Shoulder

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

Author Names

Keramat, K. U. & Habib, A.

Reviewer Name

Emily LaPlante, LAT, ATC, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

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

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

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

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

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

NIH Risk of Bias Tool:

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

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

Key Finding #1

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

Key Finding #2

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

Please provide your summary of the paper

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

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

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

The Effectiveness of Manual Therapy in Supraspinatus Tendinopathy

Author Names

Gamze Senbursa, Gül Baltaci, and Ö. Ahmet Atay

Reviewer Name

Adrienne Maniktala LAT, ATC, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

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

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

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

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

Were study participants and providers blinded to treatment group assignment?

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

Cannot Determine, Not Reported, or Not Applicable

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

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

Cannot Determine, Not Reported, or Not Applicable

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

Cannot Determine, Not Reported, or Not Applicable

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

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

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

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

Cannot Determine, Not Reported, or Not Applicable

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

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

Key Finding #1

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

Key Finding #2

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

Key Finding #3

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

Key Finding #4

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

Please provide your summary of the paper

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

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

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

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

Author Names

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

Reviewer Name

Giulia Marsella, Student Physical Therapist

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

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

NIH Risk of Bias Tool
Quality Assessment of Systematic Reviews and Meta-Analyses

Is the review based on a focused question that is adequately formulated and described?
-Yes
Were eligibility criteria for included and excluded studies predefined and specified?
-Yes
Did the literature search strategy use a comprehensive, systematic approach?
-Yes
Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?
-Yes
Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?
Were the included studies listed along with important characteristics and results of each study?
-Yes
Was publication bias assessed?
-Yes
Was heterogeneity assessed? (This question applies only to meta-analyses.)
-Cannot Determine, Not Reported, Not Applicable

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

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

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

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

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

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

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

Author Names

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

Reviewer Name

Marc Moreno-Takegami, Duke Doctor of Physical Therapy Student

Reviewer Affiliation(s)

Doctor of Physical Therapy student at Duke University

Paper Abstract

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

NIH Risk of Bias Tool

Quality Assessment of Systematic Reviews and Meta-Analyses

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

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

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

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

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

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

Was publication bias assessed?

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

Key Finding #1

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

Key Finding #2

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

Key Finding #3

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

Please provide your summary of the paper

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

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

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

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

Author Names

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

Reviewer Name

Nikol Papa

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

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

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

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

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

Were study participants and providers blinded to treatment group assignment?

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

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

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

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

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

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

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

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

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

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

Key Finding #1

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

Key Finding #2

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

Please provide your summary of the paper

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

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

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

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

Author Names

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

Reviewer Name

Jaime Pardee

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

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

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

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

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

Cannot Determine, Not Reported, or Not Applicable

Were study participants and providers blinded to treatment group assignment?

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

Cannot Determine, Not Reported, or Not Applicable

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

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

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

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

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

Cannot Determine, Not Reported, or Not Applicable

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

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

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

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

Key Finding #1

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

Key Finding #2

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

Key Finding #3

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

Please provide your summary of the paper

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

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

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

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

Author Names

Bang MD, Deyle GD

Reviewer Name

Margaret Pohl, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

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

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

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

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

Were study participants and providers blinded to treatment group assignment?

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

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

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

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

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

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

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

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

Cannot Determine, Not Reported, or Not Applicable

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

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

Key Finding #1

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

Key Finding #2

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

Please provide your summary of the paper

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

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

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

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

Author Names

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

Reviewer Name

Marie-Adelaide Robinson, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

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

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

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

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

Cannot Determine, Not Reported, or Not Applicable

Were study participants and providers blinded to treatment group assignment?

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

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

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

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

Cannot Determine, Not Reported, or Not Applicable

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

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

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

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

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

Cannot Determine, Not Reported, or Not Applicable

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

Key Finding #1

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

Key Finding #2

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

Key Finding #3

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

Key Finding #4

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

Please provide your summary of the paper

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

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

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

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

Author Names

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

Reviewer Name

Marie-Adelaide Robinson, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

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

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

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

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

Were study participants and providers blinded to treatment group assignment?

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

Cannot Determine, Not Reported, or Not Applicable

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

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

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

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

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

Cannot Determine, Not Reported, or Not Applicable

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

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

Cannot Determine, Not Reported, or Not Applicable

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

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

Key Finding #1

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

Key Finding #2

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

Please provide your summary of the paper

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

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

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

Manual Therapy and Exercise for Adhesive Capsulitis (Frozen Shoulder)

Author Names

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

Reviewer Name

Megan Saunders

Reviewer Affiliations

Duke university school of medicine, doctor of physical therapy division

Paper Abstract

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

NIH Risk of Bias Tool

Quality Assessment of Systematic Reviews and Meta-Analyses

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

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

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

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

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

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

Was publication bias assessed?

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

Key Finding #1

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

Key Finding #2

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

Key Finding #3

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

Key Finding #4

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

Please provide your summary of the paper

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

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

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

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

Author Names

Sharma, S; Hussein, M; Sharma, S

Reviewer Name

Dylan Scott, DPT

Reviewer Affiliation(s)

Duke University

Paper Abstract

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

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

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

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

Were study participants and providers blinded to treatment group assignment?

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

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

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

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

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

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

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

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

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

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

Key Finding #1

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

Key Finding #2

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

Key Finding #3

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

Key Finding #4

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

Please provide your summary of the paper

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

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

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

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

Author Names

Noten, S. et al

Reviewer Name

Emily Stadnick, 2nd year SPT at Duke

Reviewer Affiliation(s)

Duke University School of Medicine- DPT program

Paper Abstract

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

NIH Risk of Bias Tool

Quality Assessment of Systematic Reviews and Meta-Analyses

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

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

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

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

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

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

Was publication bias assessed?

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

Cannot Determine, Not Reported, Not Applicable

Key Finding #1

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

Key Finding #2

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

Please provide your summary of the paper

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

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

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

Subacromial Impingement Syndrome—Effectiveness of Physiotherapy and Manual Therapy

Author Names

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

Reviewer Name

Chance Thomas Thorkelson SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy

Paper Abstract

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

NIH Risk of Bias Tool

Quality Assessment of Systematic Reviews and Meta-Analyses

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

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

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

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

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

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

Was publication bias assessed?

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

Key Finding #1

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

Key Finding #2

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

Key Finding #3

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

Please provide your summary of the paper

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

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

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

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

Author Names

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

Reviewer Name

Luke Vitale, SPT, CSCS

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

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

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

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

Cannot Determine, Not Reported, or Not Applicable

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

Were study participants and providers blinded to treatment group assignment?

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

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

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

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

Cannot Determine, Not Reported, or Not Applicable

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

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

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

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

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

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

Key Finding #1

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

Key Finding #2

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

Key Finding #3

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

Please provide your summary of the paper

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

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

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

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

Author Names

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

Reviewer Name

Luke Vitale, SPT, CSCS

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

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

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

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

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

Were study participants and providers blinded to treatment group assignment?

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

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

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

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

Cannot Determine, Not Reported, or Not Applicable

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

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

Cannot Determine, Not Reported, or Not Applicable

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

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

Cannot Determine, Not Reported, or Not Applicable

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

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

Key Finding #1

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

Key Finding #2

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

Key Finding #3

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

Key Finding #4

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

Please provide your summary of the paper

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

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

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

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

Article Full Title

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

Author Names

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

Reviewer Name

Yanfei Li, PT, DPT, CSCS

Reviewer Affiliation(s)

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

Paper Abstract

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

Quality Assessment of Systematic Reviews and Meta-Analyses

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

Was publication bias assessed?

Yes

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

Yes

Key Finding #1

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

Key Finding #2

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

Key Finding #3

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

Please provide your summary of the paper

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

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

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

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

Article Full Title

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

Author Names

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

Reviewer Name

Jake Isaac, DPT

Reviewer Affiliation(s)

X3 Performance and Physical Therapy, Duke University Hybrid Orthopedic Residency

Paper Abstract

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

NIH Risk of Bias Tool:

Quality Assessment of Controlled Intervention Studies

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

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

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

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

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

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

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

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

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

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

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

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power? Yes

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

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

Key Finding #1

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

Key Finding #2

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

Please provide your summary of the paper

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

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

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

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