Manual medicine is based, in part, on the belief that man is a self regulating being and that the body, when in normal structural relationship, is capable of self healing and defense against disease. A manual medicine diagnosis is made using a comprehensive history, detailed and specific physical examination including Osteopathic, orthopaedic, neurologic, rheumatologic and Chiropractic exams, appropriate radiologic studies and the specific laying on of hands to palpate musculoskeletal parameters including but not limited to asymmetry of related musculoskeletal components, range of motion abnormalities of mobility, tissue texture changes, circulation of fluids and energy.
Manual medicine identifies a specific manipulable lesion, which is treated with an appropriate manipulative technique to resolve the condition.
Licensing and limitations in the scope of practice are variable throughout the United States and the world. Manual medicine is as old as medicine itself. It was practiced in Thailand 4, years ago and used in ancient Egypt. Hippocrates, the founder of modern medicine, used traction and leverage techniques to treat spinal disorders. Palmer, in, began what is known today as manual medicine, Osteopathic medicine and Chiropractic respectively.
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 form 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. This scale utilizes 11 items to assess quality of randomized controlled trials.
Effectiveness of Manual Physical Therapy for Painful Shoulder Conditions: A Systematic Review
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 23 demonstrated fair to good inter-rater reliability with an ICC of. 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 literature 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 studies 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.
After review, 7 articles were agreed upon among the readers to be excluded from the review and 3 articles had mixed reviews. Groups were similar at baseline for most important prognostic indicators.
Study provided point measures and measures of variability for at least one key outcome. Some studies evaluated active range of motion 25 , 27 — 31 while others evaluated passive range of motion 26 , Pain outcomes, while evaluated with a visual analog scale in all but 2 studies 25 , 30 were done under various conditions such as at rest, with movement, or at night so consolidation of results was impossible.
Furthermore, there was no consistent use between studies of a quality-of-life measure or functional outcome tools.
This significant heterogeneity in outcome measures prohibited meta-analysis. Ten articles that initially were chosen for review were subsequently excluded because two included subjects with concomitant neck pain 32 , 33 , one included mobilization to adjacent areas along with the glenohumeral joint 34 , two did not include manual therapy as an intervention 35 , 36 , one failed to report clear outcome measurements 37 , one study's outcomes reported did not match our review 38 ; another was excluded due to a combination of manual therapy and exercise with no actual description of procedures performed 39 , and one gave every subject an injection, placebo, or anti-inflammatory, a treatment that physical therapists cannot perform The mean quality score for the 7 included studies was 7.
The predetermined cutoff of 6 was exceeded by all of the studies included, indicating they all were considered to be of high quality; however, the articles by Johnson et al 29 and Guler-Uysal and Kozanoglu 26 were at the limit of the cutoff with scores of 6. Studies by Teys et al 25 , Vermeulen et al 31 , and Kachingwe et al 28 each received the high score of 9.
Range of motion was included as an outcome for all seven of the included studies 25 — 31 , and all demonstrated some improvement with intervention. Of these seven studies, however, only four 25 , 26 , 29 , 31 demonstrated significant improvements between groups utilizing manual therapy as an intervention.
Effectiveness of Manual Physical Therapy for Painful Shoulder Conditions: A Systematic Review
The studies by Teys et al 25 and Guler-Uysal and Kozanoglu 26 found significant increases in passive mobility with just one treatment 25 or within one week 26 as well as significant improvement from baseline to completion of the studies. Johnson et al 29 found significant increases in active external rotation range of motion at the completion of the study, and Vermeulen et al 31 found significant improvement in active range of motion at 12 months and passive range of motion at 3 and 12 months.
Six of the seven studies used some form of pain measurement scale 25 — 29 , All studies demonstrated reduction of pain with treatment; however, only two demonstrated significant differences 25 , 27 between groups for pain measurement. Teys et al 25 performed a cross-over trial in subjects with painful limited shoulders. The mobilization with movement group improved significantly between both groups in pain measures as measured by pain pressure algometry. Conroy and Hayes 27 compared two groups with sub-acromial impingement syndrome with the intervention group receiving mid-range joint mobilization.
At the completion of the trial, the mobilization group showed significant improvement compared to the non-mobilization group in measures of pain within the last 24 hours and pain with subacromial impingement testing. Examination of function was included in five 27 — 31 of the seven studies. All of these studies demonstrated improvement in the perspective of functional measurements with intervention; however, only the two 30 , 31 studies that compared manual therapy techniques for patients with adhesive capsulitis demonstrated significant between-group differences.
Yang et al 30 found that both end-range mobilization and mobilization with movement treatment approaches demonstrated statistically significant improvements in function as measured by the FLEX-SF when compared to mid-range mobilization. Vermeulen et al 31 found that function as measured by the shoulder rating questionnaire and shoulder disability questionnaire significantly improved in the high-grade mobilization group over the month period. Four different types of manual therapy were implemented within the seven included studies: Three of the studies utilized mobilization with movement 25 , 28 , Of these, Teys et al 25 and Yang et al 30 reported improvement in range of motion utilizing this approach, while Kachingwe et al 28 found no significant difference between groups; however, they noted that the mobilization with movement group gained the highest percentage change in range of motion.
Teys et al 25 reported improvement in pain values as measured by pain pressure algometry, while Kachingwe et al 28 did not find significant improvement in pain values. Only Yang et al 30 found significant improvement in functional outcomes utilizing mobilization with movement while Kachingwe et al 28 reported no significant between-group difference; however, again the mobilization with-movement group demonstrated the highest percentage change.
The Cyriax manual therapy approach consisting of deep friction massage and manipulation was utilized only by Guler-Uysal and Kozanoglu After one week of treatment, patients in the Cyriax group demonstrated significant improvements in passive range of motion into flexion, external rotation, and internal rotation compared to the modality group. After two weeks, the Cyriax group continued to demonstrate significantly improved passive range of motion into external and internal rotation compared to the modality group.
Three studies utilized an approach of mobilizations performed at the end range of motion 29 — Johnson et al 29 performed anterior and posterior mobilizations at the end of available range of motion; however, they did not describe the technique or grade of force used such as Kaltenborn or Maitland, while both Yang et al 30 and Vermeulen et al 31 utilized end-range mobilization following Maitland techniques. All three studies reported improvement in range of motion using end-range mobilization. Johnson et al 29 and Vermeulen et al 31 both reported no significant between-group differences in pain measures.
Yang et al 30 and Vermeulen et al 31 both reported improvement in function favoring end-range mobilization, while Johnson et al 29 reported only within-group significant differences and no between group-differences using the anterior and posterior mobilization techniques. Four studies included experimental groups utilizing mid-range mobilization 27 , 28 , 30 , Conroy and Hayes 27 and Vermeulen et al 31 performed mobilizations at the mid-range of available range of motion utilizing Maitland techniques, while Yang et al 30 utilized both Maitland and Kaltenborn techniques. Kachingwe et al 28 did not describe the technique used in terms of either Kaltenborn or Maitland but performed joint mobilizations at mid-position.
Of the four, none demonstrated range-of-motion improvements utilizing mid-range mobilizations. Only Conroy and Hayes 27 reported significant reduction in pain values between groups, while Vermeulen et al 31 reported a significant within-group difference for mid-range mobilizations.
Kachingwe et al 28 did not report any improvement in pain values for mid-range mobilization. Of the four, there were no reported significant improvements in function using mid-range mobilizations. A secondary purpose was to explore the individual value of specific manual therapy techniques. In terms of improving shoulder mobility, the evidence suggests that patients receiving manual therapy interventions for shoulder pain will demonstrate improvements in range of motion ROM.
Five of the seven included studies 25 , 26 , 28 — 30 demonstrated improvement in either active or passive range of motion, while Conroy and Hayes 27 and Kachingwe et al 28 did not report significant between-group differences. Although the optimal form of manual therapy technique cannot be identified from the existing literature, there does seem to be preliminary evidence to support selected types of positioning techniques. Nonetheless, these results may be confounded by the differences in types of measurements used. Teys et al 25 , Conroy and Hayes 27 , Johnson et al 29 , Yang et al 30 , and Kachingwe et al 28 assessed active range of motion.
Guler-Uysal and Kozanoglu 26 only measured passive range of motion, while Vermeulen et al 31 assessed both active and passive. Given the limited inter- and intra-rater reliability reported with AROM, the significance of the results reported in these studies may be limited. Furthermore, using active motion to assess outcomes in ROM in response to manual therapy may pose a problem with construct validity. One of the proposed mechanisms by which manual therapy increases joint motion is through stretching of the joint capsule and surrounding tissues 2.
AROM of the shoulder requires sufficient strength in the muscles crossing the joint to move the arm against gravity Active ROM is, therefore, an assessment of muscular performance, functional mobility, and willingness of the individual to move. There can be limitations in active ROM; however, since it is not a true measure of the joint's mobility, these limits may be present when there are no passive restrictions in joint motion On the other hand, passive range of motion allows the examiner to determine the amount of available motion within the individual joint and the resistance of connective tissue to stretch The normal limiting factors with PROM are soft tissues, ligaments, joint capsule, or boney architecture.
Perhaps to truly assess the effectiveness of manual therapy at the glenohumeral joint, PROM with scapula stabilization may be a better outcome to measure. Since most of the included studies in this review only measured active range of motion, and not many performed consistent measurements, it may be more appropriate to conclude that manual therapy has a positive impact on functional movement in patients with shoulder pain being conservatively managed. Although the use of manual therapy has been described to reduce pain 2 , our analysis of the research could not completely support this conclusion.
In four of the six studies that evaluated pain values 25 , 27 , 29 , 31 , a trend was found favoring the use of manual therapy for decreasing some measure of pain values.
Manual of Orthopaedics, 7e
These measurements, however, demonstrated significant heterogeneity in the conditions in which pain was measured, limiting the ability to definitively support or negate the use of manual therapy for pain management. In addition, those studies in which pain outcomes were evaluated used assessments that have good reliability in chronic musculoskeletal disorders 45 and high reliability for acute pain 46 but to date, there does not appear to be any literature that reports reliability or validity in this measure specifically for shoulder pain.
Much like the pain measures, significant heterogeneity in functional outcome measures also made conclusions related to the effectiveness of manual therapy difficult. While three of the studies 28 , 30 , 31 did indicate a positive impact of manual therapy, specifically end-range mobilizations, the differences in measurements made definitive conclusions impossible.
Only one study 31 administered a quality-of-life measure, the SF, and found no significant differences between groups; however, there were significant within-group differences from baseline to completion, suggesting that there may be a general positive impact of manual therapy on quality of life. This review has several limitations. The primary author alone JC performed the initial search for article and subsequent reading of titles and articles. Therefore, it is possible that articles may have been missed for inclusion.
Also, only articles published in English were reviewed, again leading to the possibility that articles may have been missed. A significant limitation of this review is the small sample size of included studies as only one of the included studies had or more participants. One disadvantage to performing a review on a topic with a paucity of research is that whatever is published will typically consist of smaller sample sizes, limiting overall effect size and generalizability.
The authors chose to only include manual therapy performed at the glenohumeral joint; however, we did not delineate mobilizations performed to the acromioclavicular joint or sternoclavicular joint. None of the excluded studies were excluded because of mobilizations to these joints so a potential major bias was avoided; however, future reviews on manual therapy at the shoulder and future clinical trials on manual therapy to the shoulder should pay closer attention to the entire shoulder complex.
The heterogeneity among outcome measures that is pervasive among the studies could have been avoided with more stringent inclusion criteria for the review. The reviewers also chose not to delineate years of experience or expertise in the therapists performing manual therapy interventions, a potential key factor in determining overall effectiveness.
However, as this is the first review looking at the intervention of manual therapy across diagnostic categories, the choice to have wider inclusion criteria was made to capture as many randomized controlled trials as possible. Overall, the studies included in this review demonstrate the benefit of manual therapy for improvements in mobility and a trend in improving pain measures, while increases in function and quality of life are still questionable. Limited data exist to support one form of manual therapy versus another.
We would like to acknowledge Ben Barron and Arlette Frederick for their roles as readers for quality scoring and screening for inclusion of full texts retrieved. National Center for Biotechnology Information , U. J Man Manip Ther. Author information Copyright and License information Disclaimer. Address all correspondence and requests for reprints to: This article has been cited by other articles in PMC. Abstract Multiple disease-specific systematic reviews on the effectiveness of physical therapy intervention for shoulder dysfunction have been inconclusive.
Inclusion Criteria for Review Randomized controlled trials of manual physical therapy treatment for shoulder pain of adults years of age were considered for review. Review Process From the initial search, the primary author reviewed article titles to assess relevance to the review, and if deemed appropriate, abstracts were subsequently reviewed. Open in a separate window.
PEDro Criteria Item 1: Not scored eligibility criteria specified. Subjects were randomly allocated. Tere was blinding of all subjects. Tere was blinding of all therapists. Tere was blinding of assessors of outcomes.
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Intention-to-treat analysis was performed. Between-group comparisons reported for at least one key outcome. Each group lasted for one PT session. PT without mobilization vs. Deep friction massage and manipulation, active stretching and pendulum exercises PT Group: Hot packs, short-wave diathermy, active stretching and pendulum exercises PROM: Flexion, abduction, internal rotation, external rotation Pain: Physical therapy with and without manual therapy MT Shoulder impingement syndrome —Both groups received hot packs, performed AROM, physiologic stretching, strengthening exercises, soft tissue mobilization, and patient education —Intervention group received grades I-IV Maitland mobilization at mid-range AROM: Abduction, elevation scaption , internal rotation, external rotation Pain: Only pain values are reported as AROM values were combined between groups in the reporting of quantitative data 1.
A Posterior capsule stretching, postural, rotator cuff, and scapular exercises Glenohumeral Mobilization B: Grades mobilizations in either anterior, posterior, inferior directions, determined on patient by patient basis Mobilization with Movement C: Posterior mobilization with movement glide with patient actively flexing Control D: Flexion and scaption Pain: VAS 24 hr A: Posterior mobilization no control group Idiopathic adhesive capsulitis anteriorly Anterior Mobilization AM: Visual Analog Scale measuring general unpleasantness Function: Function questions AM: Mobilization applied during several motions not described AROM: High-grade mobilization end-range vs.
Flexion, abduction, external rotation PROM: