Shoulder

Article Full Title

The Effect of Therapeutic Exercise and Mobilization on Patients With Shoulder Dysfunction: A Systematic Review With Meta-analysis

Author Names

Tracy J. Brudvig, PT, DPT, PhD, OCS, Hetal Kulkarni, PT, MSPT, Shalvi Shah, PT, MSPT

Reviewer Name

Nayeli Chowdhury, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Study Design

Systematic review with meta-analysis.

Objective

To pool and summarize the published research evidence examining if the combination of therapeutic exercise and joint mobilization is more beneficial than therapeutic exercise alone in patients with shoulder dysfunction.

Background

Therapeutic exercise is an effective intervention for patients with shoulder dysfunction, which is often supplemented by joint mobilization techniques. Numerous studies have examined the effects of the combination of therapeutic exercise and joint mobilization on patients with shoulder dysfunction.

Method

Six databases were searched for randomized controlled trials. All the randomized controlled trials published in English that have studied the effectiveness of therapeutic exercise and joint mobilization on adults with either clinically or radiographically confirmed shoulder dysfunction resulting in pain, restriction of range of motion (ROM), and/or limitation in function, were included in this review. Effect size was calculated in the form of standardized mean difference and 95% confidence interval (CI) for each variable, then combined to represent weighted standardized mean differences (WSMDs) and 95% CIs.

Results

Seven studies that met the inclusion criteria were identified, with a total of 290 participants. The WSMDs and CIs, which combined the results of all the studies for a particular variable, revealed equivocal results for all variables. The resulting WSMD (95% CI) for each of the variables was

0.2 (−0.68, 1.08) for pain, 0.15 (−0.67, 0.97) for abduction ROM, −0.04 (−0.65, 0.57) for flexion ROM, 0.01(−0.79, 0.81) for internal and external rotation ROM, and 0.09 (−0.46, 0.64) for function and disability. Even after elimination of sources of heterogeneity, the new WSMDs and CIs continued to overlap zero, giving equivocal results.

Conclusion

The current evidence is inconclusive with respect to the beneficial effects of the combination of therapeutic exercise and joint mobilization versus therapeutic exercise alone for reducing pain, increasing ROM and function, and limiting disability in patients with shoulder dysfunction.

Level of Evidence

Therapy, level 1a−. J Orthop Sports Phys Ther 2011;41(10):734–748, Epub 4 September 2011. doi:10.2519/jospt.2011.3440

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? Cannot Determine
• Was heterogeneity assessed? (This question applies only to meta-analyses.) Yes

Key Finding #1

The systematic review with meta-analysis did not find strong information to support that joint mobilizations, when combined with therapeutic exercise, significantly improves pain or function as compared to therapeutic exercise alone.

Key Finding #2

People who experience chronic symptoms may respond differently to shoulder mobilizations due to the varying physiological factors.

Key Finding #3

Further high-quality research will be needed to determine whether combining therapeutic exercise with joint mobilization leads to superior clinical outcomes.

Please provide your summary of the paper

This paper examines the effectiveness of joint mobilizations combined with therapeutic exercise for those who experience shoulder dysfunction through a systematic review and meta-analysis. Shoulder dysfunction is a common musculoskeletal condition that can cause pain, result in decreased range of motion, and can impair function. Therapeutic exercise and manual therapy are techniques that are commonly used to treat shoulder dysfunction or other musculoskeletal conditions. Combining exercise and joint mobilizations provide pain relief and result in function improvement. However, the results of the paper indicate that there is no strong evidence to support that combining exercise with joint mobilizations is superior to just utilizing therapeutic exercise alone for shoulder dysfunction. It can be challenging to determine the effectiveness of joint mobilizations due to the variability in how shoulder dysfunction presents among patients. This paper shows that further research will be needed to better determine how shoulder joint mobilizations can enhance clinical outcomes during rehabilitation.

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

The paper highlighted the lack of evidence supporting shoulder joint mobilizations as a necessary intervention to use in conjunction with therapeutic exercise. In clinical practice, joint mobilizations may be effective or beneficial for certain patients but may not work for all. When working with patients in a physical therapy session, it is important to focus on therapeutic exercise as a primary intervention. If applying manual therapy techniques, it is important to consider a person’s symptoms, mobility levels, and response to manual therapy. Each patient’s care should be unique to their patient presentation and responses to their plan of care. The results from the paper show that it is important to conduct continued research to further evaluate the effectiveness of shoulder joint mobilization techniques.

Article Full Title 
Therapeutic Exercise and Orthopedic Manual Therapy for Impingement Syndrome: A Systematic Review 

Author Names 
François Desmeules, Claude H. Côté, Pierre Frémont 

Reviewer Name 
N/A 

Reviewer Affiliation(s) 
N/A 

Paper Abstract 

Objective  

To review randomized controlled trials evaluating the effectiveness of therapeutic exercise and orthopedic manual therapy for the treatment of impingement syndrome. 

Data Source  

Reports up to October 2002 were located from MEDLINE, the Cochrane Database of Systematic Reviews, the Physiotherapy Evidence Database (PEDro), the TRIP database, and the Cumulative Index to Nursing & Allied Health Literature (CINAHL) using “shoulder” and “clinical trial”/“randomized controlled trial” as search terms. 

Study Selection  

Studies were included if (1) they were a randomized controlled trial; (2) they were related to impingement syndrome, rotator cuff tendinitis, or bursitis; (3) one of the treatments included therapeutic exercise or manual therapy. 

Data Extraction  

Two independent observers reviewed the methodological quality of the studies using an assessment tool developed by the Cochrane Musculoskeletal Injuries Group. Differences were resolved by consensus. 

Data Synthesis  

Seven trials met our inclusion criteria. After consensus, the mean methodological score for all studies was 13.9 ± 2.4 (of 24). Four studies of 7, including the 3 trials with the best methodological score (67%), suggested some benefit of therapeutic exercise or manual therapy compared with other treatments such as acromioplasty, placebo, or no intervention. 

Conclusions  

There is limited evidence to support the efficacy of therapeutic exercise and manual therapy to treat impingement syndrome. More methodologically sound studies are needed to further evaluate these interventions. 

Quality Assessment of Systematic Reviews and Meta-Analyses 

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

y 

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

y 

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

y 

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

y 

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

y 

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

y 

1. Was publication bias assessed? 

y 

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

y 

Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies 

1. Was the research question or objective in this paper clearly stated? 

y 

1. Was the study population clearly specified and defined? 

y 

1. Was the participation rate of eligible persons at least 50%? 

y 

1. Were all the subjects selected or recruited from the same or similar populations (including the same time period)? Were inclusion and exclusion criteria for being in the study prespecified and applied uniformly to all participants? 

y 

1. Was a sample size justification, power description, or variance and effect estimates provided? 

y 

1. For the analyses in this paper, were the exposure(s) of interest measured prior to the outcome(s) being measured? 

y 

1. Was the timeframe sufficient so that one could reasonably expect to see an association between exposure and outcome if it existed? 

y 

1. For exposures that can vary in amount or level, did the study examine different levels of the exposure as related to the outcome (e.g., categories of exposure, or exposure measured as continuous variable)? 

y 

1. Were the exposure measures (independent variables) clearly defined, valid, reliable, and implemented consistently across all study participants? 

y 

1. Was the exposure(s) assessed more than once over time? 

y 

1. Were the outcome measures (dependent variables) clearly defined, valid, reliable, and implemented consistently across all study participants? 

y 

1. Were the outcome assessors blinded to the exposure status of participants? 

y 

1. Was loss to follow-up after baseline 20% or less? 

y 

1. Were key potential confounding variables measured and adjusted statistically for their impact on the relationship between exposure(s) and outcome(s)? 

y 

Quality Assessment of Case-Control Studies 

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

y 

1. Was the study population clearly specified and defined? 

y 

1. Did the authors include a sample size justification? 

y 

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

y 

1. Were the definitions, inclusion and exclusion criteria, algorithms or processes used to identify or select cases and controls valid, reliable, and implemented consistently across all study participants? 

y 

1. Were the cases clearly defined and differentiated from controls? 

y 

1. If less than 100 percent of eligible cases and/or controls were selected for the study, were the cases and/or controls randomly selected from those eligible? 

y 

1. Was there use of concurrent controls? 

y 

1. Were the investigators able to confirm that the exposure/risk occurred prior to the development of the condition or event that defined a participant as a case? 

y 

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

y 

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

y 

1. Were key potential confounding variables measured and adjusted statistically in the analyses? If matching was used, did the investigators account for matching during study analysis? 

Key Finding #1 
Limited evidence supports the efficacy of TE and MT for impingement syndrome, with some RCTs showing positive outcomes. 

Key Finding #2 
Studies with higher methodological scores were more likely to show positive results for TE and MT interventions. 

Key Finding #3 
Inconsistencies in study design, outcome measures, and follow-up periods reduced the reliability of the findings. 

Key Finding #4 
More methodologically sound RCTs are needed to establish clear evidence for TE and MT in treating impingement syndrome. 

Please provide your summary of the paper 
This systematic review suggests that while some evidence supports the use of TE and MT for impingement syndrome, the overall quality of the studies is limited. The results indicate that TE and MT may be beneficial, but due to variability in study designs and inconsistent outcome measures, further research with standardized protocols is necessary. 

Please provide your clinical interpretation of this paper. 
Clinically, the review highlights the potential benefits of TE and MT for impingement syndrome but emphasizes the need for more robust evidence. While TE and MT can be included as part of a treatment plan, clinicians should be aware of the limited and inconsistent evidence supporting their effectiveness. This review underscores the importance of individualized treatment plans and the need for further high-quality research. 

Article Full Title

The Effect of Shoulder Mobilization on Scapular and Shoulder Muscle Activity During

Resisted Shoulder Abduction: A Crossover Study of Asymptomatic Individuals

Author Names

Patterson, A.; Dickerson, CR.; Ribeiro, DC.

Reviewer Name

Lauren Dreusicke

Reviewer Affiliation(s)

Duke University DPT

Paper Abstract

Objective: The primary aim was to investigate the effect of inferior shoulder mobilization on scapular and shoulder muscle activity during resisted shoulder abduction in asymptomatic individuals.

Methods: This was a lab-based, repeated-measures, crossover, randomized controlled study. Twenty-two participants were recruited. The order of experimental conditions was randomized. Each participant performed 5 repetitions of resisted shoulder abduction before and after the control and mobilization (grade +IV inferior shoulder mobilization, 3 sets, 60 seconds) conditions. Surface electromyography recorded the muscle activity of anterior, middle, and posterior deltoid; supraspinatus; infraspinatus; upper and lower trapezius; serratus anterior; and latissimus dorsi muscles.

Results: Muscle activity levels reduced for infraspinatus (11.3% MVIC, 95% CI: 1.7-20.8), middle (22.4% MVIC, 95% CI: 15.9-28.8) and posterior deltoid (8.7 % MVIC, 95% CI:

4.6-12.9), and serratus anterior (-28.1% MVIC, 95% CI: 15.6-40.8) muscles after the mobilization condition during the eccentric phase of shoulder abduction. No carryover effects were observed, and within-session reliability was excellent (intraclass correlation coefficient scores ranging from 0.94 to 0.99).

Conclusion: Our findings suggest that inferior glenohumeral mobilization reduces activity levels of some scapular and shoulder muscles. Given the exploratory nature of our study, changes in muscle activity levels may have been found by chance. Confirmatory studies are required.

NIH Risk of Bias Tool:

Quality Assessment of Controlled Intervention Studies  

1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT Yes
2. Was the method of randomization adequate (i.e., use of randomly generated assignment)?

            Yes

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

            Yes

4. Were study participants and providers blinded to treatment group assignment?

            Yes

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

            Yes

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

            Yes

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

            Yes

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

            Yes

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

            Yes

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

            Yes

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

            Yes

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

            Yes

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

            Yes

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

Key Finding #1  

After receiving inferior shoulder mobilization, follow-up reductions in muscle activity levels were seen in the infraspinatus, middle and posterior deltoid, and serratus anterior. 

Key Finding #2

Decreased muscle activity was noted more prevalently in the eccentric phase of shoulder abduction compared to the concentric phase of the movement in those receiving the inferior shoulder mobilization.

Key Finding #3

Within-session reliability of methods of muscle activity measurements was excellent (ICC scores from 0.94 to 0.99).

Please provide your summary of the paper

This repeated-measures, cross-over, randomized control trial investigated the immediate response of scapular and shoulder neuromuscular responses after control and mobilization conditions during resisted abduction. Secondarily, researchers wanted to evaluate within-session reliability of muscle activity measurements. 22 participants were randomly selected for the trials and received both of two experimental conditions. The conditions included the mobilization (an inferior shoulder passive accessory mobilization) and a control receiving no treatment. The mobilization dosing for the intervention was a Grade +IV performed for 3 sets of 60 seconds with a 1 minute rest interval between sets. The sequence of interventions as they were applied to each patient were randomized. Baseline and follow-up intervention data was collected by a motion analysis system to monitor arm movements and surface EMG monitoring muscle activity of the upper and lower trapezius, supraspinatus, infraspinatus, middle and posterior deltoid, and the serratus anterior. To detect potential changes between before and after receiving either control or mobilization, participants performed 5 repetitions of resisted shoulder abduction at 5% of their body weight using a weight. Because of the cross-over study design, participants had a 10 minute washout rest period before baseline measurements were conducted again and the other condition was applied. Each participant received both conditions. After completion of the two conditions, it was found that those receiving the inferior shoulder mobilization treatment had follow-up reductions in muscle activity levels in the infraspinatus, middle and posterior deltoid, and serratus anterior muscles in the eccentric phase of shoulder abduction that were considered statistically significant results compared to the control group. The within-session reliability was considered excellent with an Intraclass Coefficient (ICC) score ranging from 0.94 to 0.99. As this study was conducted in asymptomatic individuals, there are limitations to applying this data to those who are symptomatic. Additionally, the study design of a cross-over utilizing only a 10 minute washout period may complicate comparisons between individuals depending on which condition they received first. Authors acknowledged that some of the decreases in muscle activity post mobilization could have been due to chance and encouraged other studies and trials to confirm similar findings.

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

With this trial examining the relationship between mobilizations and the impact of muscle activity on the shoulder and scapular region, clinicians can better understand the physiological response of this treatment and how it may apply to their patients. Since patients experienced decreased muscle activity in multiple of the scapular and shoulder muscles tested, this information can be used in many ways. For clinicians looking to explore this topic further, engaging in another similar trial with symptomatic patients would be beneficial in helping to directly tie the mobilizations and muscle activity to those experiencing pain or symptoms. With patients who may be experiencing pain in this region from injury, overuse, muscle imbalances, or other mechanisms, incorporating this inferior glide used may help manage pain and relieve symptoms, lengthen tightened tissues, decrease overactive muscle activity, and potentially improve their patient’s outcomes. Applying the mobilization might also increase the extensibility of the inferior glenohumeral capsule aiding patients in overall shoulder mobility if this is a limitation for them. This trial also provides clinicians with a protocol to test and retest muscle activity in patients who qualify and if the appropriate technology to track muscle activity is available. 

Article Full Title:

Dry Needling on the Infraspinatus Latent and Active Myofascial Trigger Points in Older Adults With Nonspecific Shoulder Pain: A Randomized Clinical Trial 

Author Names:

Calvo-Lobo, C., Pacheco-da-Costa, S., Martínez-Martínez, J., Rodríguez-Sanz, D., Cuesta-Álvaro, P., & López-López, D. 

Reviewer Name:

Kayin Fails  

Article Abstract: 

Background and purpose: Shoulder pain is a prevalent condition in older adults. Some authors associate nonspecific shoulder pain with myofascial trigger points (MTrPs) in the infraspinatus muscle. Dry needling is recommended to relieve the MTrP pain of shoulders in the short term (<9 days). Active MTrPs dry needling improves shoulder pain and the irritability of the satellite MTrPs in the referred pain area. Nociceptive activity at a latent MTrP may influence motor activity and the sensitivity of MTrPs in distant muscles at a similar segmental level. Therefore, this study aimed to evaluate dry needling on 1 latent MTrP, in conjunction with 1 active MTrP, in the infraspinatus muscle of older adults with nonspecific shoulder pain. 

Methods: A single-center, randomized, single-blinded, controlled study (NCT02032602) was carried out. Sixty-six patients aged 65 years and older with trigger points in the ipsilateral infraspinatus of the painful shoulder were randomly assigned to (1) of (2) treatment groups. A session of dry needling on the infraspinatus was performed in (1) the most hyperalgesic active and latent MTrP or (2) only the most hyperalgesic active MTrP. The Numeric Rating Scale, the pressure pain threshold (primary outcome) on the anterior deltoid and extensor carpi radialis brevis latent MTrPs, and grip strength were assessed before, after, and 1 week after the intervention. 

Results: Statistically significant differences in the reduction of pain intensity (P ≤ .001; η = 0.159-0.269; d = 1.017-1.219) and the increase of pressure pain threshold (P < .001; η = 0.206-0.481; d = 0.870-1.924) were found for the (1) treatment group immediately and 1 week postintervention. Nevertheless, no statistical significant differences were found in grip strength (P >. 05; η = 0.006-0.033; d = 0.158-0.368). 

Conclusions: One dry needling intervention of the latent MTrP associated with the key active MTrP of the infraspinatus reduces pain intensity and the irritability of the satellite MTrPs located in the referred pain area in the short term in older adults with nonspecific shoulder pain. 

Quality Assessment of Controlled Intervention Studies 

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

Yes  

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

Yes  

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

Yes  

1. Were study participants and providers blinded to treatment group assignment? 

Yes, single blinded  

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

N/A 

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

Yes, 65 years and older with trigger points in the ipsilateral infraspinatus of the painful shoulder 

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

N/A 

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

N/A 

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

Yes  

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

N/A 

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

Yes  

1. 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? 

N/A 

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

N/A 

1. 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 

Significant reduction in pain intensity in Group 1 compared to Group 2 immediately and one week post-intervention. 

Key Finding #2 

Significant improvement in PPT for Group 1 immediately and one week post-intervention, particularly in the anterior deltoid and extensor carpi radialis brevis. 

Key Finding #3 

No statistically significant difference in grip strength between the two groups. 

Please provide your summary of the paper 

The study aimed to evaluate the effectiveness of dry needling on one latent Myofascial Trigger Point along with one active MTrP in the infraspinatus muscle of older adults with nonspecific shoulder pain. A randomized controlled trial was conducted with 66 patients aged 65 and older. They were divided into two groups: one received dry needling on both the most hyperalgesic active and latent MTrPs, while the other received dry needling only on the most hyperalgesic active MTrP. Results showed significant pain reduction and improved PPT in the group treated with both active and latent MTrPs immediately and one week post-intervention. There was no significant difference in grip strength between the two groups. 

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

The study concluded that dry needling targeting both active and latent MTrPs is more effective for reducing pain and increasing PPT in the short term compared to targeting only active MTrPs. This can be utilized in physical therapy to improve short term pain tolerance in patients.  

Article Full Title 

Manual therapy on the diaphragm is beneficial in reducing pain and improving shoulder mobility in subjects with rotator cuff injury: A randomized trial 

Author Names 

Isidro Fernández-López, David Peña-Otero, María Eguillor-Mutiloa, Carmen Bravo-Llatas, María de los Ángeles Atín-Arratibel 

Reviewer Name 

Greysee Floyd, SPT 

Reviewer Affiliation(s)  

Duke University Doctorate of Physical Therapy Program 

Paper Abstract 

Background: Rotator cuff dysfunction is the main cause of shoulder pain. The shoulder and the diaphragm have an important relationship through the myofascial system and through its innervation. 

Objectives: To analyse the effect of diaphragm manual therapy on the symptoms of patients with rotator cuff injury compared to manual treatment on shoulder muscles. 

Methods: A randomized, controlled, single-blind trial of 45 participants diagnosed with rotator cuff injury. The sample were divided into 3 groups of treatment: 1) Manual treatment over the shoulder by ischemic compression of myofascial trigger points (MTP) (Control/Shoulder group -SG-). 2) Diaphragm manual therapy techniques (Diaphragm group -DG-). 3) Active diaphragm mobilization by hypopressive gymnastic exercise (Breathing group -BG-). Shoulder pain using a numerical rating scale (NRS), shoulder range of motion (ROM), and pressure pain threshold (PPT) were evaluated, and compared between groups. 

Results: Both the SG and DG showed a clinically significant improvement, as well as a significant effect size, on the NRS in shoulder flexion and abduction movements. Regarding ROM improvement, only the SG obtained a significant effect size (abduction and external rotation). The PPT at the xiphoid process of the sternum showed a clinically significant improvement in the DG. 

Conclusion: Indirect treatment of the shoulder through a protocol of manual therapy techniques on the diaphragm and intervention on MTP of the rotator cuff have been clinically effective in reducing pain on the NRS immediately, in flexion and abduction movements of the shoulder, and more effective compared to the intervention in the breathing group. 

Quality Assessment of Controlled Intervention Studies  

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

            Randomized Control Trial 

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

            Yes 

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

            Yes 

1. Were study participants and providers blinded to treatment group assignment? 

            No 

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

            Yes 

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

            Yes 

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

            Yes 

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

            Yes 

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

            Yes 

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

            Yes 

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

            Yes 

1. 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 

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

            Yes 

1. 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 

Manual therapy on the diaphragm is clinically effective in reducing shoulder pain in rotator cuff injury in shoulder abduction, extension, flexion, likely due to myofascial and neurological connections between the diaphragm and shoulder. 

Key Finding #2 

Both shoulder myofascial trigger point therapy and diaphragm manual therapy demonstrated clinically significant improvement in pain during shoulder flexion and abduction. 

Key Finding #3 

Hypopressive abdominal exercises showed minimal benefits to patients with rotator cuff injury. 

Paper Summary 

This study investigated the effects of diaphragm manual therapy on patients with rotator cuff injury, comparing it to shoulder muscle manual treatment and active diaphragm mobilization. The study involved 45 participants diagnosed with rotator cuff injury. They were divided into three groups: a shoulder group that received manual treatment over the shoulder by ischemic compression of myofascial trigger points, a diaphragm group that received diaphragm manual therapy techniques, and a breathing group that performed active diaphragm mobilization by hypopressive gymnastic exercise. The primary outcome measures were shoulder pain, shoulder range of motion, and pressure pain threshold. The results showed that both the shoulder and diaphragm manual therapy groups experienced significant reductions in shoulder pain. However, only the shoulder manual therapy group showed significant improvement in shoulder range of motion. Diaphragm manual therapy led to a notable improvement in pressure pain threshold at the xiphoid process of the sternum. The findings suggest that incorporating diaphragm therapy could enhance traditional shoulder pain treatments, though further research is needed to explore long-term effects and combined approaches. 

Clinical Application 

The study suggests that manual therapy on the diaphragm can be a valuable approach for managing shoulder pain in patients with rotator cuff injuries. It addresses an alternative or complementary treatment to traditional shoulder-focused manual therapy. Clinicians may consider incorporating diaphragm manual therapy techniques into their practice. The improvement in pain and pressure pain threshold suggests that this technique could be beneficial in addressing the myofascial connections between the diaphragm and shoulder. Specifically, for patients with shoulder pain from rotator cuff injury, clinicians may consider applying manual therapy techniques to the diaphragm in addition to or instead of direct shoulder treatment. If patients demonstrate significant shoulder mobility impairments, direct shoulder manual therapy may be more beneficial to improve abduction and external rotation. This study helps create an understanding of the relationship between the diaphragm and shoulder, and offers a holistic approach to treating rotator cuff injury by considering the surrounding structures that may impact shoulder dysfunction. 

Article Full Title:

Short-Term Effects of Thoracic Spine Manipulation on Shoulder Impingement

Author Names:

Melina N. Haik PT, PhD , Francisco Alburquerque-Sendín PT, PhD, Paula R. Camargo PT, PhD

Reviewer Name:

Chad Fortin

Reviewer Affiliation:

Duke DPT 2026

Abstract:

Objective

To investigate the short-term effects of thoracic spine manipulation (TSM) on pain, function, scapular kinematics, and scapular muscle activity in individuals with shoulder impingement syndrome.

Design

Randomized controlled trial with blinded assessor and patient.

Setting

Laboratory.

Participants

Patients with shoulder impingement syndrome (N=61).

Interventions

Participants were randomly allocated to TSM group (n=30) or sham-TSM group (n=31) and attended 2 intervention sessions over a 1-week period.

Main Outcome Measures

Scapular kinematics and muscle activity were measured at day 1 (baseline, before the first intervention), day 2 preintervention (before second intervention), day 2 postintervention (after the second intervention), and day 3 (follow-up). Shoulder pain and function were assessed by the Disability of the Arm, Shoulder and Hand questionnaire and Western Ontario Rotator Cuff Index at baseline, day 2 preintervention, and follow-up. An assessor blinded to group assignment measured all outcomes.

Results

Pain decreased by 0.7 points (95% confidence interval, 1.3–0.1 points) at day 2 preintervention and 0.9 points (95% confidence interval, 1.5–0.3 points) at day 2 postintervention in the TSM group. The Disability of the Arm, Shoulder and Hand questionnaire (P=.01) and Western Ontario Rotator Cuff Index (P=.02) scores improved in both groups. Scapular upward rotation increased during arm lowering (P<.01) at day 2 postintervention (5.3°) and follow-up (3.5°) in the TSM group. Upper trapezius activity increased (P<.05) in the sham-TSM group. Middle trapezius, lower trapezius, and serratus anterior decreased activities in both groups during elevation and lowering of the arm.

Conclusions

TSM may increase scapular upward rotation during arm lowering. TSM does not seem to influence activity of the scapular muscles. The results concerning shoulder pain, function, scapular tilt, and internal rotation are not conclusive.

Quality Assessment Tool for Case Series Studies

1. Was the study question or objective clearly stated?

Yes

2. Was the study population clearly and fully described, including a case

definition?

Yes

3. Was the cases consecutive?

No

4. Were the subjects comparable?

Yes

5. Was the intervention clearly described?

Yes

6. Were the outcome measures clearly defined, valid, reliable, and

implemented consistently across all study participants?

Yes

7. Was the length of follow-up adequate?

No

8. Were the statistical methods well-described?

Yes

9. Were the results well-described?

Yes

Key Finding #1

The group that received thoracic spine manipulation experienced a significant reduction in pain per the Numerical Pain Rating Scale (NPRS).

Key Finding #2

The intervention group demonstrated significant short-term improvements in shoulder function when compared with the control group per the Shoulder Pain and Disability Index (SPADI).

Key Finding #3

Patients in the TSM group showed increased active shoulder ROM in flexion and abduction.

Key Finding #4

The study demonstrated short-term functional improvements following TSM but required further research to define long term outcomes.

Please provide your summary of the paper

Thoracic spinal manipulation (TSM) was used to address the impairments of shoulder impingement syndrome (SIS). This study took the form of an RCT and tested roughly 60 participants using both a control group that did not receive TSM. The result was thosewho received TSM demonstrated a significant immediate reduction in pain, and

improved scapular rotation, allowing for increased flexion and adduction.

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

TSM should be considered in the treatment of patients with shoulder limitations or pain, specifically in the presence of SIS. However, this should be supplemented with a sustained, long-term exercise program to ensure consistent progress that will last beyond the short term.

Article Full Title: 

Effects of a physical therapy program combined with manual lymphatic drainage on shoulder function, quality of life, lymphedema incidence, and pain in breast cancer patients with axillary web syndrome following axillary dissection 

Author Names: 

Youngki Cho, Junghwa Do, Sunyoung Jung, Ohyun Kwon and Jae Yong Jeon 

Reviewer Name: 

Maria Gonzalez 

Reviewer Affiliation: 

Duke University School of Medicine, Doctor of Physical Therapy 

Paper Abstract 

This study aims to assess the effects of physical therapy combined with manual lymphatic drainage (MLD) on shoulder function, pain, lymphedema, visible cords and quality of life in breast cancer patients with axillary web syndrome (AWS) following axillary dissection. The study had a total of 41 participants that were randomized into two groups, PT only group and PT combined with MLD group. The study found both groups to have significant improvements in shoulder function, pain and quality of life after four weeks of treatment. The PT combined with MLD group did have more significant improvements when compared to the PT only group.  

Quality Assessment of Controlled Intervention Studies 

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

1. yes 

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

1. yes 

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

1. N/A 

1. Were study participants and providers blinded to treatment group assignment? 

1. yes 

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

1. N/A 

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

1. yes 

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

1. no 

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

1. no 

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

1. N/A 

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

1. N/A 

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

1. yes 

1. 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? 

1. yes 

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

1. yes 

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

1. yes 

Key Finding #1 

Improvement in Lymphedema presence: The study observed lymphedema in the group that only received PT, while it was not present in the PT combined with MLD group. This suggest that when using PT with MLD it can better control lymphedema.  

Key Finding #2 

Shoulder function restoration has positive impact on quality of life: The study found that by improving shoulder function it can lead to improvement in quality of life. This gain in function allows for patients to engage in activities that maybe were limited due to the lack of shoulder function. 

Key Finding #3 

Pain reduction in the PT combined with MLD group: The study found a significant difference between groups when it came to pain. Those in the PT combined with MLD group reported significant less pain than the PT only group. This can be due to MLD being able to reduce muscular pain, lymphedema and chronic complex regional pain syndrome.  

Paper Summary 

The study aimed to evaluate the effects of physical therapy treatments combined with manual lymphatic drainage (MLD) on shoulder function, pain, lymphedema, visible cord, and quality of life in breast cancer patients with axillary web syndrome (AWS). The participants arm volume, shoulder function (muscular strength, active range of motion and Disabilities of the arm, shoulder and hand [DASH]), Quality of Life (QOL) questionnaire and pain were assessed at baseline and after 4 weeks of treatment. Following 4 weeks of treatment, QOL, shoulder flexor strength, DASH and pain scores were significantly improved in both groups. Lymphedema was observed in the PT only group but not in the PT combined with MLD. This concluded that while PT interventions do improve shoulder function, pain and QOL in breast cancer patients with AWS, the addition of MLD decreases arm lymphedema.  

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 had several limitations. One being the lack of a true, no-treatment, control group. This prevented the observation of the natural course of AWS to be done. The study also failed to monitor if prescribed medications like NSAIDs were being taken and how often. Medication consumption could have influenced the findings, specifically with pain. This study does present the potential for future research to be done about MLD being used in combination with PT treatments. Though this study focuses on breast cancer patients, there is room for it to be applied for other diagnoses because MLD improves blood circulation enhances the movement of lymphatic and other tissue fluids, promote tissue softening and fluid clearance to different and unblocked lymphatic areas. Seeing the improvements in strength and range of motion aside from lymphedema improvements, MLD has the potential to become a standardized treatment for Physical Therapists to consider using even if the patient does not have lymphedema.  

Article Full Title: Efficacy of Conservative Therapy in Overhead Athletes with Glenohumeral Internal Rotation Deficit: A Systematic Review and Meta-Analysis 

Author Names: Sandra Jiménez-Del-Barrio, Luis Ceballos-Laita, Almudena Lorenzo-Muñoz, María Teresa Mingo-Gómez , Manuel Rebollo-Salas, José Jesús Jiménez-Rejano 

Reviewer Name: Devin Hage  

Reviewer Affiliation(s): Duke University, Student in the DPT program  

Paper Abstract:  

• Background: To evaluate the effectiveness of conservative therapy in range of movement (ROM), strength, pain, subacromial space and physical function, in overhead athletes with glenohumeral internal rotation deficit (GIRD). 

• Methods: A systematic review and meta-analysis was designed, and the protocol was registered in PROSPERO (CRD42021281559). The databases searched were: PubMed, Cochrane Central Register of Controlled Trials, Physiotherapy Evidence Database, Web of Science and SCOPUS. Randomized controlled trials (RCTs) involving conservative therapy applied in overhead athletes with GIRD were included. Two independent assessors evaluated the quality of the studies with the PEDro scale, and with the Cochrane Risk-of-Bias tool. The overall quality of the evidence was assessed using GRADE. Data on outcomes of interest were extracted by a researcher using RevMan 5.4 software. Estimates were presented as standardized mean differences (SMD) with 95% confidence intervals (CIs). 

• Results: A total of eleven studies involving 514 overhead athletes were included in the systematic review; of these 8 were included in the meta-analysis. The methodological quality of the included RCTs ranged from high to low. Conservative therapy showed significant improvements in internal rotation, adduction, physical function and subacromial space. 

• Conclusions: Conservative therapy based on stretch, passive joint and muscular mobilizations can be useful to improve the internal rotation and adduction ROM, subacromial space, and physical function of the shoulder in overhead athletes with glenohumeral internal rotation deficit. 

Quality Assessment of Systematic Reviews and Meta-Analyses 

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

1. Yes 

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

1. Yes 

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

1. Yes 

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

1. Yes 

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

1. Yes 

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

1. yes 

1. Was publication bias assessed? 

1. Yes 

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

1. Yes 

Key Finding #1: 

•  Conservative therapy, including stretching and manual therapy, significantly improved internal rotation and adduction range of motion (ROM) in overhead athletes with GIRD 

Key Finding #2 

• Conservative therapies did not lead to statistically significant improvements in pain intensity, external rotation ROM and shoulder strength. 

Key Finding #3 

• Conservative therapy based on stretching, manual therapy, and soft tissue mobilization are more effective than control interventions or other conservative therapies for improving internal rotation and adduction ROM. 

Key Finding #4 

• Conservative therapies, including manual therapy, demonstrated moderate quality evidence for increasing subacromial space and low quality of evidence for physical function in overhead athletes with GIRD. 

Please provide your summary of the paper 

• This systematic review included 11 studies capturing a total of 514 participants; of these 11 studies, 8 were included in the meta-analysis. Glenohumeral Internal Rotation Deficit (GIRD) is a common condition in overhead athletes, marked by reduced internal shoulder rotation in the dominant arm. It results from repetitive overhead movements, leading to structural changes such as posterior capsule tightness and increased humeral retroversion. These changes increase the risk of injuries like labral tears and rotator cuff damage while negatively impacting throwing velocity and accuracy. GIRD is assessed by measuring internal rotation deficits and total shoulder motion. A deficit greater than 20° or a total motion difference exceeding 5° is considered significant. Early detection is crucial for preventing long-term damage. Non-surgical treatment involves stretching and strengthening exercises, such as the sleeper stretch and scapular stabilization drills, to restore internal rotation and improve mobility. Severe cases may require surgical intervention, like posterior capsule release. Preventive strategies, including proper warm-ups, structured mobility programs, and recovery protocols, help reduce GIRD risk. The article emphasizes early intervention and individualized rehabilitation to maintain shoulder health and athletic performance. 

• In summary, GIRD significantly affects overhead athletes, requiring effective assessment, rehabilitation, and prevention strategies to minimize injury risk and optimize performance. The systematic review concluded that conservative therapy including stretching, joint and muscular mobilizations are helpful to improve internal rotation and adduction ROM but have limitations regarding pain intensity and shoulder strength. 

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

• Conservative therapy effectively improves internal rotation and adduction range of motion (ROM) in overhead athletes with Glenohumeral Internal Rotation Deficit (GIRD). Physical therapists should incorporate stretching techniques such as the sleeper stretch and cross-body stretch, along with posterior capsule mobilization, to restore ROM. Combining self-stretching exercises with therapist-assisted mobilization can enhance results. Additionally, conservative therapy helps increase subacromial space, reducing the risk of shoulder impingement. Posterior shoulder stretching and soft tissue mobilization techniques can improve shoulder mechanics and prevent further complications. However, the study found that passive therapies alone do not significantly improve shoulder strength. Therefore, physical therapists should integrate progressive resistance exercises, such as TheraBand external rotation exercises, along with motor control and scapular stability exercises to optimize functional strength. While conservative therapy does not significantly reduce pain, physical therapists should adopt a multimodal approach, including manual therapy, exercise therapy, and patient education, to address pain holistically. It is also important to evaluate other contributing factors, such as biomechanics and training load, that may influence pain levels. Although some functional improvements were observed in athletes undergoing conservative therapy, the changes were not clinically significant. To enhance functional performance, therapists should implement sport-specific training drills that translate ROM gains into improved athletic performance. For optimal clinical outcomes, physical therapists should emphasize early intervention to address GIRD before it leads to overuse injuries. Treatment should be individualized, incorporating a combination of manual therapy, stretching, and strengthening exercises based on the athlete’s specific needs. Regular assessment of ROM, strength, and pain levels is crucial to adjusting interventions. Additionally, educating athletes on proper warm-up routines, stretching techniques, and workload management can help prevent GIRD recurrence. By applying these findings in clinical practice, physical therapists can enhance shoulder health, prevent injuries, and improve performance in overhead athletes. 

Article Full Title: 

The Clinical Signi cance of Mulligan’s Mobilization with Movement in Shoulder Pathologies: A Systematic Review and Meta-Analysis 

Author Names: 

Derya Çelik, Pınar Van Der Veer, and Pelin Tiryaki 

Reviewer Name: 

Daniela Hernandez Rodriguez 

Reviewer Affiliation(s):  

SPT 

Paper Abstract: 

Background: Mulligan’s mobilization with movement (MWM) is a manual therapy technique designed to address musculoskeletal pain and joint mobility. Despite immediate reported improvements by patients, the clinical significance of MWM compared with other interventions remains uncertain. 

Objective: To assess the clinical effectiveness of MWM for shoulder pathologies compared with other treatment methods. 

Methods: The databases PubMed, Web of Science, Cochrane Library, Scopus, and the Physiotherapy Evidence Database (PEDro) were searched up to June 2024. Inclusion criteria were limited to randomized con-trolled trials published in English and Turkish languages, focusing on the MWM technique for shoulder pathologies. Two independent reviewers evaluated methodological quality based on the PEDro scale. Outcome data 

were analyzed for pain, function, and range of motion (ROM) using SPSS Statistics 29.0. 

Results: Twenty-seven studies (1157 participants) were included. MWM demonstrated statistical superiority in function (MD= -11.24, 95% CI: [-18.33,-4.16], p= 001) and shoulder flexion and abduction ROM compared with other mobilization techniques. There was a significant MD in pain intensity, which was-1.55 cm (95% CI: [-2.60,-0.51], p= 0.00), with high heterogeneity (I2= 93%), favoring MWM in comparison with control group. MWM was significantly better for shoulder abduction ROM in comparison with physical therapy 

interventions (MD= -14.44, 95% CI: [1.98, 26.90], p= 0.02) with high heterogeneity (I2 

= 90%) and control group (SMD= 56.67, 95% CI: [7.71, 111.63], p= 0.02) with high heterogeneity (I2= 96%). However, clinical significance was not consistently achieved. 

Conclusions: Although some statistical significance was found when comparing MWM with other her treatment methods, it was observed that most of the statistically significant data did not reach clinical significance. Upon closer examination, outcome measures that showed clinical significance, either the interventions in the comparison group were inadequate, not evidence-based, or the improvements within the group were not logical. 

Quality Assessment of Systematic Reviews and Meta-Analyses 

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

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

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

Yes 

1. Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias? No 

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

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

1. Was publication bias assessed? No 

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

Key Finding #1: 

Mulligan’s mobilization with movement technique consists of pain-free, active movement during application of manual therapy, which commonly has a positive response from patients.  

Key Finding #2: 

Mulligan’s mobilization with movement technique significantly improves pain, ROM, and disability in comparison to other mobilization techniques, physical therapy interventions, and a placebo interventions group.  

Key Finding #3: 

Although Mulligan’s mobilization with movement technique shows significant improvements in pain, ROM, and disability, it is to be taken with caution because it does not have significant clinical difference.  

Please provide your summary of the paper 

The objective of this article is to evaluate the clinical efficacy of Mulligan’s mobilization with movement (MWM) technique for shoulder conditions in comparison to other treatment approaches. MWM was created to treat musculoskeletal pain, dysfunction, and restricted joint mobility. Patients usually report immediate improvements with pain, function, and ROM. This system review and meta-analysis compared MWM to other manual therapy techniques, control groups, physical therapy interventions, and sham interventions. MWM was superior in improvements in various ROMs, pain, and disability. This information should be taken with caution due to bias and lack of significant clinical difference.  

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

The information from this article can be useful in clinic. Although the MWM technique does not have significant clinical difference, it can be used in conjunction with other therapeutic techniques to improve ROM or pain. MWM can also be used independently due to patients reporting it causing immediate relief, but clinicians need additional techniques to further rehabilitate the patient. Further research is needed to figure out if MWM truly does or does not have significant clinical difference to be able to apply that information in clinic.

Article Full Title 

Mobilization Techniques in Subjects With Frozen Shoulder Syndrome: Randomized Multiple-Treatment Trial 

Author Names 

Yang J, Chang C, Chen S, Wang S, Lin J 

Reviewer Name 

Michael Hils, SPT 

Reviewer Affiliation(s) 

Duke University 

Paper Abstract 

Background and Purpose 

The purpose of this study was to compare the use of 3 mobilization techniques—end-range mobilization (ERM), mid-range mobilization (MRM), and mobilization with movement (MWM)—in the management of subjects with frozen shoulder syndrome (FSS). 

Subjects 

Twenty-eight subjects with FSS were recruited. 

Methods 

A multiple-treatment trial on 2 groups (A-B-A-C and A-C-A-B, where A=MRM, B=ERM, and C=MWM) was carried out. The duration of each treatment was 3 weeks, for a total of 12 weeks. Outcome measures included the functional score and shoulder kinematics. 

Results 

Overall, subjects in both groups improved over the 12 weeks. Statistically significant improvements were found in ERM and MWM. Additionally, MWM corrected scapulohumeral rhythm significantly better than ERM did. 

Discussion and Conclusion 

In subjects with FSS, ERM and MWM were more effective than MRM in increasing mobility and functional ability. Movement strategies in terms of scapulohumeral rhythm improved after 3 weeks of MWM. 

Key Finding 1 

End-range mobilization [ERM] and mobilization with movement [MWM] were found to be better than mid-range mobilization [MRM] in improving mobility and functional ability in patients with primary idiopathy frozen shoulder syndrome [FSS] in the “frozen” / “stiffness” phase. 

Key Finding 2 

In addition to improving mobility, MWM can also improve motor strategies, specifically scapulohumeral rhythm, in people with FSS in the stiffness phase. 

Key Finding 3 

Given the lack of improvement as compared to the other techniques, as well as the anecdotal evidence of patients losing motivation because of this lack of progress, therapists should avoid MRM as an intervention to improve mobility in patients with FSS in the stiffness phase and opt for other interventions instead. 

Summary of Paper 

In this RCT, the authors investigate the impact of various shoulder mobilization techniques, namely end-range mobilization [ERM], mid-range mobilization [MRM], and mobilization with movement [MWM], in patients with primary idiopathic frozen shoulder syndrome [FSS]. In doing so, the authors set up an experiment in which qualifying subjects are delegated to one of two treatment patterns: A-B-A-C and A-C-A-B (where A=MRM, B=ERM, and C=MWM). Given this, the authors argue that each subject acted as their own control. In this manner, the experiment assesses the potential influence of treatment order as well as the efficacy of the various treatments. Each treatment was given twice weekly for 3 weeks, with the only additional adjunct or home exercise program being “a simple exercise program comprising pendular exercises and scapular setting (isometric scapular retraction).”  At the end of 3 weeks, each patient was assessed for abduction in the scapular plane, hand-to-neck, and hand-to-scapula motions using the FASTRAK motion analysis system. This data was then used to score the patient on the Flexilevel Scale of Shoulder Function and was further broken down into arm elevation, scapular tipping, scapulohumeral rhythm, humeral lateral rotation, and humeral medial rotation. 

Ultimately, ERM and MWM were found to be better than MRM in improving mobility and functional ability. The authors posit that “Although MRM might extend the adhesive capsule, we believe that the adhesive capsule and associated contracted periarticular structures can only be stretched by ERM or MWM.” As a secondary investigation, the authors had also assessed scapulohumeral rhythm in all patients, noting that prior research had shown that improvements in glenohumeral motion did not significantly promote normalization of abnormal scapular motion in patients with FSS. They found that MWM techniques achieved scapulohumeral rhythm in their subjects. 

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

An argument could be made for the implementation of either ERM or MWM or both in patients with FSS, particularly for those whose main deficit is immobility. Notably, the 5 subjects who dropped out (“were lost to follow-up”) all failed to show up to an evaluation at the end of one of the two MRM sections, with the authors citing the reason they didn’t show up as “because there was no improvement”. Given this, an argument against MRM for patients with FSS can be made; both due to the lack of improvement as compared to the other techniques, as well as the anecdotal evidence of patients losing motivation because of this lack of progress. Lastly, it is worth noting that the authors conclude the paper by sharing that all the subjects in the study were in the “stiffness phase” of FSS progression (also referred to as the “frozen” phase), so any takeaways from this research should not necessarily be extrapolated to patients with FSS in other phases or with etiologies other than primary idiopathic FSS. 

Quality Assessment of Controlled Intervention Studies 
1. Was the study described as randomized, a randomized trial, a randomized 
clinical trial, or an RCT 

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

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

Yes 
4. Were study participants and providers blinded to treatment group 
assignment? 

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

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

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

No 

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

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

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

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

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

No 
13. Were outcomes reported or subgroups analyzed prespecified (i.e., 
identified before analyses were conducted)? 

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

Yes 

Article Full Title 

Comparative effects of gong’s mobilization and mobilization with movement in patients with adhesive capsulitis: a randomized clinical trial 
Author Names 

Fareeha Amjad, Hasha Asghar 

Reviewer Name 

Riley Hobson, SPT 

Reviewer Affiliation(s) 

Duke University School of Medicine, Doctor of Physical Therapy Division 

Paper Abstract 

Adhesive Capsulitis results in a progressive contraction of the Glenohumeral joint capsule limiting active and passive range of motion, leading to functional disabilities. Joint mobilization plays a key role in the physical therapy treatment of Adhesive Capsulitis. A relatively new technique, Gong’s Mobilization, has been introduced for the treatment of Adhesive Capsulitis. It is focused on the correction of positional faults through controlled dynamic motion of the Glenohumeral joint. The mainstay of this clinical trial is a comprehensive comparative evaluation of MWM with Gong’s Mobilization as it remains insufficiently explored. The objective of this clinical trial was to compare the effects of Gong’s Mobilization and Mobilization with Movement on pain, range of motion and functional disability in patients with Adhesive Capsulitis. In this triple blinded randomized clinical trial, sixty patients of Adhesive Capsulitis were enrolled within group A (Gong’s Mobilization) and group B (Mobilization with Movement). The treatment protocol covered 12 treatment sessions for 4 weeks. Numeric Pain Rating Scale (NPRS), Goniometer, and Urdu version of Shoulder Pain and Disability Index (U-SPADI) were used to assess the pain, range of motion and functional status respectively. These outcome measures were assessed at baseline, after 6 treatment sessions (2 weeks) and conclusively after 12 treatment sessions (4 weeks). For data analysis, within the group differences were measured by Repeated Measure ANOVA and across the group differences were measured by independent t test. A significant difference within the mean values of baseline, week 2 and week 4 NPRS, ROM, and SPADI score was observed in both study groups (p < 0.001). Results of independent t test used to calculate across the group differences indicated that Gong’s Mobilization was more effective in reducing disability (SPADI)(p < 0.001) and improving ROM(p < 0.001), meanwhile both groups were equally effective in reducing NPRS scores(p = 0.78). Moreover, a medium to large effect size was also observed for all the outcomes, pain(d = 0.5), ROM (d = 0.5–2.7), SPADI(d = 0.5). It was concluded that Gong’s Mobilization is more effective than Movement with Mobilization. Following four weeks of treatment, it pronounced statistically significant and clinically relevant results in improving pain, ROM and functional status of patients with Adhesive Capsulitis. 

Quality Assessment of Controlled Intervention Studies: 

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

Yes 

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

Yes 

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

Yes 

1. Were study participants and providers blinded to treatment group assignments? 

Yes 

1. Were the people assessing the outcomes blinded to the participant’s group assignments? 

Yes 

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

Yes 

1. Was the overall dropout rate from the study at endpoint 20% or lower of the number allocated to treatment? 

Yes 

1. Was the differential dropout rate (between treatment groups) at the endpoint 15 percentage points or lower? 

Yes 

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

Yes 

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

Yes 

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

Yes 

1. 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 

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

Yes 

1. 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 

Gong’s mobilization method produced statistically significant and clinically meaningful results for patients with adhesive capsulitis on the following outcome measures: NPRS, goniometer measurements, and U-SPADI. 

Key Finding #2 

Gong’s mobilization was more effective than mobilization with movement for improving ROM and functional status in patients with adhesive capsulitis. 

Please provide your summary of the paper 

Adhesive capsulitis is a common pathology of the glenohumeral joint which results in progressive restrictions in both active and passive range of motion. Goals for physical therapy are to gain range of motion and functional ability for increased use of the affected shoulder. This is done through stretching, active and passive ROM, and manual therapy. Mobilization of the shoulder joint is often used to address arthrokinematic dysfunction in order to improve range of motion. This study compares two forms of mobilization for the treatment of adhesive capsulitis: Gong’s mobilization and mobilization with movement. Each treatment group received the specified mobilization technique and the following outcome measures were taken at baseline, after 6 treatment sessions, and after 12 treatment sessions: NRPRS, goniometer, and U-SPADI. The study found that Gong’s mobilization was more effective in reducing disability and improving range of motion than mobilization with movement. Both groups demonstrated reduced NPRS scores. A limitation to this study is there was no control group to which participants in the mobilization groups could be compared to. 

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

The study suggests that both mobilization with movement and Gong’s mobilization can decrease pain in patients with adhesive capsulitis. Both types of mobilization resulted in increased range of motion and decreased disability, however Gong’s mobilization was more effective at obtaining these results. These findings suggest that both can be beneficial interventions for the physical therapist treating adhesive capsulitis, however Gong’s mobilization may produce better, longer lasting results in improved range of motion and decreased disability. Recommendation is to use mobilization in addition to active and passive ROM, stretching, strengthening, and other modalities to treat adhesive capsulitis. 

Article Full Title:

Some Factors Predict Successful Short-Term Outcomes in Individuals with Shoulder Pain Receiving Cervicothoracic Manipulation: A Single-Arm Trial   

Author Names:

Paul E. Mintken, Joshua A. Cleland, Kristen J. Carpenter, Melanie L. Bieniek, Mike Keirns, Julia M. Whitman

Reviewer Name:

Samantha Horan, SPT  

Reviewer Affiliation(s):

Duke University Doctor of Physical Therapy  

Paper Abstract:

Background. It has been reported that manipulative therapy directed at the cervical and thoracic spine may improve outcomes in patients with shoulder pain. To date, limited data are available to help physical therapists determine which patients with shoulder pain may experience changes in pain and disability following the application of these interventions.

Objective. The purpose of this study was to identify prognostic factors from the history and physical examination in individuals with shoulder pain who are likely to experience rapid improvement in pain and disability following cervical and thoracic spine manipulation.

Design. This was a prospective single-arm trial.

Setting. This study was conducted in outpatient physical therapy clinics. Participants. The participants were individuals who were seen by physical ther- apists for a primary complaint of shoulder pain.

Intervention and Measurements. Participants underwent a standardized examination and then a series of thrust and nonthrust manipulations directed toward the cervicothoracic spine. Individuals were classified as having achieved a successful outcome at the second and third sessions based on their perceived recovery. Poten- tial prognostic variables were entered into a stepwise logistic regression model to determine the most accurate set of variables for prediction of treatment success.

Results. Data for 80 individuals were included in the data analysis, of which 49 had a successful outcome. Five prognostic variables were retained in the final regression model. If 3 of the 5 variables were present, the chance of achieving a successful outcome improved from 61% to 89% (positive likelihood ratio 5.3).

Limitations. A prospective single-arm trial lacking a control group does not allow for inferences to be made regarding cause and effect. The statistical procedures used may result in “overfitting” of the model, which can result in low precision of the prediction accuracy, and the bivariate analysis may have resulted in the rejection of some important variables.

Conclusions. The identified prognostic variables will allow clinicians to make an a priori identification of individuals with shoulder pain who are likely to experience short-term improvement with cervical and thoracic spine manipulation. Future stud- ies are necessary to validate these findings.

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 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/service/intervention in the general or clinical population of interest?

Yes

4. Were all eligible participants that met the prespecified entry criteria enrolled?

Not stated, but is implied  

5. Was the sample size sufficiently large to provide confidence in the findings?

N/A

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 followup accounted for in the analysis?

N/A

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 outcome measures of interest taken multiple times before the intervention and multiple times after the intervention (i.e., did they use an interrupted time-series design)?

No  

12. If the intervention was conducted at a group level (e.g., a whole hospital, a community, etc.) did the statistical analysis take into account the use of individual-level data to determine effects at the group level?

N/A

Key Finding #1

Some prognostic factors were found that can potentially identify patients with shoulder pain who may find a rapid response in their pain to manual therapy performed at their cervicothoracic spine.  

Key Finding #2

If three out of five of the following variables are present, there is a 89% success rate of cervicothoracic directed manual therapy reducing affecting shoulder pain: pain-free shoulder flexion of <127º, shoulder internal rotation of <53º, a negative Neer test, not taking medications of any kind for shoulder pain, and duration of symptoms of <90 days. If four out of five of those variables are present in a patient, it is likely a 100% success rate.  

Key Finding #3

A longer duration of symptoms than 90 days was shown to have a poorer prognosis with this treatment, but a duration of symptoms ≤ 90 days was one of the strongest predictors of successful outcome.  

Key Finding #4

Both study groups improved significantly in pain-free shoulder flexion ROM following manual therapy.  

Please provide your summary of the paper

It has been known that manual and manipulative therapy directed towards to cervicothoracic spine may positively affect patients who have shoulder pain, but it has not been researched enough as to which patients do benefit from this. This study was created to find specific prognostic factors and variables that patients with shoulder pain have that lead to positive outcomes with manipulative therapy of the CT spine. Five prognostic factors were found to be linked to successful results following cervicothoracic manipulation: pain-free shoulder flexion of <127º, shoulder internal rotation of <53º, a negative Neer test, not taking medications of any kind for shoulder pain, and duration of symptoms of <90 days. If three of the five factors were present in a patient, there was a 89% success rate. If four or five out of the five factors were present, there was a 100% success rate in this study.  

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

The biggest take away of this paper is that physical therapists who treat shoulder pain should look themselves to find prognostic factors in their patients that may be more likely to lead to positive outcomes from manipulative therapy to the cervicothoracic spine. Rather than just treating the shoulder itself due to that being where complaints of pain are, find the root of the problem. Use the 5 prognostic factors found in this study to determine if cervicothoracic manipulation would be beneficial for the patient and try to find any more factors that seem to be reoccurring in patients who present with similar pain and limitations. This can be not only implemented in clinics everywhere but can also be expanded upon to be made more and more successful. This can lead to more efficient and effective treatment of shoulder pain.  

Article Full Title

The application of the Neurac technique vs. manual therapy in patients during the acute phase of subacromial impingement syndrome: A randomized single-blinded controlled trial 

Author Names

Soo-Yong Kim, Zeevi Dvir and Jae-Seop Oh

Reviewer Name

Samantha Horan

Reviewer Affiliation(s)

Duke University Doctor of Physical Therapy

Paper Abstract

Abstract.

BACKGROUD: Although the effect of exercise in patients during the subacute and/or chronic subacromial impingement syn- drome has been reported, only a few studies have examined the effect of pain free exercise in the acute phase of this disorder. OBJECTIVE: To compare the effect of training using the Neurac technique which combines body segments suspension and vibration vs. manual therapy, on various relevant outcome parameters in patients with acute subacromial impingement syndrome (PASIS).

METHOD: Twenty-six patients underwent a 4 week intervention program. Using random assignment, half of the patients were treated using the Neurac device while the other half was treated using manual therapy. The outcome parameters consisted of shoulder pain, shoulder function, range of motion (ROM) and the isokinetic strength of the external and internal rotators at 60 and 180_◦/s.

RESULTS: Following either modes of interventions, the pain, function, and ROM improved significantly compared to pre- intervention levels in both groups. Time-by-group interaction was observed for the rotational strength which increased signifi- cantly and exclusively in the Neurac group.

CONCLUSIONS: Given its positive effect on shoulder pain, function, ROM and the isokinetic strength of the external and internal rotators, we recommend the application of the Neurac technique in PASIS.

Quality Assessment of Controlled Intervention Studies

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

Yes

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

Yes, but method of randomization not explained

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

N/A

4. Were study participants and providers blinded to treatment group assignment? No, participants were blinded, but not providers.
5. Were the people assessing the outcomes blinded to the participants’ group assignments?

N/A

6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)? N/A
7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

N/A

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

N/A

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

N/A

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

Yes, other than Neurac technique and manual therapy

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

Yes

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

N/A

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

Yes

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

Key Finding #1

Both Neurac technique and manual therapy are effective interventions for the acute phase of subacromial impingement syndrome. 

Key Finding #2

Using Neurac technique or manual therapy to treat acute phase subacromial impingement syndrome can decrease pain, elevate function, and increase range of motion. 

Key Finding #3

Using the Neurac technique to treat subacromial impingement syndrome can provide the additional advantage of helping to increase rotational strength. 

Key Finding #4

It is thought that the improvements found using the Nuerac technique could be due to an increase in subacromial space that is formed by strengthening the serratus anterior and lower trap. 

Please provide your summary of the paper

26 female patients with SIS split into two groups – one group receiving Neurac technique as intervention, and the other receiving manual therapy as intervention. Both groups were treated by the same physical therapist who had 10 years of experience in both techniques.  Inclusion criteria included: pain duration of at least 3 weeks since the first episode, pain produced or increased during flexion and/or abduction on the symptomatic side, and at least four positive findings in the following five tests: Neer sign, Hawkins sign, empty can test, painful arc of movement during flexion and/or abduction, and pain with palpation on the greater tuberosity of the humerus. The Neurac group used the Redcord trainer doing exercises that consisted of kneeling shoulder extension, kneeling push-up, supine shoulder abduction, and supine shoulder external rotation. Redcord Stimula was also applied during exercises. The manual therapy interventions included shoulder joint and scapular mobilizations including A-P glides, inferior glides, and distractions. Before and after intervention, patients filled out self-report questionnaires for outcomes. The therapist also tested ROM and strength of internal and external rotators. The VAS was used for pain and the SPADI was used for shoulder function. It was found that using Neurac technique or manual therapy to treat acute phase subacromial impingement syndrome can decrease pain, elevate function, and increase range of motion, but using Neurac can also provide the additional advantage of increasing rotational strength, unlike manual therapy.  

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

This article can be applied to the clinic. It is known that providing manual therapy treatment including various glides can help decrease pain and increase ROM in a person with subacromial impingement. What is special about this paper is it looks specifically at those who are in the acute phase of impingement. What was found in this study is that by using the Neurac technique as opposed to manual therapy, there is the additional bonus of increasing the patient’s internal and external rotational strength. This is what can be applied in the clinic. Even if your clinic does not have Redcord trainers or the therapists are not trained in this technique, it is important to remember to include rotational strengthening to a patient’s exercise plan if they have subacromial impingement, and not just perform manual therapy. 

Article Full Title:

Does manual therapy improve pain, disability, and glenohumeral motion in overhead athletes? Systematic review and meta-analysis 

Author Names:

Santana, S. D., Gava, V., Oliveira, V.M.A., Santos, G.A., Lima, T.A.S., and Kamonseki., D.H.  

Reviewer Name:

Madison Irick

Reviewer Affiliation:

Duke University Doctor of Physical Therapy Division ‘26

Abstract:

Objectives: To systematically review the effects of manual therapy (MT) on pain intensity, disability, internal rotation (IR), external rotation (ER), and horizontal adduction (HA) range of motion (ROM) in overhead athletes. Data sources: Databases (Medline, EMBASE, SPORTDiscus, CINAHL, CENTRAL, Web of Science, and SCOPUS) were searched from inception up to May 2023. 

Study selection: Randomized controlled trials (RCTs) comparing MT to a non-treatment group or other treatment groups were selected. 

Data extraction: Two reviewers independently selected RCTs that investigated the effects of MT on pain intensity, disability, IR, ER, and HA ROM. 

Data synthesis: Mean difference or Standardized Mean Differences, along with 95 % confidence intervals, were calculated for the meta-analysis of each outcome of interest. The level of evidence was synthesized using GRADE.

 Results: Twelve RCTs were included, with a pooled sample of 401 athletes. MT was not superior (p > 0.05) to no treatment in improving pain, disability, IR ROM, and ER ROM, but it was superior to no treatments in improving HA. MT was not superior (p > 0.05) to other treatments in improving ER ROM and HA ROM, but it was superior other treatments in improving IR ROM and disability. Those findings were based on very low certainty of evidence. 

Conclusion: MT may not effectively improve pain and ER ROM. The very low quality of evidence, conflicting findings regarding the effects of MT on disability and IR, and the small, likely clinically irrelevant effects on HA, do not provide sufficient support for a definitive recommendation regarding the effectiveness of MT for treating overhead athletes. 

NIH Risk of Bias Tool: 

Quality Assessment of Systematic Reviews and Meta-Analyses

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

• Yes, the review investigates whether manual therapy improves pain, disability, and glenohumeral motion in overhead athletes.

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

• Yes, the document specifies the inclusion and exclusion criteria.

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

• Yes, the review follows a systematic search strategy, utilizing multiple databases and keywords to ensure a comprehensive collection of relevant studies.

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

• Yes, the review process involved independent assessment by at least two reviewers to ensure unbiased inclusion and exclusion of studies.

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

• Yes, a standard quality assessment tool was used, with independent ratings by at least two reviewers to evaluate the internal validity of included studies.

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

• Yes, the review includes a table summarizing the key characteristics and findings of each included study.

7. Was publication bias assessed?

• Yes, the review assessed publication bias using a risk of bias assessment, the Physiotherapy Evidence-Based database (PEDro) scale, and statistical methods such as funnel plots.

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

• Yes, heterogeneity among the included studies was assessed using statistical tests such as I² and subgroup analyses.

Key Findings of Study:

1. Very low-quality evidence suggests that manual therapy is superior to no treatment to improve horizontal adduction ROM (small and clinically irrelevant effects).
2. Manual therapy may not effectively improve pain intensity and glenohumeral external rotation ROM.
3. There were conflicting results regarding the effects of manual therapy on improving internal rotation ROM and disability.
4. There was not a significant difference observed between different manual therapy techniques.

Reviewer Summary: 

The results indicate that there is insufficient high-quality evidence to support the use of manual therapy for improving pain, disability, and glenohumeral motion in overhead athletes. Although the study included randomized controlled trials, the limited number of studies (12) limits generalizability and highlights the need for larger, more diverse trials to ensure reliability and reproducibility. Variability in inclusion criteria among the primary studies increased heterogeneity and potential bias. Additionally, the effects were assessed only in the short term, leaving uncertainty about their long-term sustainability.

While there was very low-quality evidence suggesting that manual therapy may be slightly more effective than no treatment in improving horizontal adduction range of motion, the effects were minimal and clinically insignificant. Given the current lack of strong evidence demonstrating significant benefits, manual therapy should be used with caution in overhead athletes to improve pain, disability, and glenohumeral motion. Until further high-quality research provides more definitive results, clinicians should consider conservative treatment approaches when managing overhead athletes in clinical practice.

Article Full Title: Effect of adding thoracic manipulation for the management of patients with adhesive capsulitis: a randomized clinical trial 

Full Article Found Here: https://pubmed.ncbi.nlm.nih.gov/38353489/ 

https://web.s.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=0&sid=f826b07d-838b-42ec-8cc1-c7e29981286e%40redis 

Author Names: Ahmed M El Melhat , Rami L Abbas, Moustafa R Zebdawi, Ali Mohamed Ali Ismail 

Reviewer Name: Grace Jager, SPT 

Reviewer Affiliation: Duke Doctor of Physical Therapy 

Study Design: Randomized Clinical Trial 

Paper Abstract: 

The study “Effect of Adding Thoracic Manipulation for the Management of Patients with Adhesive Capsulitis: A Randomized Clinical Trial” aimed to evaluate whether incorporating thoracic spine manipulation (TSM) into standard physical therapy enhances outcomes for patients with adhesive capsulitis (AC). This double-blinded, randomized controlled trial assigned 40 patients to two groups: the experimental group (EG), which received physical therapy combined with TSM, and the control group (CG), which received physical therapy with sham manipulation. Both groups participated in biweekly sessions over 12 weeks. 

Outcome measures included the Visual Analogue Scale (VAS) for pain, Shoulder Pain and Disability Index (SPADI), scapular upward rotation, and shoulder passive range of motion (PROM), assessed at baseline, after the first session, and at six and twelve weeks. Both groups significantly improved pain, disability, scapular upward rotation, and shoulder PROM at six and twelve weeks. However, after one session, the control group showed no significant improvement in pain or disability. At six weeks, the experimental group demonstrated significantly more significant improvements in pain, disability, scapular upward rotation, shoulder flexion, and abduction compared to the control group. 

The study concluded that adding thoracic spine manipulation to physical therapy offers superior clinical benefits for patients with adhesive capsulitis. Limitations include the performance of only two thoracic spine manipulation techniques based on patient comfort, limiting the generalizability of TSM benefits. Thoracic intervertebral movement was not assessed before interventions, potentially affecting results. Additionally,  shoulder internal rotation range of motion was not measured, despite evidence suggesting it may be more restricted than other shoulder movements, which could have led to an overestimation of improvements in shoulder function.  

Quality Assessment of Controlled Intervention Studies  

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

1. Yes  

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

1. No  

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

1. No  

4. Were study participants and providers blinded to treatment group assignment?

1. No  

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

1. Yes 

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

1. Yes  

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

1. N/A ( no dropouts ) 

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

1. N/A 

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

1. Yes 

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

1. No  

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

1. Yes  

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

1. No 

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

1. No 

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

1. Yes  

NIH Risk of Bias Score:  

Quality Assessment of Controlled Intervention Studies: 6/14  

Moderate score: Indicating the study may have areas of bias that may affect reliability of findings.  

A higher score indicates a lower bias. 

Key Findings #1: Thoracic spine manipulation in addition to standard physical therapy resulted in greater improvements in pain, disability, and shoulder mobility after six weeks of treatment compared to standard physical therapy alone. 

Key Findings #2: Significant Early Benefits: The experimental group showed greater improvements in pain, disability, and shoulder movement at six weeks compared to the control group. 

Summary of the Paper: 

This randomized clinical trial investigated the efficacy of incorporating thoracic spine manipulation (TSM) into standard physical therapy for patients with adhesive capsulitis (AC). Forty patients were randomly assigned to either an experimental group receiving physical therapy plus TSM or a control group receiving physical therapy with sham manipulation. Over 12 weeks, both groups attended biweekly sessions. Outcomes measured included pain (VAS), disability (SPADI), scapular upward rotation, and shoulder passive range of motion (PROM), assessed at multiple intervals. Findings revealed significant improvements in both groups over time; however, the experimental group experienced notably greater enhancements in pain relief, disability reduction, scapular upward rotation, and shoulder flexion and abduction, particularly at the six-week mark. The study concluded that adding TSM to physical therapy offers superior benefits for AC patients in reducing pain, disability, scapular upward rotation, shoulder flexion, and abduction. The main limitation noted was the exclusion of passive internal rotation assessment. 

Clinical Interpretation: 

Clinically, this study supports integrating TSM for managing adhesive capsulitis (AC) to improve pain, disability, and shoulder mobility compared to standard physical therapy alone. Additionally, TSM may accelerate pain relief and functional recovery, particularly in early rehabilitation, potentially shortening treatment duration and reducing reliance on pharmaceutical pain management or corticosteroid injections, which carry health risks. From a biomechanical perspective, restricted thoracic motion can alter scapular kinematics, potentially worsening shoulder dysfunction in AC. TSM aims to improve thoracic mobility and optimize scapular positioning and movement, reducing mechanical stress on the glenohumeral joint and enhancing overall treatment outcomes. 

Based on the study findings, PTs should incorporate thoracic spine manipulations early in treatment for adhesive capsulitis to improve pain, disability, and shoulder mobility. Notably, TSM appears particularly effective in pain reduction, as spinal manipulative therapy influences segment-related neurological reflex pathways, altering pain thresholds. However, patient selection and the long-term efficacy of TSM require further investigation. While evidence supports its use, TSM should be applied with informed clinical discernment and in conjunction with other evidence-based interventions for comprehensive AC management. 

Article Full Title:

Efficacy of manual therapy on shoulder pain and function in patients with rotator cuff injury: A systematic review and meta‑analysis

Author Names:

Liu S, Chen L, Shi Q, et al.

Reviewer Name:

Wesley Jenq

Key Findings:

1. Manual therapy alone did not significantly reduce pain when compared to placebo.
2. Manual therapy alone did not significantly improve function.
3. Manual therapy with exercise significantly improved pain relief and function when compared to exercise alone.
4. Manual therapy with multimodal physical therapy improved pain relief and function when compared to physical therapy alone.

Summary:

This article evaluates the effectiveness of manual therapy on pain relief and functional improvement in patients with rotator cuff injuries. The results of the study indicate that manual therapy did not significantly reduce pain or improve junction when done alone. The study did find, however, that when combined with multimodal physical therapy including exercise, manual therapy significantly improved both pain relief and functional outcomes. The study findings suggest that manual therapy is effective in combination with various aspects of physical therapy including exercise, but is not effective alone. This leads to meaningful improvements in managing shoulder injuries such as rotator cuff injuries. 

Clinical Interpretation:

The clinical implications of this study suggest that manual therapy (MT) should not be used as a standalone treatment for rotator cuff injury (RCI), as it does not significantly reduce pain or improve function on its own. However, when combined with exercise therapy and multimodal physical therapy, MT provides meaningful improvements in both pain relief and functional recovery. Therefore, clinicians should integrate MT as part of a comprehensive rehabilitation approach rather than relying on it in isolation.

Article Full Title 

Effectiveness of Proprioceptive Neuromuscular Facilitation and Myofascial Release Techniques in Patients with Subacromial Impingement Syndrome 

Author Names 

Merve Sinem Çelik, Emel Sönmezer, Manolya Acar 

Reviewer Name 

Autumn Kidd, SPT 

Reviewer Affiliation(s) 

Duke University’s Doctor of Physical Therapy Division 

Paper Abstract 

Purpose: To compare the effectiveness of proprioceptive neuromuscular facilitation and myofascial release technique in patients with subacromial impingement syndrome on pain, range of motion, muscle strength, quality of life, functionality and disability. Methods: Thirty patients were randomly divided into two groups: proprioceptive neuromuscular facilitation group (n ¼ 15) and proprioceptive neuromuscular facilitation combined with myofascial release technique group (n ¼ 15). Both treatment methods were performed 3 times a week for 4 weeks. Pain severity was assessed by Visuel Analog Scale, range of motion by a goniometer, muscle strength by digital hand dynamometer, quality of life by Nottingham health profile, functionality by arm, shoulder and hand problems questionnaire, disability by shoulder pain and disability index. All measurements were used before and after treatments. Pain severity, range of motion and muscle strength were also evaluated after the first session. Results: After the treatment, shoulder pain, range of motion, muscle strength, functionality and disability were improved in two groups (p < 0.05). Proprioceptive neuromuscular facilitation showed improvement in pain, whereas myofascial release technique improved pain, physical activity, emotional state, sleep and total dimensions of life quality (p < 0.05). Proprioceptive neuromuscular facilitation was more effective in reducing activity pain, whereas myofascial release technique was more effective in increasing flexion, external and internal rotation range of motion, flexion and abduction muscle strength after the first session (p < 0.05). Conclusions: The combined application of proprioceptive neuromuscular facilitation and myofascial release technique has a more acute and cumulative positive effect on pain, range of motion, muscle strength, functionality, disability and quality of life in patients with subacromial impingement syndrome. 

NIH Risk of Bias Tool 

Quality Assessment of Controlled Intervention Studies 

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

yes 

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

yes 

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

yes 

1. Were study participants and providers blinded to treatment group assignment? 

Unable to tell 

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

unable to tell 

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

yes 

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

yes 

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

yes 

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

yes 

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

yes 

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

yes 

1. 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 

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

Unable to tell 

1. 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 

Range of motion was improved in both groups (PNF alone and PNF with MRT) by 4 weeks but shoulder flexion, abduction, and ER were improved after just 1 week of the combined therapy.  

Key Finding #2 

PNF can be beneficial to use to reduce both acute and cumulative pain in patients with SIS in as little as four weeks.  

Key Finding #3 

In addition to range of motion and pain improvements, PNF with MRT can improve muscle strength, quality of life, and disability and functional status within one week.  

Please provide your summary of the paper 

While reading this article, the results showed that with the use of proprioceptive neuromuscular facilitation (PNF) and myofascial release techniques (MRT) can help improve range of motion, pain, and muscle strength in as little as one week. These results were consistent with patients who have subacromial impingement syndrome. It also showed that these improvement could be seen in patients who received just PNF treatment techniques, however, the results were shown in four weeks, not one. This study was a randomized control trial that used 30 patients, randomly divided into a PNF or PNF and MRT treatment group where treatment was performed 3 times a week for 4 weeks. The observed measures include pain using the visual analog scale, range of motion by a goniometer, muscle strength by a dynamometer, quality of life by Nottingham health profile, and a DASH.  

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 may impact clinical practice because it will allow clinicians in the future to guide their work when treating patients with subacromial impingement syndrome. It allows the clinicians to see the work that was done by the clinicians in this study and use similar approaches to gain successful outcomes in their own patients with expected timelines as well. By knowing the expected timeline to see results, clinicians can decide whether PNF alone or PNF with MRT is the best approach to help improve pain, range of motion, and strength amongst other things in patients with subacromial impingement syndrome.   

Article Full Title: Thoracic manual therapy is not more effective than placebo thoracic manual therapy in patients with shoulder dysfunctions: A systematic review with meta-analysis 

Author Names: Bizzarria. P, Buzzattic. L, Cattryssec.E , Scafoglieric. A 

Reviewer Name: Samantha Kim  

Reviewer Affiliation(s): Duke University DPT 

Paper Abstract: Background: Manual treatments targeting different regions (shoulder, cervical spine, thoracic spine, ribs) have been studied to deal with patients complaining of shoulder pain. Thoracic manual treatments seem able to produce beneficial effects on this group of patients. However, it is not clear whether the patient improvement is a consequence of thoracic manual therapy or a placebo effect. Objectives: To compare the efficacy of thoracic manual therapy and placebo thoracic manual treatment for patients with shoulder dysfunction. Methods: Electronic databases (MEDLINE, CENTRAL, PEDro, CINAHL, WoS, EMBASE, ERIC) were searched through November 2016. Randomized Controlled Trials assessing pain, mobility and function were selected. The Cochrane bias estimation tool was applied. Outcome results were either extracted or computed from raw data. Meta-analysis was performed for outcomes with low heterogeneity. Results: Four studies were included in the review. The methodology of the included studies was generally good except for one study that was rated as high risk of bias. Meta-analysis showed no significant effect for “pain at present” (SMD -0.02; 95% CI: −0.35, 0.32) and “pain during movement” (SMD -0.12; 95% CI: −0.45, 0.21). Conclusion: There is very low to low quality of evidence that a single session of thoracic manual therapy is not more effective than a single session of placebo thoracic manual therapy in patients with shoulder dysfunction at immediate post-treatment. 

Quality Assessment of Systematic Reviews and Meta-Analyses 

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

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

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

1. Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias? No 

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

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

1. Was publication bias assessed? Yes 

1. Was heterogeneity assessed? (This question applies only to meta-analyses.) Yes, low heterongenity 

Key Finding #1 

Patients have poor prognosis when symptoms continue past 6 months and 40% of them have symptoms still present after 18months.  

Key Finding #2 

Patients that are deemed with “non-specific shoulder pain” have a correlation of improvement when manual therapy is done to the thoracic spine that is based on concept of regional interdependence.  

Key Finding #3 

After reviewing methods of thoracic manual therapy vs placebo manual therapy, the results revealed low discrepancy on a more effective implementation for shoulder dysfunction.  

Key Finding #4 

This study revealed the clinical relevance and justification for manual therapy as a manual therapy treatment for shoulder dysfunction. There needs to be stronger evidence and greater research to provide better understanding on the effectiveness on manual therapy for nonspecific shoulder dysfunction.  

Please provide your summary of the paper 

This research article provided a systematic and meta-analysis review on the discrepancy on the effectiveness of manual therapy verses placebo effect on “non-specific” shoulder dysfunction. The results found that thoracic manual therapy (TMT) did not show superior effectiveness compared to placebo effects. The study used methods of patient reported outcomes and tested range of motions with pain scale. With this study there were multiple study trials that found no significant differences between real and placebo TMT. Methods were used for the real TMT with a thoracic thrust manipulation and the placebo being “manual movement” without meeting end range. With these results called for the necessity of greater clinical relevance with thoracic manual therapy and the need for more research on effective treatment option to address shoulder dysfunction and correlation of the thoracic spine.  

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

After reviewing this research article, I believe there was the validity of manual therapy and placebo effect both being effective for the patient and their impairment. I also believe that finding the clinical relevance and discrepancy between the two methods lack research evidence on one being more beneficial then the other. I believe this technique could either be better executed or methods being more consistent with the follow up of strength and stretching. This thought is based on the understanding and clinical research showing the effectiveness of manual therapy combined with strength and stretching. Overall, I believe this paper needs to revisit the methods portion of how the researchers provided more efficient and consistent testing while also having a greater number of participants and higher heterogeneity within the research.  

Article Full Title: “Dry Needling in Overhead Athletes with Myofascial Shoulder Pain: A Systematic Review”

Author Names: Andrea Demeco, Alessandro de Sire, Antonello Salerno, Nicola Marotta, Stefano Palermi, Antonio Frizziero, Cosimo Costantino

Reviewer Name: Mason Kosik

Reviewer Affiliation(s): Duke DPT CO 2026

Paper Abstract: The treatment of myofascial pain in athletes requires a set of rehabilitation techniques that aim to be effective quickly. In this context, dry needling (DNY) has shown interesting results due to its ability to reduce pain in the short term. Thus, the aim of this study was to investigate the role of DNY in managing myofascial shoulder pain in overhead athletes. PubMed, Scopus and Web of Science were screened up to March 2024, to identify studies that met the following inclusion criteria: overhead athletes with shoulder pain with a DNY approach for myofascial trigger points (MTrPs), RCT, case–control study, feasibility study as the study design. Exclusion criteria were studies that did not include athletes, studies that did not focus on the treatment of MTrPs with DNY, other reviews, no full-text availability and papers written in a language other than English. Out of 399 articles, 165 were excluded as duplicates. Of the 234 articles screened, only 6 articles met the inclusion criteria. A total of 6 studies were included in the systematic review. Initial results showed that DNY improved pain rapidly and in the short term; however, there is still no consensus on the minimum number and the interval between treatments. Major findings reported a rapid potential decrease in perceived pain, shoulder disability and an increase in muscle strength; in this scenario, DNY might be a valid solution in a sports rehabilitation setting.

Quality Assessment of Systematic Reviews and Meta-Analyses

1. Is the review based on a focused question that is adequately formulated and described? Yes
2. Were eligibility criteria for included and excluded studies predefined and specified? Yes
3. Did the literature search strategy use a comprehensive, systematic approach? Yes
4. Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

Yes

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

yes

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

Yes

7. Was publication bias assessed?

Not reported

Key Finding #1: All six studies found that dry needling (DNY) treatment improved pain ratings in overhead athletes with myofascial shoulder pain immediately after treatment.

Key Finding #2: Studies comparing DNY to other manual therapy techniques/modalities found no differences between groups in pain rating.

Key Finding #3: Significant improvements in shoulder ROM following DNY treatment compared to control groups.

 Please provide your summary of the paper

     This systematic review looked into the effects of dry needling treatment on overhead athletes. Six studies were included in the review, and the outcomes measured in these studies were pain, pain pressure threshold disability, range of motion, strength, shoulder function, and stiffness/tone. The subjects in each of the studies were overhead athletes, so the results of this study are relevant primarily to this population. The main findings from the outcomes assessed were that DNY appears to be effective in the short term at relieving pain in athletes with myofascial shoulder pain. However, it does not appear to be more effective than other manual therapy modalities in managing myofascial shoulder pain in overhead athletes. There is also evidence that DNY can acutely improve shoulder ROM following 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 results of this systematic review suggest that DNY could be a useful modality for physical therapists working with overhead athletes, particularly for athletes dealing with myofascial shoulder pain. Though a number of outcomes were assessed, DNY seems to be useful for short term pain management, and for acute ROM limitations that may be impacting an athletes performance and/or rehab. Because DNY did not out-perform other manual therapy modalities, it should be presented as an option for athletes for whom it may be appropriate, and it can be continually used for athletes who respond well to initial DNY treatment. Like other manual therapy modalities, DNY should never be the main treatment for athletes, but instead it should be a part of a progressive rehab program directed by a physical therapist. 

Article Full Title 

Combined Effects of Glenohumeral Mobilization, Stretching, and Thoracic Manipulation on Shoulder Internal Rotation Range of Motion 

Author Names 

Swanson, B. T., Hagenbruch, M., Lapaan, B., & Skipalskiy, K. 

Reviewer Name 

Emma Kurtz, SPT 

Reviewer Affiliation(s) 

Duke University School of Medicine, Doctor of Physical Therapy Division 

Paper Abstract 

Background/purpose: Interventions including posterior glenohumeral mobilizations (PGM), sleeper stretches, and thoracic manipulation are commonly used to address posterior shoulder tightness. The purpose of this study was to assess the effects of adding thoracic manipulation to PGM and sleeper stretches on passive range of motion (PROM), joint mobility, and infraspinatus electromyographic (EMG) activity in shoulders with decreased internal rotation (IR) PROM. 

Design: Randomized Sequential Intervention Laboratory Study. 

Methods: Forty individuals with clinically significant IR loss attended two study sessions. Participants were randomized to receive five 30 seconds bouts of either grade III PGM or sleeper stretching. Following a seven-day washout period, all participants attended a second session and received a prescriptive supine HVLA manipulation targeting the T3-4 segment, followed by the previously randomized intervention. Outcome measures included internal rotation PROM, horizontal adduction PROM, posterior glenohumeral joint translation assessed via ultrasound imaging, and EMG activity of the infraspinatus during a PGM. All outcome measures were assessed pre- and immediately post-intervention and compared statistically. 

Results: There were significant within-group, but not between-group, differences for IR and horizontal adduction PROM following a single session of PGM or sleeper stretch. When combined with thoracic manipulation, significantly smaller within session changes of IR PROM were observed for both PGM (mean difference 4.4, p=0.017) and sleeper stretches (mean difference 6.4, p=0.0005). There were no significant between group differences for horizontal adduction PROM, humeral head translation, or EMG activity across all time points. 

Discussion: Both GH posterior mobilizations and sleeper stretches improved IR and horizontal adduction PROM in a single session. The addition of thoracic manipulation prior to local shoulder interventions resulted in smaller gains of both IR and horizontal adduction ROM. 

Level of evidence: Level 2. 

Keywords: manipulation; mobilization; range of motion; shoulder; stretching; thoracic spine. 

Quality Assessment of Controlled Intervention Studies 

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

Yes 

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

Yes 

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

Yes 

1. Were study participants and providers blinded to treatment group assignment? 

No 

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

Yes 

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

Yes 

1. 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 

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

Cannot Determine, Not Reported, or Not Applicable 

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

Yes 

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

Yes 

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

Yes 

1. 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 

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

Yes 

1. 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 

Posterior mobilizations of the glenohumeral joint improved PROM for IR and horizontal adduction within a session.  

Key Finding #2 

Utilization of the sleeper stretch improved PROM for IR and horizontal adduction within a session.  

Key Finding #3 

Addition of thoracic manipulation before the other interventions reduced infraspinatus EMG activity but also slowed down IR and horizontal adduction ROM gains, in other words there was less improvement in session when the thoracic manipulation was utilized before the other intervention methods.  

Please provide your summary of the paper 

This study was examining the effects of posterior glenohumeral mobilizations (PGM) and the sleeper stretch on passive range of motion (PROM), infraspinatus EMG activity, and mobility of the joint particularly in patients experiencing limitations in IR PROM of the shoulder. Participants were divided into two treatment groups, either receiving grade III posterior glenohumeral mobilizations or performing holds of the sleeper stretch in side-lying. Both groups additionally received a thoracic manipulation around the T3-4 segment at the second session preceding their intervention. Both the PGM and the sleeper stretch improved IR and horizontal adduction PROM in an individual session, but the addition of the thoracic manipulation reduced PROM gains for the two groups.  

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 demonstrated that both posterior glenohumeral mobilizations as well as use of the sleeper stretch provide benefit when trying to improve ROM. Ultimately, this study determined that the implementation of thoracic manipulations slowed down improvements in IR and horizontal adduction PROM. Implementation of this technique into treatment must be carefully considered to determine if it is providing benefit to the patient but a multimodal approach involving mobilizations and stretching may prove beneficial to patients.   

Article Full Title:  

Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients with Subacromial Impingement Syndrome: A Case Series 

Author Names: 

Tate, A. R., Mcclure, P. W., Young, I. A., Salvatori, R., & Michener, L. A. (2010). Comprehensive Impairment-Based Exercise and Manual Therapy Intervention for Patients With Subacromial Impingement Syndrome: A Case Series. Journal of Orthopaedic & Sports Physical Therapy, 40(8), 474–493. https://doi.org/10.2519/jospt.2010.3223 

Reviewer Name: Shelby Matheson, SPT 

Reviewer Affiliations: Duke University School of Medicine, Doctor of Physical Therapy Division 

Abstract:  

Background: Few studies have defined the dosage and specific techniques of manual therapy and exercise for rehabilitation for patients with subacromial impingement syndrome. This case series describes a standardized treatment program for subacromial impingement syndrome and the time course and outcomes over a 12-week period. 

Case Description: Ten patients (age range, 19-70 years) with subacromial impingement syndrome defined by inclusion and exclusion criteria were treated with a standardized protocol for 10 visits over 6 to 8 weeks. The protocol included a 3-phase progressive strengthening program, manual stretching, thrust and non-thrust manipulation to the shoulder and spine, patient education, activity modification, and a daily home exercise program of stretching and strengthening. Patients completed a history and measures of impairments and functional disability at 2, 4, 6, and 12 weeks.  

Outcomes: Treatment success was defined as both a 50% improvement on the Disabilities of the Arm, Shoulder, and Hand (DASH) score and a global rating of change of at least “moderately better.” At 6 weeks, 6 of 10 patients had a successful (mean ± SD) DASH outcome score (initial, 33.9 ± 16.2; 6 weeks, 8.1 ± 9.2). At 12 weeks, 8 of 10 patients had a successful DASH outcome score (initial, 33.1 ± 14; 12 weeks, 8.3 ± 6.4). As a group, the largest improvement was in the first 2 weeks. The most common impairments for all 10 patients were rotator cuff and trapezius muscle weakness (10 of 10 patients), limited shoulder internal rotation motion (8 of 10 patients), and reduced kyphosis of the mid-thoracic area (7 of 10 patients).  

Discussion: A program aimed at strengthening rotator cuff and scapular muscles, with stretching and manual therapy aimed at thoracic spine and the posterior and inferior soft-tissue structures of the glenohumeral joint appeared to be successful in the majority of patients. This case series describes a comprehensive impairment-based treatment which resulted in symptomatic and functional improvement in 8 of 10 patients in 6 to 12 weeks.  

Level of Evidence: Therapy, level 4. 

Study Design: Case Series 

NIH Risk of Bias Tool: 

Quality Assessment Tool for Case Series Studies 

1. Was the study question or objective clearly stated? Yes. 

1. Was the study population clearly and fully described, including a case definition? Yes. 

1. Were the cases consecutive? Yes. 

1. Were the subjects comparable? Yes. 

1. Was the intervention clearly described? Yes. 

1. Were the outcome measures clearly defined, valid, reliable, and implemented consistently across all study participants? Yes. 

1. Was the length of follow-up adequate? Yes. 

1. Were the statistical methods well-described? No. 

1. Were the results well-described? Yes. 

Key Findings:  

1. A treatment approach for SAIS involving thrust and non-thrust manipulation techniques, a consistent stretching program, a progressive 3-phase strengthening program, patient education, and a home exercise program has been shown in this study to improve pain and functional outcomes for patients.  

1. This program should include manual therapy targeted at the thoracic spine, posterior shoulder, and inferior shoulder; strengthening of the scapular stabilizers and rotator cuff focused on reducing pain and gaining motor control during functional movements; and education on posture and body mechanics, and avoiding positions that invoke symptoms.  

1. By discharge, 6 of 10 patients achieved success in terms of shoulder pain and functional improvements, and by the 12-week follow-up appointment, all 6 patients maintained these improvements with the addition of 2 more patients achieving success.  

Reviewer Summary:  

Manual therapy techniques coupled with a targeted exercise program and appropriate patient education has been shown in previous studies to improve pain and functional limitations in patients experiencing symptoms consistent with subacromial impingement syndrome (SAIS), which is a common condition treated by physical therapists. This case series was designed to tailor a treatment program that includes manual therapy techniques, stretching and strengthening exercises, patient education, and a home exercise program as a standardized intervention for SAIS and to describe patient outcomes both in the short- (6 weeks) and long-term (12 weeks). Ten patients exhibiting symptoms consistent with SAIS and who had not previously undergone surgery or prior shoulder rehabilitation on the symptomatic side were treated for 10 visits over a period of 6-8 weeks. An initial evaluation including an upper quarter screen, postural assessment, spring testing, active and passive range of motion of the shoulder, manual muscle testing of the middle and lower traps and serratus anterior, and special tests for impingement, labral tears, instability, and full-thickness rotator cuff tears were performed for all patients and their specific impairments determined. Patients were assessed and treated by 1 of 8 physical therapists specifically trained in the manual therapy interventions performed during this study. All clinicians were provided a list of manual therapy, stretching, and strengthening interventions they could use during treatment. Manual therapy thrust and/or non-thrust manipulations were performed for 10-15 minutes of each session and physical therapists were required to perform at least one technique each for the thoracic spine, posterior glenohumeral joint, and inferior glenohumeral joint. Specific techniques were determined based on examination findings, but all clinicians were encouraged to implement a thrust manipulation technique for the thoracic spine as this has been shown to promote greater shoulder range of motion. Motor control/strengthening exercises were performed in 3 phases, with mastery of one phase preceding progression to the next phase. Each exercise was performed in 2-3 sets of 10 repetitions using a succession of Thera-Bands. Phase 1 involved rotator cuff strengthening with the humerus in a neutral position, Phase 2 introduced elevation exercises and progressive strengthening for the serratus anterior and trapezius, and Phase 3 incorporated trunk strengthening and higher-level strengthening of the shoulder muscles, as well as endurance training. Stretching exercises, performed in 3 repetitions of 30-second holds, were implemented throughout all 3 phases. Patient education targeted appropriate posture and body mechanics to avoid pain. A home exercise program that reflected the program executed in the clinic was provided to each patient. For outcome measures, the authors utilized pain intensity during functional activity via the Penn Shoulder Scale, the Disabilities of the Arm and Shoulder (DASH) questionnaire, and the Global Rating of Change (GRC) question at 2, 4, 6, and 12 weeks. Based on these outcome measures, they found that 6 of 10 patients achieved success (defined by an improvement of >50% on the DASH and a rating of “moderately better” or greater on the GRC) at discharge (6-weeks), and 8 of 10 patients achieved success at the 12-week follow-up. Improvements in pain scores at both 6 and 12 weeks exceeded the minimal detectable change. This outcome suggests that a comprehensive therapy program including targeted manual therapy, exercise, and education can be used as an effective treatment approach to managing symptoms of SAIS in order to improve function, mobility, and pain. 

Clinical Interpretation: 

Considering that shoulder pain, specifically SAIS, is a common impairment treated by physical therapists, it is important to determine the most appropriate treatment approach for these patients. As research shows that weakness in the trapezius and rotator cuff muscles, shoulder internal rotation range of motion deficits, and reduced thoracic kyphosis and hypomobility of the thoracic spine are among the most common impairments in patients with SAIS, tailoring a treatment to specifically target these deficits should improve patients’ symptoms. Thus, physical therapists should consider implementing the manual therapy, exercise, and education program presented in this study to treat patients presenting with symptoms consistent with SAIS for the purpose of reducing pain and gaining functional strength and movement.  

Article Full Title 

Comparison of high-grade and low-grade mobilization techniques in the management of adhesive capsulitis of the shoulder: randomized controlled trial 

Author Names 

Vermeulen, H; Rozing, P; Obermann, W; Cessie, S; Violet Vlieland, T 

Reviewer Name 

Elena Renke 

Reviewer Affiliation(s) 

Duke University School of Medicine, Doctor of Physical Therapy Division 

Paper Abstract 

Background and purpose: In many physical therapy programs for subjects with adhesive capsulitis of the shoulder, mobilization techniques are an important part of the intervention. The purpose of this study was to compare the effectiveness of high-grade mobilization techniques (HGMT) with that of low-grade mobilization techniques (LGMT) in subjects with adhesive capsulitis of the shoulder. 

Subjects: One hundred subjects with unilateral adhesive capsulitis lasting 3 months or more and a > or =50% decrease in passive joint mobility relative to the nonaffected side were enrolled in this study. 

Methods: Subjects randomly assigned to the HGMT group were treated with intensive passive mobilization techniques in end-range positions of the glenohumeral joint, and subjects in the LGMT group were treated with passive mobilization techniques within the pain-free zone. The duration of treatment was a maximum of 12 weeks (24 sessions) in both groups. Subjects were assessed at baseline and at 3, 6, and 12 months by a masked assessor. Primary outcome measures included active and passive range of motion and shoulder disability (Shoulder Rating Questionnaire [SRQ] and Shoulder Disability Questionnaire [SDQ]). An analysis of covariance with adjustments for baseline values and a general linear mixed-effect model for repeated measurements were used to compare the change scores for the 2 treatment groups at the various time points and over the total period of 1 year, respectively. 

Results: Overall, subjects in both groups improved over 12 months. Statistically significant greater change scores were found in the HGMT group for passive abduction (at the time points 3 and 12 months), and for active and passive external rotation (at 12 months). A statistically significant difference in trend between both groups over the total follow-up period of 12 months was found for passive external rotation, SRQ, and SDQ with greater change scores in the HGMT group. 

Discussion and conclusion: In subjects with adhesive capsulitis of the shoulder, HGMTs appear to be more effective in improving glenohumeral joint mobility and reducing disability than LGMTs, with the overall differences between the 2 interventions being small. 

Quality Assessment of Controlled Intervention Studies 

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

Yes 

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

Yes 

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

Not Reported 

1. Were study participants and providers blinded to treatment group assignment? 

No 

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

Yes 

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

Yes 

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

Yes 

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

Yes 

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

Not Reported 

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

Yes 

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

Yes 

1. 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 

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

Yes 

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

Yes 

Key Finding #1 

Both high-grade mobilization techniques (HGMT) and low-grade mobilization techniques (LGMT) resulted in improved range of motion and decreased shoulder disability over 12 months in patients with adhesive capsulitis of the shoulder. 

Key Finding #2 

HGMT resulted in significantly greater improvements in shoulder ROM for patients with adhesive capsulitis of the shoulder compared to those who received LGMT.  

Key Finding #3 

HGMT resulted in a greater improvement in shoulder disability for individuals with adhesive capsulitis as measured by the Shoulder Rating Questionnaire (SRQ) and Shoulder Disability Questionnaire (SDQ) compared to those who received LGMT.  

Please provide your summary of the paper 

The purpose of this study was to identify any difference in the effectiveness of using high-grade mobilization techniques (HGMT) compared to low-grade mobilization techniques (LGMT) to improve shoulder range of motion (ROM) and decrease shoulder disability in individuals with unilateral adhesive capsulitis of the shoulder. The subjects received either HGMT at an end-range position or LGMT within a pain-free range for 24 sessions over 12 weeks. At 3, 6, and 12 months primary outcome measures of shoulder active and passive ROM as well as shoulder disability measured by the Shoulder Rating Questionnaire (SRQ) and Shoulder Disability Questionnaire (SDQ) were taken and compared to baseline measures. It was found that while both treatment groups resulted in improved outcomes over the 12 months, the HGMT group experienced greater improvements. The HGMT group had statistically greater improvements for passive abduction as well as active and passive external rotation compared to the LGMT group. Additionally, shoulder disability was more significantly improved in the HGMT group. The study concluded that HGMT interventions were more effective for the management of adhesive capsulitis of the shoulder, but LGMT interventions can still provide benefits.  

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 findings of this paper, high-grade mobilization techniques (HGMT) applied at the end-range of motion can be used as an effective intervention to manage adhesive capsulitis of the shoulder in order to improve range of motion (ROM) and shoulder disability. In patients who may not be able to tolerate HGMT, low-grade mobilization techniques (LGMT) may also be implemented within a pain-free range to improve ROM and shoulder disability, but this technique is less effective than HGMT. Overall the difference in effectiveness between HGMT and LGMT was found to be significant but small. Therefore patient and clinician preference may be more important in deciding which intervention to use in order to most effectively manage the adhesive capsulitis.  

Article Full Title: 

Effect of Two Rehabilitation Protocols on Range of Motion and Healing Rates After Arthroscopic Rotator Cuff Repair: Aggressive Versus Limited Early Passive Exercises 

Author Names: 

Bong Gun Lee, M.D., Nam Su Cho, M.D., and Yong Girl Rhee, M.D. 

Reviewer Name: 

Haylee Rice 

Reviewer Affiliation: 

Duke University School of Medicine, Doctor of Physical Therapy Division 

Paper Abstract 

Purpose: To compare range of motion and healing rates between 2 different rehabilitation protocols after arthroscopic single-row repair for full-thickness rotator cuff tear. Methods: Sixty-four shoulders available for postoperative magnetic resonance imaging (MRI) evaluation after arthroscopic rotator cuff repair were enrolled in this study. Aggressive early passive rehabilitation (manual therapy [2 times per day] and unlimited self–passive stretching exercise) was performed in 30 shoulders (group A) and limited early passive rehabilitation (limited continuous passive motion exercise and limited self–passive exercise) in 34 shoulders (group B). A postoperative MRI scan was performed at a mean of 7.6 months (range, 6 to 12 months) after surgery. Results: Regarding range of motion, group A improved more rapidly in forward flexion, external rotation at the side, internal and external rotation at 90° of abduction, and abduction than group B until 3 months postoperatively with significant differences. However, there were no statistically significant differences between the 2 groups at 1-year follow-up (P  .827 for forward flexion, P  .132 for external rotation at the side, P  .661 for external rotation at 90° of abduction, and P  .252 for abduction), except in internal rotation at 90° of abduction (P  .021). In assessing the repair integrity with postoperative MRI scans, 7 of 30 cases (23.3%) in group A and 3 of 34 cases (8.8%) in group B had retears, but the difference was not statistically significant (P  .106). Conclusions: Pain, range of motion, muscle strength, and function all significantly improved after arthroscopic rotator cuff repair, regardless of early postoperative rehabilitation protocols. However, aggressive early motion may increase the possibility of anatomic failure at the repaired cuff. A gentle rehabilitation protocol with limits in range of motion and exercise times after arthroscopic rotator cuff repair would be better for tendon healing without taking any substantial risks. Level of Evidence: Level II, randomized controlled trial. 

Quality Assessment of Controlled Intervention Studies 

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

• Yes  

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

• Yes 

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

• Yes 

1. Were study participants and providers blinded to treatment group assignment? 

• Yes 

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

• Yes 

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

• Yes 

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

• Yes 

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

• Yes 

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

• Unknown 

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

• Unknown 

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

• Yes  

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

• No 

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

• Yes 

1. 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 

• Aggressive early passive motion may lead to failure of the repaired cuff.  

Key Finding #2 

• Both groups A and B showed improvement in pain, ROM, muscle strength, and function.  

Key Finding #3 

• Group A regained ROM faster than group B, specifically in forward flexion, abduction and ER and IR at 90 degrees of abduction.  

Please provide your summary of the paper 

• The purpose of this study was to compare the effects of two rehabilitation protocols on range of motion and healing rates after rotator cuff repair. The first rehabilitation protocol involved aggressive early passive exercises and the second focused on limited early passive exercises. 64 participants were divided into two groups.  30 were assigned to the aggressive early passive rehabilitation group (group A) which involved manual therapy 2 times per day (forward flexion to tolerable angle and ER up to 30 degrees) and unlimited self-passive stretching exercises. 34 were assigned to the limited early passive group (group B) which involved limited continuous passive motion exercise and limited self-passive exercise. Pain, ROM, and muscle strength were evaluated preoperatively, at 3 months, 6 months, and 1-year post-op. Structural outcome of the repair was evaluated with a postoperative MRI 1-year post-op. The study concluded that both rehab approaches were effective in improving ROM, pain, and muscle strength. Results also showed that although aggressive early rehabilitation led to faster recovery of ROM it is associated with a higher risk of re-injury. Future studies with a larger sample size and measures to assure adherence are needed to better determine the effectiveness of post-op rehabilitation protocols.  

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 are valuable as they demonstrate that both rehabilitation approaches can be effective. This insight allows clinicians to tailor treatment plans based on the unique needs of each patient. While some patients may be better suited for an aggressive early rehabilitation protocol, others may require a more cautious approach. Understanding that both protocols offer benefits enables PTs to make informed decisions and customize rehabilitation plans for optimal outcomes. 

Article Full Title:  

Do Manual Therapy Techniques Help in Patients with Frozen Shoulder?: A Systematic Literature Review 

Author Names 

Husna Ishaq, Mizbah Zuber, Praveen Kumar Kandakurti, & Watson Arulsingh 

Reviewer Name 

Megan Ringo, Student Physical Therapist 

Reviewer Affiliation(s) 

Duke DPT, Class of 2026 

Paper Abstract: 

Objectives: The objective of this review is to find out the updated manual therapy techniques for patients with frozen shoulders. 

Design: A systematic review of literature. 

Methods: Databases including Medline, PEDro, CINAHL, and the Cochrane Library were searched from 2005 to 2021. Only English language publications reporting findings in humans were included. 

Results: After a thorough investigation of 23 articles, 4 RCTs were found in support of the Kaltenborn technique. This technique showed better results in 2–6 weeks for reduction of pain, and enhancement of ROM and functional activity. In the case of Mulligan’s technique, 3 RCTs were compiled in support of a high level of evidence. Mulligan’s technique showed results in 2–3 months with positive effects on pain, ROM, and functional improvement. Immediate relief of shoulder pain and improvement of shoulder ROM were reported after the mobilization on the asymptomatic cervical and thoracic spine. 

Conclusion: Most of the techniques revolved around immediate relief of pain and short-term fix for the condition. Future studies and research can focus on more RCTs required on the long-term benefits of primary adhesive capsulitis. 

KEY WORDS: adhesive capsulitis, frozen shoulder, manual therapy, cervical spine, thoracic spine 

NIH Risk of Bias Tool 

Quality Assessment of Systematic Reviews and Meta-Analyses 

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

Yes 

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

Yes 

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

Yes 

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

Yes 

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

Yes 

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

Yes 

7. Was publication bias assessed?

No 

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

N/A 

Key Finding #1 

Strong level of evidence with use of Kaltenborn mobilization in terms of enhancement in range of motion in individuals with primary adhesive capsulitis. Recommended dosage is 3 sets of 10 glides, 3 times per week. 

Key Finding #2 

Strong level of evidence with use of Mulligan mobilization in terms of enhancement in abduction range of motion in individuals with primary adhesive capsulitis. Recommended dosage is 10 repetitions of 3 sets prioritizing posterolateral and inferior glides.  

Key Finding #3 

Strong level of evidence for scapular mobilization in terms of enhancement in range of motion, specifically with external rotation, in individuals with primary adhesive capsulitis.  

Please provide your summary of the paper 

The purpose of this study was to compile the existing literature examining the current manual therapy intervention approaches in the treatment of individuals with adhesive capsulitis, and analyze which methods may be more effective than others. In order to keep the findings from these papers consistent and accurate to the individuals they were treating, the authors of this systematic review decided to focus on studies specifically treating individuals with primary adhesive capsulitis. Four investigators were in charge of searching the literature from 2005 to 2021, and an initial 34 articles were selected. Following further screening, 11 articles were excluded due to the fact that they did not fit the inclusion criteria. As a result, 23 articles in total were utilized for this systematic review, and 9 total manual therapy techniques were reported throughout. Level I evidence supported the use of scapular mobilization, end range mobilization of GHJ, Mulligan mobilization, and the Maitland mobilization techniques in regards to improvement in range of motion in individuals with primary adhesive capsulitis. Level II evidence supports the use of manual muscle release, and thoracic and rib manual therapy in regards to short term results. Limitations to this study include certain ambiguity in some of the articles used in regards to classification of the specific type of adhesive capsulitis their participants had.  

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 could potentially be very beneficial for newer clinicians or DPT students entering their first jobs in outpatient orthopedics. A lot of times the amount of available interventions can be overwhelming for individuals who are new to clinical practice, and this review did a great job of summarizing everything that is currently out there in regards to treatment of primary adhesive capsulitis, and clearly states which interventions are most impactful.  Additionally, recommended dosage was provided in this paper for each specific intervention which makes clinical reintegration of this knowledge incredibly feasible for the new professional.  

Article Full Title: Effectiveness of the end-range mobilization and scapular mobilization approach in a subgroup of subjects with frozen shoulder syndrome: a randomized control trial 

Author Names: Yang, J., Jan, M., Chang, C., & Lin, J. 

Reviewer Name: Alex Roque, MA, SPT 

Reviewer Affiliation(s): Duke Doctor of Physical Therapy 

Paper Abstract: Treatment strategies targeting abnormal shoulder kinematics may prevent pathology or if the pathology develops, shorten its duration. We examined the effectiveness of the end-range mobilization/scapular mobilization treatment approach (EMSMTA) in a subgroup of subjects with frozen shoulder syndrome (FSS). Based on the kinematics criteria from a prediction method, 34 subjects with FSS were recruited. Eleven subjects were assigned to the control group, and 23 subjects who met the criteria were randomly assigned to the criteria-control group with a standardized physical therapy program or to the EMSMTA group. Subjects attended treatment sessions twice a week for 8 weeks. Range of motion (ROM), disability score, and shoulder complex kinematics were obtained at the beginning, 4 weeks, and 8 weeks. Subjects in the EMSMTA group experienced greater improvement in outcomes compared with the criteria-control group at 4 weeks (mean difference¼ 0.2 of normalized hand-behind-back reach) and 8 weeks (mean difference¼ 22.4 degrees humeral external rotation, 0.31 of normalized hand-behind-back reach, 7.5 disability, 5 degrees tipping and 0.32 rhythm ratio). Similar improvements were found between the EMSMTA group and control group. The EMSMTA was more effective than a standardized physical therapy program in a subgroup of subjects who t the criteria from a prediction method. 

Quality Assessment of Controlled Intervention Studies 

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

1. Yes 

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

1. Yes 

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

1. No 

1. Were study participants and providers blinded to treatment group assignment? 

1. No 

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

1. Yes 

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

1. Yes 

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

1. Yes 

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

1. Yes 

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

1. Yes 

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

1. Yes 

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

1. Yes 

1. 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? 

1. Yes 

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

1. Yes 

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

1. Yes 

NIH Risk of Bias Score: 13/14 

Key Finding #1 

Frozen shoulder patients who underwent end-range mobilization/scapular mobilization treatment experienced greater improvements in range of motion, disability score, and shoulder complex kinematics compared to patients who received standard physical therapy.  

Key Finding #2 

Eleven frozen shoulder patients (control group) who received underwent standard physical therapy who did not meet the following criteria – 8 degrees of scapular posterior tipping, 97 degrees of humeral elevation, and 39 degrees of humeral external rotation during arm elevation – improved similarly to frozen shoulder patients who met the criteria and received end-range mobilization/scapular mobilization treatment. 

Please provide your summary of the paper 

This study examined whether better treatment outcomes would occur in frozen shoulder subjects who received specific treatment techniques. Thirty-four frozen shoulder patients were recruited if they had at least 50% loss of passive range of the shoulder joint in at least two or more directions (flexion, abduction, and external rotation) compared to the nonaffected side and experienced symptoms for at least three months. Eleven patients did not meet the following criteria – 8 degrees of scapular posterior tipping, 97 degrees of humeral elevation, and 39 degrees of humeral external rotation during arm elevation – were placed in the control group. The remaining patients, who met at least one of the criteria, were placed in the criteria-control group or the intervention group. The intervention group received end range mobilization/scapular mobilization treatment approach (EMSMTA) in addition to standard physical therapy while the control and criteria-control groups underwent only standard physical therapy. Subjects attended treatment sessions twice a week for eight weeks. Outcome were passive range of motion (ROM), Flexilevel Scale of Shoulder Function (FLEX-SF) as a disability assessment, and shoulder complex kinematic using the FASTRAK motion analysis system. Outcomes were measured at baseline, four weeks, and eight weeks. The intervention group had greater outcome improvements compared to the criteria-control group at four-week and eight-week marks. However, improvements between the intervention group and the control group were similar.  

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

The authors of this study found that subgroups of frozen shoulder patients experience better outcomes when interventions are tailored to their impairments. These findings emphasize the importance of thorough examination and assessment to identify each patient’s unique impairments and guide their personalized treatment plans. Physical therapists should consider incorporating end-range mobilization and scapular mobilization treatment in frozen shoulder patients who meet at least one of the following criteria: 8 degrees of posterior tipping, 97 degrees of humeral elevation, or 39 degrees of humeral external rotation during arm elevation. Patients who do not meet the criteria are likely to improve with standard physical therapy. Bringing the findings to a more general scope, physical therapists should take into account each patient’s individual impairments and implement interventions that address those specific needs.