Author Names
Desjardins-Charbonneau, A., Roy, J S., Dionne, C., Frémont, P., Macdermid, J., Desmeules, F.
Reviewer Name
Alyssa Bush, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
The objective of this study was to evaluate the efficacy of manual therapy (MT) for patients with rotator cuff (RC) tendinopathy. Rotator cuff tendinopathy is a highly prevalent musculoskeletal disorder, for which MT is a common intervention used by physical therapists. However, evidence regarding the efficacy of MT is inconclusive. A literature search using terms related to shoulder, RC tendinopathy, and MT was conducted in 4 databases to identify randomized controlled trials that compared MT to any other type of intervention to treat RC tendinopathy. Randomized controlled trials were assessed with the Cochrane risk-of-bias tool. Meta-analyses or qualitative syntheses of evidence were performed. Twenty-one studies were included. The majority had a high risk of bias. Only 5 studies had a score of 69% or greater, indicating a moderate to low risk of bias. A small but statistically significant overall effect for pain reduction of MT compared with a placebo or in addition to another intervention was observed (n=406), which may or may not be clinically important, given a mean difference of 1.1 (95% confidence interval: 0.6, 1.6) on a 10-cm visual analog scale. Adding MT to an exercise program (n=226) significantly decreased pain (mean difference, 1.0; 95% confidence interval: 0.7, 1.4), as reported on a 10-cm visual analog scale, which may or may not be clinically important. Based on qualitative analyses, it is unclear whether MT used along or added to an exercise program improves function. For patients with RC tendinopathy, based on low- to moderate-quality evidence, MT may decrease pain; however, it is unclear whether it can improve function. More methodologically sound studies are needed to make definitive conclusions.
- Is the review based on a focused question that is adequately formulated and described?
- 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?
- No
- Was heterogeneity assessed? (This question applies only to meta-analyses.)
- Yes
Key Finding #1
Out of eleven RCTs that assessed treatment effect using pain as an outcome measure, ten provided results and pooled analysis revealed a significant effect in favor of the MT intervention when used alone or in combination with another intervention (10-cm VAS mean difference, 1.2; 95% CI: 0.8, 1.6).
Key Finding #2
Results of 4 RCTs that assessed efficacy of MT (shoulder girdle and cervical spine mobilization and manipulations) compared with a placebo to address pain demonstrated a significant effect in favor of MT (10-cm VAS mean difference, 1.0; 95% CI: 0.6, 1.4).
Key Finding #3
In pooled analysis of 5 RCTs that observed the effects on pain of MT and exercises compared to exercises alone, a significant difference was observed for the addition of MT to exercises for overall pain reduction at 4 weeks (10-cm VAS mean difference, 1.0; 95% CI: 0.7, 1.4).
Please provide your summary of the paper
Based on the primary meta-analysis of 10 RCTs, the study found low- to moderate-evidence that, overall, MT either alone or in combination with other modalities may be effective in reducing pain. Analysis of RCTs that compared shoulder girdle and cervical spine mobilization and manipulation to address pain compared with placebo also favored MT. Additionally, analysis of RCTs that addressed the effect of adding MT to an exercise program to reduce pain in patients with RC tendinopathy found a significant difference in pain levels at 4 weeks. Although pooled analyses revealed significant differences, MT interventions were varied, therefore the effects could differ based on technique. The authors also noted that MT may need to be based on individual patients’ impairments for optimal efficacy, which was not accounted for in the included studies of the systematic review. Previous research had stated inconclusive or conflicting results for the efficacy of MT used alone, but this study concluded that MT used alone or in combination with other modalities significantly decreases pain. However, it was unclear in this study whether the pain reduction was clinically important or if MT alone can improve function. This study was limited by a small sample size and some RCTs having limited methodological quality.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
This study provided new evidence to show that MT, when used alone or in combination with other interventions, may decrease pain for patients with RC tendinopathy. Clinicians may choose to implement MT as part of a plan of care with the goal of pain reduction in patients with RC tendinopathy based on this evidence. Additionally, clinicians may choose to integrate MT with other interventions as part of a comprehensive plan of care. The implementation of MT into a patient’s plan of care should account for individual impairments, as noted in this study. However, this study demonstrates that MT should not be relied on as the sole intervention to treat RC tendinopathy. Although a statistically significant difference in pain level was found, clinicians should use caution when interpreting the results of this study; it cannot be concluded that this difference is clinically significant since the point estimate for difference in VAS score was below the suggest minimal clinically important difference. This study demonstrates that the use of MT in treating RC tendinopathy may be a future area of research, as more RCTs that are methodologically sound are needed to draw further conclusions.
