Restricted accessReview articleFirst published online 2023-9
Effectiveness of Combined Program of Manual Therapy and Exercise Vs Exercise Only in Patients With Rotator Cuff-related Shoulder Pain: A Systematic Review and Meta-analysis
Therapeutic exercise is considered the mainstay in the management of rotator cuff-related shoulder pain (RCRSP). Manual therapy (MT) interventions have also shown to be effective in RCRSP. However, the benefits of adding MT along with exercise interventions for the management of RCRSP remain unknown.
Objective:
To evaluate the additional benefits of MT with exercise compared with exercise in isolation for the management of RCRSP.
Data Sources:
A search of PubMed, Scopus, PEDro, and EBSCO from the inception date of each database through April 20, 2022, was conducted for randomized trials comparing the additional effects of MT in exercise interventions compared with exercise alone for pain management and function in patients with RCRSP. Standardized mean differences (SMDs) and 95% CIs were calculated using a random-effects inverse variance model according to the outcome of interest and comparison group. Methodological quality was assessed with PEDro and quality of evidence with the grading of recommendations assessment, development and evaluation approach.
Study Design:
Meta-analysis of randomized controlled trials.
Level of Evidence:
Level 2.
Results:
Twelve articles were found eligible and 8 of them demonstrated high methodological quality. Eleven articles were included for quantitative analysis. Pain with movement was not significantly different between MT and exercise versus exercise alone (SMD [95% CI] = −0.15 [−0.41 to 0.12]; I2 = 0%), whereas pain at rest was significantly improved in the groups that used exercise only with a moderate effect size (SMD [95% CI] = 0.47 [0.04 to 0.89]; I2 = 75%). Furthermore, shoulder function was not significantly different between MT and exercise versus exercise alone in the short term (SMD [95% CI] = 0.23 [−0.22 to 0.69]; I2 = 88%) or the long term (SMD [95% CI] = −0.02 [−0.21 to 0.16]; I2 = 2%).
Conclusion:
Adding MT to exercise interventions for the management of RCRSP is not more effective than exercise alone for pain and function in adult patients.
AbdullaSYSoutherstDCôtéP, et al. Is exercise effective for the management of subacromial impingement syndrome and other soft tissue injuries of the shoulder? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Man Ther. 2015;20:646-656.
2.
BangMDDeyleGD. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. J Orthop Sports Phys Ther. 2000;30:126-137.
3.
BergmanGJWintersJCGroenierKH, et al. Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and pain: a randomized, controlled trial. Ann Intern Med. 2004;141:432-439.
4.
BoutronITubachFGiraudeauBRavaudP. Methodological differences in clinical trials evaluating nonpharmacological and pharmacological treatments of hip and knee osteoarthritis. JAMA. 2003;290:1062-1070.
5.
BoylesRERitlandBMMiracleBM, et al. The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Man Ther. 2009;14:375-380.
6.
BraunCBularczykMHeintschJHanchardNCA. Manual therapy and exercises for shoulder impingement revisited. Phys Ther Rev. 2013;18:263-284.
7.
BraunCHanchardNCA. Manual therapy and exercise for impingement related shoulder pain. Phys Ther Rev. 2010;15:62-83.
8.
CamargoPRAlburquerque-SendínFAvilaMA, et al. Effects of stretching and strengthening exercises, with and without manual therapy, on scapular kinematics, function, and pain in individuals with shoulder impingement: a randomized controlled trial. J Orthop Sports Phys Ther. 2015;45:984-997.
9.
ÇelikDKaya MutluE. Does adding mobilization to stretching improve outcomes for people with frozen shoulder? A randomized controlled clinical trial. Clin Rehabil. 2016;30:786-794.
10.
ChenJFGinnKAHerbertRD. Passive mobilisation of shoulder region joints plus advice and exercise does not reduce pain and disability more than advice and exercise alone: a randomised trial. Aust J Physiother. 2009;55:17-23.
11.
ChuP-CWangT-GGuoYL. Work-related and personal factors in shoulder disorders among electronics workers: findings from an electronics enterprise in Taiwan. BMC Public Health. 2021;21:1525.
12.
CohenJ. Statistical power analysis for the behavioral sciences. Academic Press; New York, NY: New York University: 2013.
13.
ConroyDEHayesKW. The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome. J Orthop Sports Phys Ther. 1998;28:3-14.
14.
CoronadoRABialoskyJEBishopMD, et al. The comparative effects of spinal and peripheral thrust manipulation and exercise on pain sensitivity and the relation to clinical outcome: a mechanistic trial using a shoulder pain model. J Orthop Sports Phys Ther. 2015;45:252-264.
15.
de Miguel ValtierraLSalom MorenoJFernández-de-Las-PeñasCClelandJAArias-BuríaJL. Ultrasound-guided application of percutaneous electrolysis as an adjunct to exercise and manual therapy for subacromial pain syndrome: a randomized clinical trial. J Pain. 2018;19:1201-1210.
16.
de MortonNA. The PEDro scale is a valid measure of the methodological quality of clinical trials: a demographic study. Aust J Physiother. 2009;55:129-133.
17.
Desjardins-CharbonneauARoyJSDionneCE, et al. The efficacy of manual therapy for rotator cuff tendinopathy: a systematic review and meta-analysis. J Orthop Sports Phys Ther. 2015;45:330-350.
18.
EbadiSForoghBFallahEBabaei GhazaniA. Does ultrasound therapy add to the effects of exercise and mobilization in frozen shoulder? A pilot randomized double-blind clinical trial. J Bodyw Mov Ther. 2017;21:781-787.
19.
EliasonAHarringeMEngströmBWernerS. Guided exercises with or without joint mobilization or no treatment in patients with subacromial pain syndrome: a clinical trial. J Rehabil Med. 2021;53:00190.
20.
FathollahnejadKLetafatkarAHadadnezhadM. The effect of manual therapy and stabilizing exercises on forward head and rounded shoulder postures: a six-week intervention with a one-month follow-up study. BMC Musculoskel Disord. 2019;20:86.
21.
FredinKLoråsH. Manual therapy, exercise therapy or combined treatment in the management of adult neck pain—a systematic review and meta-analysis. Musculoskel Sci Pract. 2017;31:62-71.
22.
GomesCDibai-FilhoAVMoreiraWA, et al. Effect of adding interferential current in an exercise and manual therapy program for patients with unilateral shoulder impingement syndrome: a randomized clinical trial. J Manipul Physiol Ther. 2018;41:218-226.
23.
GuyattGOxmanADAklEA, et al. GRADE guidelines: 1. Introduction—GRADE evidence profiles and summary of findings tables. J Clin Epidemiol. 2011;64:383-394.
24.
HaiderRBashirMSAdeelMIjazMJAyubA. Comparison of conservative exercise therapy with and without Maitland thoracic manipulative therapy in patients with subacromial pain: clinical trial. JPMA. 2018;68:381-387.
25.
HidalgoBHallTBossertJ, et al. The efficacy of manual therapy and exercise for treating non-specific neck pain: a systematic review. J Back Musculoskel Rehabil. 2017;30:1149-1169.
26.
HoCYSoleGMunnJ. The effectiveness of manual therapy in the management of musculoskeletal disorders of the shoulder: a systematic review. Man Ther. 2009;14:463-474.
27.
KamonsekiDHChristensonPRezvanifarSCCalixtreLB. Effects of manual therapy on fear avoidance, kinesiophobia and pain catastrophizing in individuals with chronic musculoskeletal pain: systematic review and meta-analysis. Musculoskel Sci Pract. 2021;51:102311.
28.
KayaDOBaltaciGToprakUAtayAO. The clinical and sonographic effects of kinesiotaping and exercise in comparison with manual therapy and exercise for patients with subacromial impingement syndrome: a preliminary trial. J Manipul Physiol Ther. 2014;37:422-432.
29.
KromerTOde BieRABastiaenenCH. Physiotherapy in patients with clinical signs of shoulder impingement syndrome: a randomized controlled trial. J Rehabil Med. 2013;45:488-497.
30.
KromerTOde BieRABastiaenenCH. Effectiveness of physiotherapy and costs in patients with clinical signs of shoulder impingement syndrome: one-year follow-up of a randomized controlled trial. J Rehabil Med. 2014;46:1029-1036.
31.
KromerTOTautenhahnUGde BieRAStaalJBBastiaenenCH. Effects of physiotherapy in patients with shoulder impingement syndrome: a systematic review of the literature. J Rehabil Med. 2009;41:870-880.
32.
LewisJ. Rotator cuff related shoulder pain: assessment, management and uncertainties. Man Ther. 2016;23:57-68.
33.
MaitlandGD. Vertebral manipulation. Elsevier Health Sciences; Butterworth, London: 1986.
34.
Martinez-CalderonJMeeusMStruyfF, et al. The role of psychological factors in the perpetuation of pain intensity and disability in people with chronic shoulder pain: a systematic review. BMJ Open. 2018;8:e020703.
35.
MintkenPEClelandJACarpenterKJ, et al. Some factors predict successful short-term outcomes in individuals with shoulder pain receiving cervicothoracic manipulation: a single-arm trial. Phys Ther. 2010;90:26-42.
36.
MintkenPEMcDevittAWClelandJA, et al. Cervicothoracic manual therapy plus exercise therapy versus exercise therapy alone in the management of individuals with shoulder pain: a multicenter randomized controlled trial. J Orthop Sports Phys Ther. 2016;46:617-628.
37.
Pace do AmaralMTFreire de OliveiraMMFerreira NdeO, et al. Manual therapy associated with upper limb exercises vs. exercises alone for shoulder rehabilitation in postoperative breast cancer. Physiother Theory Pract. 2012;28:299-306.
38.
PageMJGreenSMcBainB, et al. Manual therapy and exercise for rotator cuff disease. Cochrane Database Syst Rev. 2016;6:CD012224.
39.
ParaskevopoulosEGioftsosGGeorgoudisGPapandreouM. Perceived barriers and facilitators of sports rehabilitation adherence in injured volleyball athletes: a qualitative study from Greece. J Clin Sport Psychol. 2021;1:1-20.
40.
PaungmaliAO’LearySSouvlisTVicenzinoB. Hypoalgesic and sympathoexcitatory effects of mobilization with movement for lateral epicondylalgia. Phys Ther. 2003;83:374-383.
41.
PowellJKLewisJS. Rotator cuff-related shoulder pain: is it time to reframe the advice, “You need to strengthen your shoulder”?J Orthop Sports Phys Ther. 2021;51:156-158.
42.
RoyJSMacDermidJCWoodhouseLJ. Measuring shoulder function: a systematic review of four questionnaires. Arthritis Rheum. 2009;61:623-632.
43.
SaitoHHarroldMECavalheriVMcKennaL. Scapular focused interventions to improve shoulder pain and function in adults with subacromial pain: a systematic review and meta-analysis. Physiother Theory Pract. 2018;34:653-670.
44.
SampathKKManiRMiyamoriTTumiltyS. The effects of manual therapy or exercise therapy or both in people with hip osteoarthritis: a systematic review and meta-analysis. Clin Rehabil. 2016;30:1141-1155.
45.
SenbursaGBaltaciGAtayA. Comparison of conservative treatment with and without manual physical therapy for patients with shoulder impingement syndrome: a prospective, randomized clinical trial. Knee Surg Sports Traumatol Arthrosc. 2007;15:915-921.
46.
SharmaSEjaz HussainMSharmaS. Effects of exercise therapy plus manual therapy on muscle activity, latency timing and SPADI score in shoulder impingement syndrome. Complement Ther Clin Pract. 2021;44:101390.
47.
SharmaSGhrouzAKHussainME, et al. Progressive resistance exercises plus manual therapy is effective in improving isometric strength in overhead athletes with shoulder impingement syndrome: a randomized controlled trial. BioMed Res Intl. 2021;2021:9945775.
48.
SkybaDARadhakrishnanRRohlwingJJWrightASlukaKA. Joint manipulation reduces hyperalgesia by activation of monoamine receptors but not opioid or GABA receptors in the spinal cord. Pain. 2003;106:159-168.
49.
SmytheARathiSPavlovaN, et al. Self-reported management among people with rotator cuff related shoulder pain: an observational study. Musculoskel Sci Pract. 2021;51:102305.
50.
SterlingMJullGWrightA. Cervical mobilisation: concurrent effects on pain, sympathetic nervous system activity and motor activity. Man Ther. 2001;6:72-81.
51.
SteuriRSattelmayerMElsigS, et al. Effectiveness of conservative interventions including exercise, manual therapy and medical management in adults with shoulder impingement: a systematic review and meta-analysis of RCTs. Br J Sports Med. 2017;51:1340-1347.
52.
StoopRClijsenRLeoniD, et al. Evolution of the methodological quality of controlled clinical trials for myofascial trigger point treatments for the period 1978-2015: a systematic review. Musculoskel Sci Pract. 2017;30:1-9.
53.
StrunceJBWalkerMJBoylesREYoungBA. The immediate effects of thoracic spine and rib manipulation on subjects with primary complaints of shoulder pain. J Man Manip Ther. 2009;17:230-236.
54.
Tejera-FalcónEToledo-MartelNDCSosa-MedinaFM, et al. Dry needling in a manual physiotherapy and therapeutic exercise protocol for patients with chronic mechanical shoulder pain of unspecific origin: a protocol for a randomized control trial. BMC Musculoskel Disord. 2017;18:400.
55.
YiasemidesRHalakiMCathersIGinnKA. Does passive mobilization of shoulder region joints provide additional benefit over advice and exercise alone for people who have shoulder pain and minimal movement restriction? A randomized controlled trial. Phys Ther. 2011;91:178-189.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
