence regarding the efficacy of MT is inconclusive. A literature search using terms related to shoulder, RC tendinopathy, and MT was conducted in 4 databases to identify randomized controlled trials that compared MT to any other type of intervention to treat RC tendinopathy. Randomized controlled trials were assessed with the Cochrane risk-of-bias tool. Meta-analyses or qualitative syntheses of evidence were performed. Twenty-one studies were included. The majority had a high risk of bias. Only 5 studies had a score of 69% or greater, indicating a moderate to low risk of bias. A small but statistically significant overall effect for pain reduction of MT compared with a placebo or in addition to another intervention was observed (n=406), which may or may not be clinically important, given a mean difference of 1.1 (95% confidence interval: 0.6, 1.6) on a 10-cm visual analog scale. Adding MT to an exercise program (n=226) significantly decreased pain (mean difference, 1.0; 95% confidence interval: 0.7, 1.4), as reported on a 10-cm visual analog scale, which may or may not be clinically important. Based on qualitative analyses, it is unclear whether MT used along or added to an exercise program improves function. For patients with RC tendinopathy, based on low- to moderate-quality evidence, MT may decrease pain; however, it is unclear whether it can improve function. More methodologically sound studies are needed to make definitive conclusions.

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

Out of eleven RCTs that assessed treatment effect using pain as an outcome measure, ten provided results and pooled analysis revealed a significant effect in favor of the MT intervention when used alone or in combination with another intervention (10-cm VAS mean difference, 1.2; 95% CI: 0.8, 1.6).

Key Finding #2

Results of 4 RCTs that assessed efficacy of MT (shoulder girdle and cervical spine mobilization and manipulations) compared with a placebo to address pain demonstrated a significant effect in favor of MT (10-cm VAS mean difference, 1.0; 95% CI: 0.6, 1.4).

Key Finding #3

In pooled analysis of 5 RCTs that observed the effects on pain of MT and exercises compared to exercises alone, a significant difference was observed for the addition of MT to exercises for overall pain reduction at 4 weeks (10-cm VAS mean difference, 1.0; 95% CI: 0.7, 1.4).

Please provide your summary of the paper

Based on the primary meta-analysis of 10 RCTs, the study found low- to moderate-evidence that, overall, MT either alone or in combination with other modalities may be effective in reducing pain. Analysis of RCTs that compared shoulder girdle and cervical spine mobilization and manipulation to address pain compared with placebo also favored MT. Additionally, analysis of RCTs that addressed the effect of adding MT to an exercise program to reduce pain in patients with RC tendinopathy found a significant difference in pain levels at 4 weeks. Although pooled analyses revealed significant differences, MT interventions were varied, therefore the effects could differ based on technique. The authors also noted that MT may need to be based on individual patients’ impairments for optimal efficacy, which was not accounted for in the included studies of the systematic review. Previous research had stated inconclusive or conflicting results for the efficacy of MT used alone, but this study concluded that MT used alone or in combination with other modalities significantly decreases pain. However, it was unclear in this study whether the pain reduction was clinically important or if MT alone can improve function. This study was limited by a small sample size and some RCTs having limited methodological 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 study provided new evidence to show that MT, when used alone or in combination with other interventions, may decrease pain for patients with RC tendinopathy. Clinicians may choose to implement MT as part of a plan of care with the goal of pain reduction in patients with RC tendinopathy based on this evidence. Additionally, clinicians may choose to integrate MT with other interventions as part of a comprehensive plan of care. The implementation of MT into a patient’s plan of care should account for individual impairments, as noted in this study. However, this study demonstrates that MT should not be relied on as the sole intervention to treat RC tendinopathy. Although a statistically significant difference in pain level was found, clinicians should use caution when interpreting the results of this study; it cannot be concluded that this difference is clinically significant since the point estimate for difference in VAS score was below the suggest minimal clinically important difference. This study demonstrates that the use of MT in treating RC tendinopathy may be a future area of research, as more RCTs that are methodologically sound are needed to draw further conclusions.

Effects of Stretching and Strengthening Exercises, With and Without Manual Therapy, on Scapular Kinematics, Function, and Pain in Individuals With Shoulder Impingement: A Randomized Controlled Trial

Author Names

Camargo, P. R.; Alburquerque-Sendín, F.; Avila, M. A.; Haik, M. N.; Vieira, A.; & Salvini, T. F.

Reviewer Name

Kyra Callens, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Study Design Randomized controlled trial. Objective To evaluate the effects of an exercise protocol, with and without manual therapy, on scapular kinematics, function, pain, and mechanical sensitivity in individuals with shoulder impingement syndrome. Background Stretching and strengthening exercises have been shown to effectively decrease pain and disability in individuals with shoulder impingement syndrome. There is still conflicting evidence regarding the efficacy of adding manual therapy to an exercise therapy regimen. Methods Forty-six patients were assigned to 1 of 2 groups, one of which received a 4-week intervention of stretching and strengthening exercises (exercise alone) and the other the same intervention, supplemented by manual therapy targeting the shoulder and cervical spine (exercise plus manual therapy). All outcomes were measured preintervention and postintervention at 4 weeks. Outcome measures were scapular kinematics in the scapular and sagittal planes during arm elevation, function as determined through the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, pain as assessed with a visual analog scale, and mechanical sensitivity as assessed with pressure pain threshold. Results Independent of the intervention group, small, clinically irrelevant changes in scapular kinematics were observed postintervention. A significant group-by-time interaction effect (P = .001) was found for scapular anterior tilt during elevation in the sagittal plane, with a 3.0° increase (95% confidence interval [CI]: −1.5°, 7.5°) relative to baseline in the exercise-plus–manual therapy group compared to a decrease of 0.3° (95% CI: −4.2°, 4.8°) in the exercise-alone group. Pain, mechanical sensitivity, and the DASH score improved similarly for both groups by the end of the intervention period. Conclusion Adding manual therapy to an exercise protocol did not enhance improvements in scapular kinematics, function, and pain in individuals with shoulder impingement syndrome. The noted improvements in pain and function are not likely explained by changes in scapular kinematics. The study is registered at www.clinicaltrials.gov (NCT02035618).

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?

Cannot Determine, Not Reported, or Not Applicable

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?

Cannot Determine, Not Reported, or Not Applicable

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

This study indicated that an exercise program with the addition of manual therapy did not show an increase in improvements in those with shoulder impingement syndrome.

Key Finding #2

The exercise-alone group demonstrated greater improvements as compared to the exercise-plus–manual therapy group.

Please provide your summary of the paper

This randomized controlled trial analyzed the effectiveness of exercise-alone versus exercise-plus–manual therapy protocol in patients with shoulder impingement syndrome. Outcome measures given pre- and post-interventions were used to assess the patient’s scapular kinematics, function, pain, and mechanical sensitivity. The results of this study showed that there was not an enhanced improvement with the addition of manual therapy. However, improvements were shown in regards to pain and function with both the exercise-alone and exercise-plus–manual therapy groups. An absence of change in scapular kinematic indicates that the improvement in pain and function are likely not a result of alterations in scapular motion. The results of this study should be interpreted with caution due to the wide confidence intervals in certain variables, indicating that individuals with shoulder impingement syndrome may or may not benefit from the addition of manual therapy.

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

The clinical interpretation of this study is that exercise alone is more effective in gaining improvements with individuals with shoulder impingement syndrome than exercise plus manual therapy. Therefore, an exercise protocol should be the first intervention when treating such patients. However, since this study showed wider confidence intervals, it cannot be determined that a patient with this condition may or may not show improvement with the addition of manual therapy. Manual therapy should be implemented into a patient’s treatment if they are not showing improvement with an exercise alone program.

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

Author Names

Ho, C; Sole, G; Munn, J

Reviewer Name

Andres Carro, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Abstract A systematic review of randomised 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/dysfunc- tion) 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-Movement 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?

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

Vermeulen et al. (2006) found that high grade joint mobilizations of the shoulder were more effective than low grade mobilizations when measuring active range of motion (AROM), passive range of motion (PROM), and long-term functional outcomes immediately after the treatment and 12 months after the intervention period for patients with adhesive capsulitis (AC).

Key Finding #2

Nicholson (1985) found that mobilizations with exercise had a greater effect on PROM than exercise alone for patients with AC.

Key Finding #3

For patients with shoulder impingement syndrome (SIS), Bang and Deyle (2000) found that “pragmatic manual therapy” was effective in the improvement of function when compared to exercise alone, and Citaker et al. (2005) found that joint mobilization had a greater effect on function than PNF.

Key Finding #4

Winters et al. found that manipulation was more effective for function than “traditional physiotherapy” for treating those with complaints originating from the shoulder girdle, yet in those with synovial shoulder complaints manipulation was no more effective than traditional physiotherapy.

Please provide your summary of the paper

This is a high quality systematic review of the literature on the use of manual therapy (MT) for the treatment of musculoskeletal (MSK) disorders of the shoulder. This systematic review shows that manual therapy can be a useful as a solo and/or an adjunct therapy for certain MSK shoulder disorders, but there are some instances where the evidence does not support the use of MT. For example, manipulation was shown to be ineffective in treating complaints of the shoulder that had a synovial structure origination when compared to traditional physiotherapy or corticosteroid injection. The review found that limited evidence for the use of MT in the management of those with shoulder impingement syndrome (SIS), yet still state that clinicians should consider the use of soft tissue and joint mobilization in addition to exercise for patients with SIS. The review also found that while MT may not be more effective than other interventions for improving pain and ROM for patients with adhesive capsulitis (AC), high-grade mobilizations may be more effective in improving ROM and function in the long term than low-grade mobilizations. Finally, this review found conflicting evidence for the use of MT in the management of unspecified shoulder pain and improving function in the short term and moderate evidence that MT was not more effective in these same measures of patient outcome in the long term, yet massage and MWM techniques demonstrated utility for short-term outcomes when compared to no treatment. The authors conclude that further high quality RCTs need to be conducted and reviewed that have clear shoulder diagnosis definitions, clear treatment descriptions, and adequate follow-up periods and sample sizes.

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

There are multiple outcomes for patients with different shoulder pathologies that manual therapy (MT) can be beneficial for such as active and passive ROM, long term function, and pain. Yet in some instances there is conflicting evidence in the efficacy of MT when compared to other modalities and forms of treatment. This indicates the need for additional high quality RCTs in the hopes that a trend of evidence will be seen pertaining to the true effect of manual therapy on different shoulder pathologies. In the meantime, this systematic review can be utilized by the clinician as a guide to their clinical reasoning as to why they may want to use manual therapy as a treatment for adhesive capsulitis, shoulder impingement syndrome, and non-specific shoulder pain.

The Effect of Mulligan Mobilization on Pain and Life Quality of Patients With Rotator Cuff Syndrome: A Randomized Controlled Trial

Author Names

Menek, B., Tarakci, D., Algun, Z. C.

Reviewer Name

Casie Coffman SPT, NBC-HWC

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

BACKGROUND: Mulligan mobilization techniques cause pain and affect the function in patients with Rotator cuff syndrome. OBJECTIVE: The aim of the study was to investigate the effect of Mulligan mobilization on pain and quality of life in individuals with Rotator cuff syndrome. METHODS: This study was conducted on 30 patients with Rotator cuff syndrome. The patients were randomized into Mulligan and control group. All the patients participating in this study were treated with conventional physiotherapy. Additionally, the Mobilization with movement (MWM) technique was used in the Mulligan group. Visual Analog Scale (VAS), Disabilities of the Arm, Shoulder, and Hand (DASH), goniometer for the normal range of motion (ROM) and Short Form-36 (SF-36) questionnaires were used for assessment. RESULTS: Statistically significant improvement was found in the post-treatment VAS, DASH, SF-36, and ROM values significantly improved in both groups (p < 0.05). However, the Mulligan group showed much better results when compared to the control group in ROM, VAS, DASH (p < 0.05). In the SF-36 questionnaire, significant results were obtained for both groups, except the social function parameter. For the SF-36 parameters, both groups performed equally. CONCLUSIONS: Mulligan mobilization was more effective than general treatment methods for pain as well as normal joint motion, DASH scoring and some parameters of SF-36 compared with general treatment methods.

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

The mulligan and control groups both demonstrated statistically significant improvement post-intervention measured by pain severity (VAS), shoulder ROM, the DASH, and SF-36.

Key Finding #2

Statistically significant between-group differences favored the mulligan group for VAS, shoulder ROM, and DASH scores post-intervention.

Key Finding #3

Within the SF-36, a statistically significant between-group difference was demonstrated in the social function domain post-intervention. All other components of the SF-36 changed similarly when comparing the mulligan and control groups.

Please provide your summary of the paper

This single-blind RCT compared the effects of mulligan mobilization plus conventional physiotherapy versus conventional therapy alone on pain and quality of life in individuals with rotator cuff syndrome. 30 participants aged 30-70 years had rotator cuff tendinitis, tendinosis, or a partial tear. They did not have a history of shoulder surgery. Conventional physiotherapy incorporated stretching, strengthening, and the use of cold packs, ultrasound, and TENS 5 days per week for 6 weeks. The additional technique used in the mulligan group involved ~20 minutes of mobilization to the humeral head while participants actively flexed, abducted, externally rotated, and internally rotated their arm within pain-free ranges. The direction of force was applied perpendicularly to the osteokinematic motion. While both groups displayed statistically significant improvements in pain severity (VAS), shoulder ROM, and DASH scores, between-group differences favored the mulligan group for each of these measures. Both groups demonstrated statistically significant differences in SF-36 scores post-intervention as well. Social function was the only category of the SF-36 that revealed significant between-group difference, which favored the mulligan group.

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 from this study suggests that mulligan mobilization may heighten the benefits of conventional physiotherapy in individuals with rotator cuff syndrome. More specifically, individuals may see better improvements in pain severity, motion, and function. Given these findings, mulligan mobilization and conventional physiotherapy are valuable conservative treatments for this population.

Short-Term Effects of High-Intensity Laser Therapy, Manual Therapy, and Kinesio Taping in Patients With Subacromial Impingement Syndrome

Author Names

Pekyavas, N. O., Baltaci, G

Reviewer Name

Erin Dennis, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Subacromial impingement syndrome (SAIS) is a major contributing factor of shoulder pain; and treatment approaches (Kinesio® taping [KT], Exercise [EX], manual therapy [MT], and high-intensity laser therapy [HILT]) have been developed to treat the pain. The key objective of this study was to compare the effects of KT, MT, and HILT on the pain, the range of motion (ROM), and the functioning in patients with SAIS. Seventy patients with SAIS were randomly divided into four groups based on the treatment(s) each group received [EX (n = 15), KT + EX (n = 20), MT + KT + EX (n = 16), and MT + KT + HILT + EX (n = 19)]. All the patients were assessed before and at the end of the treatment (15th day). The main outcome assessments included the evaluation of severity of pain by visual analogue scale (VAS) and shoulder flexion, abduction, and external rotation ROM measurements by a universal goniometry. Shoulder pain and disability index (SPADI) was used to measure pain and disability associated with shoulder pathology. Statistically significant differences were found in the treatment results of all parameters in MT + KT + EX and HILT + MT + KT + EX groups (p < 0.05). When the means of ROM and SPADI results of three groups were compared, statistically significant differences were found between all the groups (p < 0.05). These differences were significant especially between the groups MT + KT + EX and KT + EX (p < 0.05) and HILT + MT + KT + EX and KT + EX (p < 0.05). HILT and MT were found to be more effective in minimizing pain and disability and increasing ROM in patients with SAIS. Further studies with follow-up periods are required to determine the advantages of these treatments conclusively.

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

HILT and MT were found to be more effective in minimizing pain and disability and increasing ROM in patients with SAIS.

Key Finding #2

Statistically significant differences were found pre- and post-treatment in all parameters in both the MT + KT + EX and HILT + MT + EX groups.

Key Finding #3

The only significant difference found between the MT + KT + EX and HILT + MT + KT + EX groups was a change in shoulder abduction ROM following treatment in which greater increases in ROM were found in the HILT + MT + KT + EX group.

Please provide your summary of the paper

This article studied the effect of various interventions on 70 patients diagnosed with SAIS who had been admitted to the hospital with complaints of shoulder pain. The authors found that HILT and MT were the most effective interventions in minimizing pain and disability, as well as increasing shoulder ROM over 15 treatment sessions. When comparing the HILT + MT + KT + EX and MT + KT + EX groups, the only significant difference was change in shoulder abduction ROM post-intervention in which HILT was found to be more effective. The EX and KT + EX groups did not have statistically significant changes following treatment. Limitations of this study include the lack of a follow-up period to track long-term effects of these interventions which would provide useful clinical application for rehabilitation programs concerning SAIS.

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 tracked pain severity scores, ROM, and shoulder function/disability across 15 treatment sessions in patients with SAIS. The results indicate that HILT and MT are more effective in minimizing pain and disability and increasing ROM after 15 sessions, encouraging their use in clinical practice in addition to traditional exercises. However, as there was no follow-up period in this study, the long-term effects of HILT and MT are unclear and further research is needed to elucidate the longevity of these rehabilitative programs. Lastly, the authors revealed the use of KT did not have any effect on shoulder ROM or shoulder function measures and therefore may not need effective in the plan of care for individuals with SAIS when manual therapy and HILT are utilized in the clinic.

Thoracic Manual Therapy in the Management of Non-Specific Shoulder Pain: A Systematic Review

Author Names

Peek, A, Miller. C, Heneghan. N

Reviewer Name

Jaydee Dillon, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objectives: Non-specific shoulder pain (NSSP) is often persistent and disabling leading to high socioeconomic costs. Cervical manipulation has demonstrated improvements in patients with NSSP, although risks associated with thrust techniques are documented. Thoracic manual therapy (TMT) may utilize similar neurophysiological effects with less risk. The current evidence for TMT in treating NSSP is limited to systematic reviews of manual therapy (MT) applied to the upper quadrant. These reviews included trials that used shoulder girdle manual therapy (SG-MT) in the TMT group. This limits the scope of their conclusions with regard to the exclusive effectiveness of TMT for NSSP. Methods: This review used a steering group for subject and methodological expertise and was reported in line with Preferred Reporting items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Key databases were searched (1990–2014) using relevant search terms and medical subject headings (MeSH); eligibility was evaluated independently by two reviewers based on pre-defined criteria. Study participants had NSSP including impingement syndrome and excluding cervical pain. Interventions included cervicothoracic junction and TMT with or without supplementary exercises. Studies that included MT applied to the shoulder girdle including the glenohumeral joint, acromioclavicular joint or sternoclavicular joint in the TMT group, without a control, were excluded. Included studies utilized outcome measures that monitored pain and disability scores. Randomized controlled trials (RCTs) and clinical studies were eligible. Using a standardized form, each reviewer independently extracted data. Risk of bias was assessed using GRADE and PEDro scale. Results were tabulated for semi-quantitative comparison. Results: Over 912 articles were retrieved: three RCTs, one single-arm trial and three pre–posttest studies were eligible. Studies varied from poor to high quality. Three RCTs demonstrated that TMT reduced pain and disability at 6, 26 and 52 weeks compared with usual care. Two pre–posttest studies found between 76% and 100% of patients experienced significant pain reduction immediately post-TMT. An additional pre–posttest study and a single-arm trial showed reductions in pain and disability scores 48 hours post-TMT. Discussion: Thoracic manual therapy accelerated recovery and reduced pain and disability immediately and for up to 52 weeks compared with usual care for NSSP. Further, high-quality RCTs investigating the effect of TMT in isolation for the treatment of patients with NSSP are now required.

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?

Cannot Determine, Not Reported, Not Applicable

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?

Cannot Determine, Not Reported, Not Applicable

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

Cannot Determine, Not Reported, Not Applicable

Key Finding #1

Thoracic manual therapy achieves similar neurophysiological effects as cervical manipulations, while avoiding risks associated with cervical manipulations.

Key Finding #2

Treatment to the thoracic spine may biomechanically restore the 15 degrees of thoracic extension required to achieve full shoulder elevation, improve the recruitment of muscles in the shoulder girdle, or have a neurophysiological effect on pain and dysfunction.

Key Finding #3

All three randomized control trials investigated in this systematic review demonstrated statistically significant acceleration of recovery and reduction of pain and disability in the group receiving thoracic manual therapy.

Key Finding #4

The use of cervical manipulation has demonstrated a positive influence on pain and disability scores in patients with NSSP, although risks associated with thrust techniques are a concern.

Please provide your summary of the paper

The purpose of this study was to investigate the effect of thoracic manual therapy in the treatment of nonspecific shoulder pain (NSSP). NSSP has been defined as a plethora of shoulder condition including, but not limited to bursal irritation, tendinopathies, and acromial variances. Thoracic manual techniques used included manipulations or mobilizations applied to the thoracic spine or cervicothoracic junction. The study consisted of reviewing non-randomized and randomized control trials (RCT), in addition to pre-posttest studies. Results of the RCTs concluded that thoracic manual therapy could accelerate recovery in patients with NSSP, in terms of both pain and disability. The changes were not statistically significant at 6 weeks, however, were statistically significant from 12-52 weeks. The non-randomized control trials found immediate improvement in the visual analog scale and numerical pain rating scale exceeding the MCID in 76% and 100% of 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 study provides evidence that thoracic manual therapy can have a positive impact on pain and disability of patients with non-specific shoulder pain. At least in an orthopedic clinic, this is a common diagnosis for patients seeking treatment, therefore it is important to have different interventions to utilize. Although, we have learned that there is a very low risk of injury with cervical manipulations, this is something that can be intimidating for patients to receive. This article outlines that thoracic manual therapy can have the same neurophysiological effect while avoiding these risks or bias. Therefore, this research has demonstrated that clinicians can use thoracic manipulation to accelerate recovery, including pain reduction and reduced disability in patients with NSSP.

The Management of Shoulder Impingement and Related Disorders: A Systematic Review on Diagnostic Accuracy of Physical Tests and Manual Therapy Efficacy

Author Names

Innocenti, T., Ristori, D., Miele, S., & Testa, M.

Reviewer Name

Shelby Dobratz, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Diagnostic accuracy of physical tests and effectiveness of musculoskeletal rehabilitation of shoulder disorders are still debated. Objectives: To investigate diagnostic accuracy of physical tests, efficacy of physiotherapy and coherence between target of assessment and intervention for shoulder impingement and related disorders like bursitis, rotator cuff and long head biceps tendinopathy and labral lesions. Methods: A systematic search of four databases was conducted, including RCTs and cross-sectional studies. Cochrane Risk of Bias and QUADAS-2 were adopted for critical appraisal and a narrative synthesis was undertaken. Results: 6 RCTs and 2 cross-sectional studies were appraised. Studies presented low to moderate risk of bias. There is a lack of evidence to support the mechanical construct guiding the choice of physical tests for diagnosis of impingement. Manual techniques appear to yield better results than placebo and ultrasounds, but not better than exercise therapy alone. Discrepancy between the goal of assessment strategies and the relative proposed treatments were present together with high heterogeneity in terms of selection of patients, type of endpoints and follow-ups. Conclusions: Musculoskeletal physiotherapy seems to be an effective treatment for patients with shoulder pain although it is still based on weak diagnostic clinical instruments. The adoption of more functional and prognostic assessment strategies is advisable to improve coherence between evaluation and treatment. Keywords: Diagnosis; Exercise; Musculoskeletal; Physical test; Rotator cuff; Shoulder.

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?

Cannot Determine, Not Reported, Not Applicable

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

Cannot Determine, Not Reported, Not Applicable

Key Finding #1

Despite weak diagnostic ability of clinical tests for patients with shoulder problems, musculoskeletal physiotherapy was effective.

Key Finding #2

Specific manual joint techniques decreased pain and increased mobility in this population compared to placebo.

Key Finding #3

Practicing physical therapists should be treating patients with shoulder impingement with a holistic care approach, over a disease-based approach.

Please provide your summary of the paper

This study examined the effectiveness of manual therapies in shoulder impingement and related disorders. Delgado-Gil et al. discovered significantly decreased pain and increased pain-free range of motion (ROM) when implementing mobilization with movement (MWM) compared to placebo (2015). However, an additional study comparing therapeutic exercise and therapeutic exercise plus manual therapy found no significant difference in scapular kinematics, functionality and pain compared to exercise alone (Camargo et al., 2015). It should be considered that disability/participation indexes were used in more than two of the studies reviewed, as well as varying choices of follow-up times. Overall, satisfactory effectiveness of musculoskeletal physiotherapy was concluded within this patient population.

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

Pain and functional disability are often not primarily related to structural factors in these patients with shoulder impingement and related disorders. To overcome these problems, clinicians should move from a disease-based approach to a more functional and prognostic approach. This way, many will adopt more functional diagnostic procedures and could implement more social and psychological features to gear interventions towards. In addition, manual therapies and mobilization techniques were shown to decrease pain and improve functional disability, but not greater than exercise alone, which can be carried through to the clinic.

Manipulative Therapy for Shoulder Pain and Disorders: Expansion of a Systematic Review

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?

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

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.

Cervicothoracic Manual Therapy Plus Exercise Therapy Versus Exercise Therapy Alone in the Management of Individuals With Shoulder Pain: A Multicenter Randomized Controlled Trial

Author Names

Mintken P E, McDevitt A W, Cleland J A, Boyles R E, Beardslee A R, Burns S A, Haberl M D, Hinrichs L A, Michener L A.

Reviewer Name

Razan Mazin Fayyad, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Cervicothoracic manual therapy has been shown to improve pain and disability in individuals with shoulder pain, but the incremental effects of manual therapy in addition to exercise therapy have not been investigated in a randomized controlled trial. Objective: To compare the effects of cervicothoracic manual therapy and exercise therapy to those of exercise therapy alone in individuals with shoulder pain. Methods: Individuals (n = 140) with shoulder pain were randomly assigned to receive 2 sessions of cervicothoracic range-of-motion exercises plus 6 sessions of exercise therapy, or 2 sessions of high-dose cervicothoracic manual therapy and range-of-motion exercises plus 6 sessions of exercise therapy (manual therapy plus exercise). Pain and disability were assessed at baseline, 1 week, 4 weeks, and 6 months. The primary aim (treatment group by time) was examined using linear mixed-model analyses and the repeated measure of time for the Shoulder Pain and Disability Index (SPADI), the numeric pain-rating scale, and the shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH). Patient-perceived success was assessed and analyzed using the global rating of change (GROC) and the Patient Acceptable Symptom State (PASS), using chi-square tests of independence. Results: There were no significant 2-way interactions of group by time or main effects by group for pain or disability. Both groups improved significantly on the SPADI, numeric pain-rating scale, and QuickDASH. Secondary outcomes of success on the GROC and PASS significantly favored the manual therapy-plus-exercise group at 4 weeks (P = .03 and P<.01, respectively) and on the GROC at 6 months (P = .04). Conclusion: Adding 2 sessions of high-dose cervicothoracic manual therapy to an exercise program did not improve pain or disability in patients with shoulder pain, but did improve patient-perceived success at 4 weeks and 6 months and acceptability of symptoms at 4 weeks. More research is needed on the use of cervicothoracic manual therapy for treating shoulder pain.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

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 addition of cervicothoracic manual therapy to an evidence-based exercise program did not improve pain or disability in individuals with shoulder pain over exercise alone.

Key Finding #2

Both study groups had clinically significant improvements in pain and disability, despite the chronic nature of the symptoms.

Key Finding #3

A greater percentage of the individuals in the manual therapy-plus-exercise group experienced a successful outcome or acceptability of symptoms.

Please provide your summary of the paper

Shoulder pain is experienced by many individuals throughout their lifetime. Exercise has been used in the treatment of shoulder disorders. Many studies have shown the importance of exercise in the improvement of pain and disability in individuals with shoulder pain. In addition, multimodal care, which includes manual therapy and exercise, has also been reported to improve outcomes in individuals with shoulder pain. Generally speaking, treatment of shoulder pain has been mostly directed toward the glenohumeral joint. However, this doesn’t take into account the adjacent structures such as the cervicothoracic spine and adjacent ribs. To date, no studies have compared the effectiveness of a comprehensive stretching and strengthening program combined with cervicothoracic manual therapy to that of exercise alone. Therefore, this study aimed to examine the effects of cervicothoracic manual therapy plus exercise versus exercise alone in individuals with shoulder pain. 140 individuals were randomized to 2 sessions of cervicothoracic range-of-motion exercises plus 6 sessions of exercise therapy, or 2 sessions of high-dose cervicothoracic manual therapy and range-of-motion exercises plus 6 sessions of exercise therapy. Pain and disability were assessed as primary outcomes and patient-perceived success was assessed as a secondary outcome. Results showed no significant difference between the two groups in terms of primary outcomes. Both groups showed significant improvements in pain and disability. In terms of secondary outcomes, a greater percentage of the individuals in the manual therapy-plus-exercise group experienced a successful outcome or acceptability of symptoms. Overall, the study does not support the addition of cervicothoracic manual therapy to an exercise program to decrease pain and disability in individuals with shoulder pain, however, manual therapy may lead to greater rates of patient-perceived success.

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

This study showed how the addition of high-dose cervicothoracic manual therapy and range-of-motion exercises to an exercise program does not have increased benefits over an exercise program alone. The paper goes on to discuss several limitations of the study, which include a higher-than-expected drop-out rate, the patient population in the study having chronic symptoms, an insufficient dosage and prescriptive manual therapy, and variation in the delivery of care by multiple therapists. With that, addressing these limitations and conducting more research on the use of cervicothoracic manual therapy for the treatment of shoulder pain is needed. Such studies would enhance our understanding and allow for the implementation of supported exercises in the clinic.

Effect of Fascial Manipulation on Glenohumeral Internal Rotation Deficit in Overhead Athletes: A Randomized Controlled Trial

Author Names

Mathew, N., Raja, P., Davis, F.

Reviewer Name

Jasmin Flores, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background. Glenohumeral Internal Rotation Deficit (GIRD) is common among over- head athletes and is considered as one of the risk factors for upper extremity injuries. GIRD is usually managed by stretching and soft tissue release of the posterior shoulder capsule. Fascial manipulation is a manual therapy technique used in the management of musculoskeletal disorders. This study compared the efficacy of fascial manipulation (FM) with posterior capsular ball release and stretching on GIRD. Purpose. The purpose of this study is to determine the effect of Fascial Manipulation (FM) on the Internal Rotation Range of Motion (IRROM) in athletes with GIRD. Since studies have shown a possible association between GIRD and shoulder injuries, improving the IRROM in athletes with GIRD may help in reducing the risk of shoulder injuries. Thus, FM may be used as an effective strategy in increasing IRROM in overhead athletes with GIRD, thus preventing upper extremity injuries. Study Design. Randomized controlled trial. Methods. Asymptomatic overhead athletes with GIRD more than 20° when compared with the non-dominant shoulder were randomly assigned to two groups. The experimental group has received three sessions of FM treatment in two weeks. FM applied to densified Centre of Coordination (CC) points located on the myofascial sequences for 5 to 8 minutes at each CC point. The control group has received three sessions of posterior shoulder capsule release using a tennis ball under supervision. Along with the ball release, the thera- pist taught home-based, unsupervised sleeper, and cross-body adduction stretches, for the control group. A universal goniometer was used to measure the IRROM before and after all three treatment sessions in both groups. Results. There were no statistically significant differences between the control and experi- mental groups (p< 0.05). However, immediate improvement in the IRROM following FM was more substantial in the experimental group following each session. Conclusions. This study indicates that FM may be used as an adjunct to stretching in asymp- tomatic participants with GIRD to increase the IRROM. There is a scope for future studies to be done to investigate the effect of FM on symptomatic overhead athletes with GIRD. KEY WORDS Fascial manipulation (FM); Glenohumeral internal rotation deficit (GIRD); internal rota- tion range of motion

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?

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?

Cannot Determine, Not Reported, or Not Applicable

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)?

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

There was a significant improvement in the internal rotation range of motion in athletes with GIRD between the treatment sessions in both the conventional treatment group and the control group.

Key Finding #2

The control group, which received stretching and tennis ball release, had no immediate significant effects, but there was a gradual improvement in the IRROM after the 3 sessions.

Key Finding #3

The experimental group received three sessions of fascial manipulation treatment in two weeks, and they showed a clinically significant improvement in IRROM, but it did not last long as there was a decrease in IRROM during follow-ups.

Please provide your summary of the paper

This randomized controlled trial compared 2 groups of athletes with Glenohumeral Internal Rotation Deficit (GIRD). The control group received three sessions of posterior shoulder capsule release with a tennis ball, along with a home exercise program of the cross-body adduction and sleeper stretches. The experimental group received three session of fascial manipulation treatment in two weeks. Between both groups, there was no significant improvement in the internal rotation ROM. However, there was an immediate improvement in internal rotation following each session in the experimental group, but the improvement did not last long. For the control group, there was a gradual improvement in internal ROM, but no significant immediate effects. The study did have some limitations in that it was only 3 sessions, they did not track the patients for any long term affects, and there were only 20 participants.

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

Considering there weren’t any statistically significant findings from this study, it is difficult to know if these methods should be used in treating patients with GIRD. Even though there was some significant improvement in internal rotation, when using fascial manipulation, immediately following the treatment sessions, it did not last long/it did not carry over to the next session. However, this article does give some insight on the importance of using fascial manipulation alongside stretching of the shoulder posterior capsule and a tennis ball release in the management of patients with GIRD. Long term effects are unknown based on this article, which leaves some unanswered questions on the most effective treatment method. All in all, when treating patients with GIRD, it can be useful to use different treatments to improve shoulder internal rotation to prevent injuries in overhead athletes.

Effects of an Anteroposterior Mobilization of the Glenohumeral Joint in Overhead Athletes With Chronic Shoulder Pain: A Randomized Controlled Trial

Author Names

Lluch, E., Pecos-Martín, D., Domenech-García, V., Herrero, P., Gallego-Izquierdo, T.

Reviewer Name

Maria Hamilton, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Passive oscillatory mobilizations are often employed by physiotherapists to reduce shoulder pain and increase function. However, there is little data about the neurophysiological effects of these mobilizations. Objectives: To investigate the initial effects of an anteroposterior (AP) shoulder joint mobilization on measures of pain and function in overhead athletes with chronic shoulder pain. Design: Double-blind, controlled, within-subject, repeated-measures design. Method: Thirty-one overhead athletes with chronic shoulder pain participated. The effects of a 9-min, AP mobilization of the glenohumeral joint were compared with manual contact and no-contact interventions. Self-reported pain, pressure pain threshold (PPT), range of movement (ROM), muscle strength, and disability were measured immediately before and after each intervention. Results/findings: No significant differences were found among the treatment conditions in any of the variables investigated. A significantly greater mean decrease in self-reported shoulder pain was observed following treatment condition [0.63 (0.12, 1.14); p = 0.01]. PPT at the affected shoulder increased significantly following both the treatment [0.23 (−0.43, 0.02); p = 0.02] and manual contact [0.28 (−0.51, 0.04); p = 0.01] conditions. Shoulder AP joint mobilization also increased PPT at a distal, non-painful site [0.42 (−0.85, 0.01); p = 0.04]. No changes were observed in shoulder ROM or muscle strength. Conclusions: This study found no superior effects in various pain or function-related outcome measures of a passive oscillatory anteroposterior mobilization applied to the glenohumeral joint compared to manual contact and no-contact interventions in overhead athletes with chronic shoulder pain. Some ability to modulate shoulder pain and local and widespread pain sensitivity was observed in the short term after the passive oscillatory anteroposterior mobilization.

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?

Cannot Determine, Not Reported, or Not Applicable

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

The NPRS did not differ between treatments, but changed over time. There was a significant decrease in NRPS for the treatment condition immediately after the intervention.

Key Finding #2

The pressure pain threshold (PPT) on the affected shoulder did not differ between treatments but changed over time, having a significant increase in PPT for the manual contact and treatment conditions immediately after the interventions.

Key Finding #3

There were no significant changes in shoulder ROM between the conditions.

Please provide your summary of the paper

The purpose of this study was to analyze the effect of a glenohumeral AP mobilization on pain and muscle strength in overhead athletes with chronic shoulder pain. There were two independent variables for this study: Other variables that were included in the analysis of the study included pressure pain threshold (PPT), shoulder disability, and shoulder ROM. There were three different treatment conditions: AP shoulder mobilization, manual contact, no-contact group, with each group experiencing their respective condition for 10 minutes (3 sets of 3 minutes with 30 second rest breaks). The patients completed an outcome measure immediately after their intervention, except for the DASH due to it being administered before and 24 hours after treatment. For self-reported shoulder pain and disability and PPT, there were no difference between treatments, however, there were differences when looking at the time post-treatment. There was a significant decrease in NPRS for those who were in the AP mobilization group immediately after treatment. In addition, there was a significant increase in PPT for the affected shoulder for the AP mobilization and manual contact groups.

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 of this study suggests that glenohumeral AP mobilizations are effective in reducing pain in patients with chronic shoulder pain. For the study, the physical therapists performed grade III AP glides with the arm in 90* of glenohumeral abduction and full internal rotation. According to Maitland’s grading, a grade III mobilization is useful for patients with joint hypomobility. However, since the participants in this study were healthy and did not have any limitations in shoulder ROM, there were no significant differences in shoulder ROM, marking a limitation to the study. Another limitation to the study is that only one treatment was used during the session based on the group the patients were assigned to, making it hard for any significant changes to occur. Ultimately, the findings of this study suggest that AP mobilizations can be useful for promoting pain relief for individuals with chronic pain, however, other interventions in conjunction with the mobilizations could provide more long-lasting benefits.

Progressive Resistance Exercise Plus Manual Therapy Is Effective in Improving Isometric Strength in Overhead Athletes With Shoulder Impingement Syndrome: A Randomized Controlled Trial

Author Names

Sharma, S.; Ghrouz, A.; Hussain, M.; Sharma, S; Aldabbas, M; Ansari, S.

Reviewer Name

Brenna Hammer, SPT, LAT, ATC

Reviewer Affiliation(s)

Duke University School of Medicine Doctor of Physical Therapy

Paper Abstract

Reduction in isometric strength of the scapulohumeral muscles is a commonly seen impairment in overhead athletes afflicted with shoulder impingement syndrome (SIS). The purpose of this study was to compare the effects of two different treatment programs: progressive resistance exercises plus manual therapy (PRE plus MT) and motor control exercises (MCE), on isometric strength of upper trapezius (UT), middle trapezius (MTr), lower trapezius (LT), serratus anterior (SA), supraspinatus (Supr.), anterior deltoid (A.D), and latissimus dorsi (LD). 80 male university-level overhead athletes clinically diagnosed with SIS were randomly allocated into either of the two groups: PRE plus MT and MCE group. Athletes in the PRE plus MT group underwent graduated exercises with resistance elastic band, stretching exercises, and mobilization of the thoracic and shoulder joints. MCE group was submitted to motor control exercises in varied planar positions. Athletes in both groups underwent management 3 times a week for 8 weeks. Isometric strength of UT, MTr, LT, Supr, A.D, SA, and LD was measured at three-time points: baseline, 4th week, and 8th week. Relative to baseline, both interventions were found to be effective in increasing and optimizing the isometric strength of muscles (p<0:05) except for supraspinatus in the MCE group (p>0:05). However, athletes in PRE plus MT group presented a more pronounced increase in isometric strength than those in the MCE group. Between groups analysis found the largest isometric strength improvement in PRE plus MT group for A.D, followed by Supr. and UT muscles (p<0:05; effect size: 0.39 to 0.40). The study concluded that compared to MCE, PRE plus MT provides greater improvement in the isometric strength of scapulohumeral muscles.

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?

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

Overhead athletes with shoulder impingement syndrome treated with manual therapy and progressive resistance exercise had greater isometric strength gains after 8 weeks than athletes treated with motor control exercises.

Key Finding #2

Both motor control exercises and progressive resistance exercises combined with manual therapy were effective in increasing isometric strength of scapulohumeral muscles.

Please provide your summary of the paper

The purpose of this study was to compare the effect of progressive resistance exercises (PRE) plus manual therapy (MT) versus motor control exercises (MCE) on scapulohumeral muscle isometric strength. The population studied was male collegiate athletes with a clinical diagnosis of shoulder impingement study. Athletes were randomly assigned into two groups to receive either PRE and MT or MCE 3 times per week for 8 weeks, with measurements being taken at baseline, 4 weeks, and 8 weeks. The PRE and MT group performed a variety of range of motion, stretching, and strengthening activities with increasing intensity throughout the 8 weeks indicated by increasing theraband color every 4 treatment days. This group also received non-thrust manual therapy (posterior and inferior glenohumeral glides) for a total of 12 sessions across the 8 week study. The MCE group performed a group of six free exercises for the upper quadrant region (shoulder abduction in the frontal plane, shoulder retraction, neck retraction, shoulder shrugging, stretching of upper trapezius, and stretching of pectoralis major). Further information about resistance, repetition, progression, etc. was not provided. At the end of the 8 week intervention, both groups showed improvements in isometric strength of scapulohumeral musculature with the exception of supraspinatus strength in the MCE group. The PRE and MT group had larger improvements in strength compared to the MCE 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 supports the efficacy of PRE and MT to improve shoulder strength in male overhead athletes. Female athletes were not studied here, nor was the general population, making these results difficult to apply to general clinical practice. Additionally, the only measured outcome was isometric strength – symptoms and disability related to a diagnosis of shoulder impingement syndrome were not studied here, so we are unaware of the effect of these interventions on other aspects of this condition. PRE and MT were combined as one intervention group whereas MCE was applied independently; it would be beneficial to further the study of MCE versus PRE alone, and/or PRE and MT versus MCE and MT to gain a better understanding of which parts of these interventions were having the greatest effect on outcomes and to draw stronger conclusions of how to best introduce these techniques to clinical practice.

Which Method for Frozen Shoulder Mobilization: Manual Posterior Capsule Stretching or Scapular Mobilization?

Author Names

Duzgun I, Turgut E, Eraslan L, Elbasan B, Oskay D, Atay OA

Reviewer Name

Megan Hayden, SPT

Reviewer Affiliation(s)

Duke University Doctor of Physical Therapy

Paper Abstract

Objectives: This study aimed to compare the superiority of scapular mobilization, manual capsule stretching, and the combination of these two techniques in the treatment of frozen shoulder patients to evaluate the acute effects of these techniques on shoulder movements. Methods: This study designed to a single-blinded, randomized, and pre-post assessment study. This study was included 54 patients diagnosed with stage 3 frozen shoulder. Group 1 (n=27) received scapular mobilization, and Group 2 (n=27) received manual posterior capsule stretching. After the patients were assessed, the interventions were re-applied with a crossover design to obtain results for the combined application (n=54). The range of motion, active total elevation, active internal rotation, and posterior capsule tensions of the shoulder joint were recorded before and immediately after mobilization. Results: Statistical analysis showed an increase in all range of motion values (p<0.05), except for shoulder internal rotation (p>0.05), without significant difference among the groups (p>0.05). The posterior capsule flexibility did not change in any group (p>0.05). Conclusions: Scapular mobilization and manual posterior capsule interventions were effective in improving the acute joint range of motion in frozen shoulder patients. Keywords: Frozen Shoulder, Manual Therapy, Rehabilitation, Scapula, Posterior Capsule Go to:

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)?

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

There was no statistical difference between manual posterior capsule stretching, scapular mobilization, or both; however, all groups displayed improvements in ROM.

Key Finding #2

The study did not compare the effects of manual therapy to traditional exercise programs so more research needs to be conducted to examine any potential differences in treatment plans.

Key Finding #3

Only acute effects were measured; the impact of long-term effects was not examined in this study.

Please provide your summary of the paper

This was a RCT used to compare 2 manual therapy treatments on both shoulder ROM and pain levels for those with a level 3 frozen shoulder. Both decreased motion of the scapula and posterior shoulder capsule have been linked to limited improvements seen in those with frozen shoulder. Changes in pain were recorded using the VAS, and goniometry was used for pre and post-test measurements of shoulder flexion, abduction, and internal and external rotation. Overall, all 3 intervention groups showed statistically significant improvements in acute ROM and pain from pre and post-intervention. However, there was no difference between intervention groups.

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

More research must be done to examine more long-term effects of these manual therapy treatments, and there was no examination that compared these treatments to traditional exercise therapy alone. However, all treatment groups displayed positive, acute changes. Physical therapists can use this information to guide their plan of care and having more options allows a PT to create unique plans of care based on what they are comfortable with and what the patient is comfortable with.

Comparison of Manual Therapy Techniques With Therapeutic Exercise in the Treatment of Shoulder Impingement: A Randomized Controlled Pilot Clinical Trial

Author Names

Kachingwe, A., Phillips, B., Sletten, E., & Plunkett, S.

Reviewer Name

Natalie Hosmer, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

The purpose of this double-blind, randomized controlled pilot study was to compare the effectiveness of four physical therapy interventions in the treatment of primary shoulder impingement syndrome: 1) supervised exercise only, 2) supervised exercise with glenohumeral mobilizations, 3) supervised exercise with a mobilization-with-movement (MWM) technique, or 4) a control group receiving only physician advice. Thirty-three subjects diagnosed with primary shoulder impingement were randomly assigned to one of these four groups. Main outcome measures included 24-hour pain (VAS), pain with the Neer and Hawkins-Kennedy tests, shoulder active range of motion (AROM), and shoulder function (SPADI). Repeated-measures analyses indicated significant decreases in pain, improved function, and increases in AROM. Univariate analyses on the percentage of change from pre- to post-treatment for each dependent variable found no statistically significant differences (P<0.05) between the four groups. Although not significant, the MWM and mobilization groups had a higher percentage of change from pre- to post-treatment on all three pain measures (VAS, Neer, Hawkins-Kennedy). The three intervention groups had a higher percentage of change on the SPADI. The MWM group had the highest percentage of change in AROM, and the mobilization group had the lowest. This pilot study suggests that performing glenohumeral mobilizations and MWM in combination with a supervised exercise program may result in a greater decrease in pain and improved function although studies with larger samples and discriminant sampling methods are needed.

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)?

Cannot Determine, Not Reported, or Not Applicable

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?

Cannot Determine, Not Reported, or Not Applicable

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

The researchers found that while there was no significant difference between those that received manual therapy and those that did not, the groups that received mobilization with movement and glenohumeral mobilizations did report a higher percentage of change.

Key Finding #2

The mobilization with movement group showed the highest percentage of change in AROM.

Please provide your summary of the paper

This randomized controlled pilot clinical trial investigated the effects of four different treatment methods—supervised exercise only, supervised exercise and glenohumeral mobilizations, supervised exercise with mobilization with movement techniques, and physician advice only—on individuals with primary shoulder impingement syndrome. The main outcome measures used were VAS, pain with the Neer and Hawkins-Kennedy tests, shoulder AROM, and the SPADI. These measures were taken pre- and post-treatment. The researchers found that there was no significant difference between the four groups. Although the difference was not significant, the groups receiving manual therapy displayed a higher percentage of change on all three pain measures. Additionally, the mobilization with movement group showed to be the most effective in improving AROM.

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

While this paper does suggest that manual therapy, especially mobilizations with movement potentially could improve function and decrease pain in individuals with primary shoulder impingement syndrome, the results were insignificant. Looking into other studies prior to choosing this as a treatment option will allow the clinician to develop a more evidence-based clinical decision.

Effectiveness of Manual Therapy and Stretching for Baseball Players With Shoulder Range of Motion Deficits

Author Names

Bailey, L , Thigpen, C , Hawkins, R , Beattie, P , Shanley, E

Reviewer Name

Bradley Hudson, SPT

Reviewer Affiliation(s)

APTA, NSCA, Duke School of Medicine Doctor of Physical Therapy Division

Paper Abstract

Background: Baseball players displaying deficits in shoulder range of motion (ROM) are at increased risk of arm injury. Currently, there is a lack of consensus regarding the best available treatment options to restore shoulder ROM. Hypothesis: Instrumented manual therapy with self-stretching will result in clinically significant deficit reductions when compared with self-stretching alone. Study Design: Controlled laboratory study. Methods: Shoulder ROM and humeral torsion were assessed in 60 active baseball players (mean age, 19 ± 2 years) with ROM deficits (nondominant − dominant, ≥15°). Athletes were randomly assigned to receive a single treatment of instrumented manual therapy plus self-stretching (n = 30) or self-stretching only (n = 30). Deficits in internal rotation, horizontal adduction, and total arc of motion were compared between groups immediately before and after a single treatment session. Treatment effectiveness was determined by mean comparison data, and a number-needed-to-treat (NNT) analysis was used for assessing the presence of ROM risk factors. Results: Prior to intervention, players displayed significant (P < 0.001) dominant-sided deficits in internal rotation (−26°), total arc of motion (−18°), and horizontal adduction (−17°). After the intervention, both groups displayed significant improvements in ROM, with the instrumented manual therapy plus self-stretching group displaying greater increases in internal rotation (+5°, P = 0.010), total arc of motion (+6°, P = 0.010), and horizontal adduction (+7°, P = 0.004) compared with self-stretching alone. For horizontal adduction deficits, the added use of instrumented manual therapy with self- stretching decreased the NNT to 2.2 (95% CI, 2.1-2.4; P = 0.010). Conclusion: Instrumented manual therapy with self-stretching significantly reduces ROM risk factors in baseball players with motion deficits when compared with stretching alone. Clinical Relevance: The added benefits of manual therapy may help to reduce ROM deficits in clinical scenarios where stretching alone is ineffective. Keywords: posterior shoulder tightness (PST); glenohumeral internal rotation deficit (GIRD); instrumented manual therapy; baseball

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

Instrument assisted manual therapy plus self-stretching displays greater improvement in ROM deficits compared to self-stretching alone in baseball players.

Key Finding #2

ROM risk factors can be managed effectively with instrumented manual therapy added to self-stretching.

Key Finding #3

Manual therapy techniques directed at the musculotendinous tissue may provide more acute benefits in improving ROM deficits when compared to posterior shoulder mobilizations.

Key Finding #4

Single treatment session can effectively reduce ROM risk factors in baseball players.

Please provide your summary of the paper

This study examined the effectiveness of instrumented assisted manual therapy and stretching vs stretching alone for shoulder range of motion (ROM) deficits in baseball players. The study was a controlled laboratory study with a randomized control and intervention group. The inclusion criteria for the study were male baseball players > 15 years of age with current participation in organized baseball team, shoulder ROM deficits of 15o in total arc of motion, accompanied with at least 15o of Internal rotation (IR)/ horizonal adduction deficits. The exclusion criteria are if participants reported activity limiting shoulder pain within 3 months, were not actively participating in all team activities, and had previous surgical history on either shoulder. The manual therapy + self-stretching group received 4 minutes of supervised posterior shoulder stretching followed by 4 minutes of instrumented manual therapy targeting the infraspinatus and teres minor muscles. The control group just received the supervised 4 minutes of posterior shoulder stretching. All ROM measurements taken with a digital inclinometer and performed the sleeper and cross-body adduction stretch for 2 sets of 1 minute each with 30 seconds of rest in-between sets. The results of this study indicate that the treatment group that received manual therapy + self-stretching had greater improvements in ROM deficits when compared to the self-stretching alone group. By the results of this study baseball players with horizontal adduction only deficits will benefit the most from instrumented manual therapy + self-stretching. While baseball players with only total arc of motion + IR deficits can respond well to self-stretching only. Some limitations to this study were that athletes were not followed longitudinally to determine if the interventions may have decreasing long-term injury risk benefits, isolated and long-term benefits of instrumented manual therapy are unknown, and its unknown which tissues are responsible for the ROM changed observed. In conclusion, manual therapy + self-stretching is a beneficial way to restore ROM deficits and decrease injury risk in baseball players.

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 in this article suggest that instrumented assisted manual therapy + self-stretching is an appropriate choice to improve shoulder ROM and decrease risk of injury in baseball players. The results tend to point toward using manual therapy + self-stretching especially with horizontal adduction ROM deficits. For total arc of motion and IR deficits manual therapy can also be used for beneficial results but self-stretching alone will also yield beneficial results. Using a combination instrumented manual therapy + posterior shoulder self-stretching is recommended to restore shoulder ROM in baseball players.

Acute Effects of Instrument-Assisted Soft Tissue Mobilization for Improving Posterior Shoulder Range of Motion in Collegiate Baseball Players

Author Names

Laudner, K , Compton, B , McLoda, T , Walters, C

Reviewer Name

Bradley Hudson, SPT

Reviewer Affiliation(s)

APTA, NSCA, Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Due to the repetitive rotational and distractive forces exerted onto the posterior shoulder during the deceleration phase of the overhead throwing motion, limited glenohumeral (GH) range of motion (ROM) is a common trait found among baseball players, making them prone to a wide variety of shoulder injuries. Although utilization of instrument-assisted soft tissue mobilization (IASTM), such as the Graston® Technique, has proven effective for various injuries and disorders, there is currently no empirical data regarding the effectiveness of this treatment on posterior shoulder tightness. Purpose: To determine the effectiveness of IASTM in improving acute passive GH horizontal adduction and internal rotation ROM in collegiate baseball players. Methods: Thirty-five asymptomatic collegiate baseball players were randomly assigned to one of two groups. Seventeen participants received one application of IASTM to the posterior shoulder in between pretest and posttest measurements of passive GH horizontal adduction and internal rotation ROM. The remaining 18 participants did not receive a treatment intervention between tests, serving as the controls. Data were analyzed using separate 2×2 mixed-model analysis of variance, with treatment group as the between-subjects variable and time as the within-subjects variable. Results: A significant group-by-time interaction was present for GH horizontal adduction ROM with the IASTM group showing greater improvements in ROM (11.1°) compared to the control group (-0.12°) (p<0.001). A significant group-by-time interaction was also present for GH internal rotation ROM with the IASTM group having greater improvements (4.8°) compared to the control group (-0.14°) (p<0.001). Conclusions: The results of this study indicate that an application of IASTM to the posterior shoulder pro- vides acute improvements in both GH horizontal adduction ROM and internal rotation ROM among base- ball players. Level of Evidence: 2b Keywords: Manual therapy, rehabilitation, shoulder, throwing athlete

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

A single application of IASTM treatment to the posterior shoulder can produce acute benefits in GH ROM in college baseball players.

Key Finding #2

IASTM treatment group showed greater improvements in GH horizontal adduction ROM in college baseball players.

Key Finding #3

IASTM treatment group showed greater improvements in GH internal rotation ROM in college baseball players.

Please provide your summary of the paper

This study examined the acute effects of instrumented assisted soft tissue mobilization (IASTM) to improve glenohumeral (GH) ROM in college baseball players. This study was done on 35 college baseball players and was a randomized blind study design. The inclusion criteria was as follows, must have been a member of a National Collegiate Athletic Association (NCAA) Division 1 baseball team and have had no recent history (within 6 months) of upper extremity (UE) or any previous UE surgeries on their throwing arm. The participants were split up into two randomly assigned groups. One group received the IASTM, and the other group did not receive the treatment since they were the control group. The IASTM treatment was applied for 20 seconds in the direction parallel to the muscle fibers treated with the instrument at a 45o angle immediately followed by 20 seconds of treatment perpendicular to the muscle fibers at a 45o angle. The total treatment time was 40 seconds. A single measurement of GH horizontal adduction and IR were taken pre and post treatment using a digital inclinometer. The results of this study indicate that using an IASTM treatment can acutely improve GH horizontal adduction ROM by 11.1 and IR ROM by 4.8 in college baseball players. IASTM is thought to localize and treat soft tissue restrictions to produce a localized inflammatory response, reduce new scar tissue, and break down existing scar tissue. Limitations to this study were that the Graston technique (GT) was predetermined for each patient by having the same amount of time, stroke rate, direction, and number of strokes. Secondly, the only GT tool that was used was the GT-4, when the recommendation is to use a variety of tools at different angles. Future studies should aim at incorporating different treatment techniques to determine which is most effective, look at ROM improvements with multiple treatments, and to track ROM improvements over a long period of time in asymptomatic individuals and individuals with documented ROM deficits. In conclusion, IASTM treatment is shown to be a beneficial treatment option to acutely improve GH ROM in college baseball players.

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 article indicate IASTM to the posterior shoulder is a beneficial treatment choice to improve GH horizontal adduction and IR ROM in college baseball players. The results of this particular study were from only one treatment session, and it would be beneficial for future studies to look at improvements over multiple treatment session and over a longer period of time. Incorporating IASTM into treatment for college baseball players can yield acute gains in GH horizontal adduction and IR ROM which can be beneficial for sports performance.

Manual Therapy and Exercise for Rotator Cuff Disease

Author Names

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

Reviewer Name

Hannah Koch, SPT

Reviewer Affiliation(s)

Duke University

Paper Abstract

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

NIH Risk of Bias Tool

Quality Assessment of Systematic Reviews and Meta-Analyses

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

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

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

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

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

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

Was publication bias assessed?

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

Cannot Determine, Not Reported, Not Applicable

Key Finding #1

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

Key Finding #2

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

Key Finding #3

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

Key Finding #4

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

Please provide your summary of the paper

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

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

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

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