Multiple disease-specific systematic reviews on the effectiveness of physical therapy intervention for shoulder dysfunction have been inconclusive. To date, there have been two systematic reviews that examined manual therapy specifically but both considered effects within diagnoses. The purpose of this systematic review was to identify the effectiveness of manual therapy to the glenohumeral joint across all painful shoulder conditions. A search of MEDLINE, CINAHL, Web of Science, and Cochrane Central Register of Randomized Controlled Trials for articles dated 1996 to June 2009 was performed. Inclusion for review were manual therapy performed to the glenohumeral joint only; non-surgical painful shoulder disorders; subjects 18-80 years; and outcomes of range of motion, pain, function, and/or quality of life. Quality assessment was performed using the PEDro scale with subsequent data extraction. Seventeen related articles were found with seven fitting the inclusion criteria. The average PEDro score was 7.86, meeting the cutoff score for high quality. Significant heterogeneity in outcome measures prohibited meta-analysis. Five studies demonstrated benefits utilizing manual therapy for mobility, and four demonstrated a trend towards decreasing pain values. Functional outcomes and quality-of-life measures varied greatly among all studies. Manual therapy appears to increase either active or passive mobility of the shoulder. A trend was found favoring manual therapy for decreasing pain, but the effect on function and quality of life remains inconclusive. Future research utilizing consistent outcome measurements is necessary.
A number of disease-specific systematic reviews examining efficacy of physical therapy6–11 negate the effects of therapeutic modalities and support the utilization of manual therapy and exercise. To our knowledge, there are two dedicated reviews examining the effectiveness of manual therapy specifically: 1) one for subacromial impingement8 and 2) the other for subacromial impingement, adhesive capsulitis, and non-specific shoulder disorders10. Both reviews support manual therapy as an intervention, however with caution, as the evidence is limited due to methodological flaws and small sample sizes that falsely inflated any effect demonstrated8,10. The most recent review10 examined the effects of manual therapy for several common shoulder pathologies but included studies that used cervical and/or thoracic interventions as well as interventions specific to the shoulder complex. That review also failed to identify specific types of manual therapy interventions that were most useful. Further, both reviews examined the effectiveness of manual therapy within the context of a specific diagnostic label (e.g., impingement, adhesive capsulitis), despite evidence to suggest that treatment effectiveness specified toward a diagnosis is limited6–12.
Diagnostic labeling related to shoulder pathologies has been found to demonstrate limited uniformity and variability of defined signs and symptoms per diagnosis as well as no beneficial treatment effect by utilizing such an approach12. Furthermore, individual variability in pain complaints13, variations in disease classification, limited agreement in identifying diagnostic severity14, and inconsistency in report of mobility of the shoulder across pathothogies14,15 suggest that a specific patho-anatomical diagnosis is less than optimal to guide a treatment plan. Similar challenges exist during diagnosis and treatment of the low back16–18. Consequently, the purpose of this systematic review is to examine the effectiveness of manual physical therapy as an intervention specific to the glenohumeral joint as a conservative management across all painful shoulder conditions. Of particular interest were specific types of manual therapy (e.g., mobilization, manipulation, soft tissue mobilization, etc) to further delineate the individual value of approaches.
Ovid MEDLINE, CINAHL, Web of Science, and Cochrane Central Register of Controlled Trials were searched to retrieve the papers for this review. Key words utilized across databases were manipulation, mobilization, manual therapy, shoulder, shoulder pain, impingement, frozen shoulder, adhesive capsulitis, physical therapy, and randomized control trial. As subject headings varied between the databases, various combinations of these key words were used. The search was limited to studies published on humans, in the English language, and between the years of 1996 and June 2009 so as to capture more recent publications. Finally, the search was also done utilizing the same strategy directly in the Journal of Orthopedic and Sports Physical Therapy, Physical Therapy Journal, Journal of Manual and Manipulative Therapy, Archives of Physical Medicine and Rehabilitation, and Manual Therapy. A search of bibliographies of acquired studies was also performed.
Inclusion Criteria for Review
Randomized controlled trials of manual physical therapy treatment for shoulder pain of adults 18-80 years of age were considered for review. Only randomized controlled trials were included because this study design is generally considered the highest level of evidence short of systematic reviews/meta-analysis19. Any age range was captured if the condition was considered a standard form of care by rehabilitation clinicians. All participants were referred to physical therapy for conservative management of shoulder pain and all interventions were performed by a physical therapist. Studies were excluded if participants reported or demonstrated any symptoms associated with cervical or thoracic symptoms, arm pain other than the shoulder, or radicular symptoms. Also excluded were studies that reported participants who had undergone surgical management for the present condition or for any condition in the upper quarter including the cervical and thoracic spine less than one year previous, had any evidence of gross instability of the glenohumeral joint, or had a history of traumatic dislocation.
The interventions of interest were manual therapy performed by a physical therapist, including low- and high-velocity mobilizations, directed only to the glenohumeral joint without additional joint mobilization to the shoulder girdle, thoracic spine, or cervical spine. Previous studies have shown that treatment to the cervical and/or thoracic spine can be beneficial in treating impingement20; therefore, studies that included joint mobilization to these areas were excluded so as not to confound any effects of manual therapy to the glenohumeral joint. Studies that performed manipulation under general anesthesia were also excluded from this review. Finally, articles were chosen if they included at least one of the following outcome measures: active or passive range of motion, a functional outcome measure specific to the shoulder, a quality-of-life measure, and a pain measure.
From the initial search, the primary author reviewed article titles to assess relevance to the review, and if deemed appropriate, abstracts were subsequently reviewed. Full texts were obtained of articles that appeared to match the review criteria as well as articles that were ambiguous in their abstract so as not to exclude any possible articles due to underreporting exact interventions in the abstract.
Full texts were reviewed by a team of reviewers consisting of three licensed physical therapists (LM, AF, BB) and one third-year DPT student (JC). Of the therapists, one is a fellow in the American Academy of Orthopedic Manual Physical Therapy with 20 years of orthopedic clinical practice (LM), one practices in a hospital-based outpatient orthopedic clinic with 28 years of experience in orthopedics (AF), and the third practices in an outpatient private practice orthopedic clinic with 4 years of experience (BB).
The four reviewers performed data extraction with a data extraction form21. Prior to the review, reviewers were trained by reading an unrelated article about low back pain and performing quality scoring using the PEDro scale and extracting pertinent data. Each author individually extracted data and assessed applicability of the reviewed study for inclusion in the review. Reviewers were not blinded to the authors or titles of articles reviewed. After reading was done and inclusion criteria applied, the reviewers compared which articles to exclude.
The quality of research articles was assessed using the PEDro (Physiotherapy Evidence Database) scale22. This scale utilizes 11 items to assess quality of randomized controlled trials. This scale is scored by giving one point for an answer of yes and zero points for an answer of no, with a potential for 10 possible points. While there are 11 questions, the first pertains to the external validity of the article being rated and is not computed as a part of the score. When items on the PEDro scale were not mentioned in articles included in the review, the reviewers were asked to report an answer of no, and no points were awarded. Items that were unclear were noted as such and brought up for discussion among the reviewers. A reliability study done by Maher et al (2003)23 demonstrated fair to good inter-rater reliability with an ICC of .68 when using consensus ratings generated by 2 or 3 raters. Furthermore, consensus scores for this scale were within 1 point on 85% and within 2 points in 99% of all reviews. This scale has also found to be a more comprehensive assessment of quality with similar reliability to the commonly used Jadad Scale in stroke rehabilitation literature24. A cut point of 6 on the PEDro scale was used to indicate high-quality studies as this has been reported to be sufficient to determine high quality versus low quality in previous studies23.
The search strategy yielded 1,214 potential articles (Figure (Figure1).1). The primary author evaluated the titles and found 22 to be suitable for this review and reviewed abstracts for inclusion/exclusion criteria. Of the 22 abstracts, 17 full texts were retrieved that either met the inclusion criteria or did not provide sufficient information in the abstract to exclude. Each of the four reviewers then read and applied the inclusion/exclusion criteria as well as PEDro scoring independently. After review, 7 articles were agreed upon among the readers to be excluded from the review and 3 articles had mixed reviews. The readers met regarding the 3 articles and a final decision was made to exclude these articles because the mobilizations performed included mobilization to the spine and/or ribs, or had a study design in which every participant received an injection of some kind. This left a total of 7 articles included in the analysis