Author Names
Ho, C; Sole, G; Munn, J
Reviewer Name
Andres Carro, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Abstract A systematic review of randomised controlled trials (RCTs) was conducted to determine the effectiveness of manual therapy (MT) techniques for the management of musculoskeletal disorders of the shoulder. Seven electronic databases were searched up to January 2007, and reference lists of retrieved articles and relevant MT journals were screened. Fourteen RCTs met the inclusion criteria and their methodological qualities were assessed using the PEDro scale. Results were analyzed within diagnostic subgroups (adhesive capsulitis (AC), shoulder impingement syndrome [SIS], non-specific shoulder pain/dysfunc- tion) and a qualitative analysis using levels of evidence to define treatment effectiveness was applied. For SIS, there was no clear evidence to suggest additional benefits of MT to other interventions. MT was not shown to be more effective than other conservative interventions for AC, however, massage and Mobilizations-with-Movement may be useful in comparison to no treatment for short-term outcomes for shoulder dysfunction.
NIH Risk of Bias Tool
Quality Assessment of Systematic Reviews and Meta-Analyses
- Is the review based on a focused question that is adequately formulated and described?
- Yes
- Were eligibility criteria for included and excluded studies predefined and specified?
- Yes
- Did the literature search strategy use a comprehensive, systematic approach?
- Yes
- Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?
- Yes
- Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?
- Were the included studies listed along with important characteristics and results of each study?
- Yes
- Was publication bias assessed?
- Yes
- Was heterogeneity assessed? (This question applies only to meta-analyses.)
- Cannot Determine, Not Reported, Not Applicable
Key Finding #1
Vermeulen et al. (2006) found that high grade joint mobilizations of the shoulder were more effective than low grade mobilizations when measuring active range of motion (AROM), passive range of motion (PROM), and long-term functional outcomes immediately after the treatment and 12 months after the intervention period for patients with adhesive capsulitis (AC).
Key Finding #2
Nicholson (1985) found that mobilizations with exercise had a greater effect on PROM than exercise alone for patients with AC.
Key Finding #3
For patients with shoulder impingement syndrome (SIS), Bang and Deyle (2000) found that “pragmatic manual therapy” was effective in the improvement of function when compared to exercise alone, and Citaker et al. (2005) found that joint mobilization had a greater effect on function than PNF.
Key Finding #4
Winters et al. found that manipulation was more effective for function than “traditional physiotherapy” for treating those with complaints originating from the shoulder girdle, yet in those with synovial shoulder complaints manipulation was no more effective than traditional physiotherapy.
Please provide your summary of the paper
This is a high quality systematic review of the literature on the use of manual therapy (MT) for the treatment of musculoskeletal (MSK) disorders of the shoulder. This systematic review shows that manual therapy can be a useful as a solo and/or an adjunct therapy for certain MSK shoulder disorders, but there are some instances where the evidence does not support the use of MT. For example, manipulation was shown to be ineffective in treating complaints of the shoulder that had a synovial structure origination when compared to traditional physiotherapy or corticosteroid injection. The review found that limited evidence for the use of MT in the management of those with shoulder impingement syndrome (SIS), yet still state that clinicians should consider the use of soft tissue and joint mobilization in addition to exercise for patients with SIS. The review also found that while MT may not be more effective than other interventions for improving pain and ROM for patients with adhesive capsulitis (AC), high-grade mobilizations may be more effective in improving ROM and function in the long term than low-grade mobilizations. Finally, this review found conflicting evidence for the use of MT in the management of unspecified shoulder pain and improving function in the short term and moderate evidence that MT was not more effective in these same measures of patient outcome in the long term, yet massage and MWM techniques demonstrated utility for short-term outcomes when compared to no treatment. The authors conclude that further high quality RCTs need to be conducted and reviewed that have clear shoulder diagnosis definitions, clear treatment descriptions, and adequate follow-up periods and sample sizes.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
There are multiple outcomes for patients with different shoulder pathologies that manual therapy (MT) can be beneficial for such as active and passive ROM, long term function, and pain. Yet in some instances there is conflicting evidence in the efficacy of MT when compared to other modalities and forms of treatment. This indicates the need for additional high quality RCTs in the hopes that a trend of evidence will be seen pertaining to the true effect of manual therapy on different shoulder pathologies. In the meantime, this systematic review can be utilized by the clinician as a guide to their clinical reasoning as to why they may want to use manual therapy as a treatment for adhesive capsulitis, shoulder impingement syndrome, and non-specific shoulder pain.
