The Efficacy of Manual Therapy for Rotator Cuff Tendinopathy: A Systematic Review and Meta-analysis

Abstract

® T t STUDY DESIGN:Systematic review and metaanalysis. T t OBJECTIVES:To evaluate the efficacy of manual therapy (MT) for patients with rotator cuff (RC) tendinopathy. T t BACKGROUND: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. T t METHODS: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. T t RESULTS: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 alone or added to an exercise program improves function. T t CONCLUSION: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. T t LEVEL OF EVIDENCE:Therapy, level 1a-. Ther 2015;45(5):330-350. Epub 26 Mar 2015. doi:10.2519/jospt.2015 T t KEY WORDS: mobilization, physical therapy, shoulder impingement syndrome, shoulder pain S houlder pain is highly prevalent and among mus culoskeletal disorders is the third most common reason for visiting a primary care physician. 16,33,46 As many as two thirds of people who have shoulder complaints receive a diagnosis of rotator cuff (RC) tendinopathy. 46 Rotator cuff tendinopathy often leads to decreased function, 34 lower health related quality of life, 34 poor sleep quality, 47 and work absenteeism. J Orthop Sports Phys 40Rotator cuff tendinopathy is a broad diagnosis, and mounting evidence suggests that diagnoses such as shoulder impingement syndrome, RC tendinitis/ tendinosis, as well as subacromial bursitis may be considered as the same clinical entity. 19 Conservative treatment of RC tendinopathy generally includes rest, nonsteroidal anti-inflammatory drugs, and rehabilitation interventions such as exercise.19 High-level evidence supports exercise as an effective treatment. 20 In conjunction with exercise, physical therapists often add manual therapy (MT) interventions to address impairm...

Effectiveness of physical therapy treatment of clearly defined subacromial pain: a systematic review of randomised controlled trials

“…In one of the reviews,35 only 24% of the trials had a low risk of bias and, therefore, the conclusions were based on low-to-moderate quality of evidence. We aimed to summarise the high-quality evidence of conservative interventions to treat SAPS aiming to provide better guidelines for clinical practice.…”

Systematic Review of Nondrug, Nonsurgical Treatment of Shoulder Conditions

“…Three focused on various types of MT 13,17,21 ; 2 on extracorporeal shockwave therapy (ESWT) 34,37 ; and 1 each on transcutaneous nerve stimulation (TENS), 31 taping, 32 multimodal therapies, 46 and exercise. 33 For MT (skilled hand movements performed by a therapist 17 ), manipulation and mobilization were included. One acceptablequality study found low-to moderate-quality evidence that MT may have a beneficial effect on pain, but the evidence was unclear for function.…”

“…One acceptablequality study found low-to moderate-quality evidence that MT may have a beneficial effect on pain, but the evidence was unclear for function. 17 Another acceptable-quality study found that the evidence was fair that MT including manipulation either alone or combined with exercise and modalities was effective. 13 A high-quality review found that manipulation/mobilization combined with exercise had a moderate level of positive evidence for effectiveness.…”

“…31 For taping, an acceptable-quality review found that the evidence for taping alone or with other therapies was insufficient to make a conclusion. 32 For exercise, 1 acceptable-quality review compared PT exercise therapy with surgery for patients with rotator cuff tears. It found moderate evidence that surgery was superior to exercise therapy in the mid-to long term.…”

“…12 Reviews of MTs (eg, manipulation and mobilization) and multimodal treatments have found favorable effects supporting their use for the management of shoulder conditions. [13][14][15][16][17] However, clinical trials studying these treatments are inconsistently conducted, tend to have low to moderate levels of scientific rigor, and infrequently collect long-term outcomes. Therefore, evidence is still inconclusive regarding the appropriate use of many MTs for shoulder conditions.…”