Real versus Sham Manual Therapy in Addition to Therapeutic Exercise in the Treatment of Non-Specific Shoulder Pain: A Randomized Controlled Trial

Which Multimodal Physiotherapy Treatment Is the Most Effective in People with Shoulder Pain? A Systematic Review and Meta-Analyses

The study aimed to determine if combined physiotherapy treatments offer additional benefits over exercise-only programs for shoulder pain and to identify the most effective combined treatment. A systematic review, registered in PROSPERO (CRD42023417709), and meta-analyses were conducted. Quality analysis was performed using the PEDro scale on randomized clinical trials published from 2018 to 2023. Twenty articles met the inclusion criteria. The most commonly used combination was exercise plus manual therapy, without being statistically superior to exercise alone. The meta-analysis indicated that combining exercise with low-level laser therapy (mean difference of -1.06, 95% CI: -1.51 to -0.60) and high-intensity laser therapy (mean difference of -0.53, 95% CI: -1.12 to 0.06) resulted in the greatest reduction in SPADI scores. Adding manual therapy provided limited additional benefit (mean difference of -0.24, 95% CI: -0.74 to 0.27). Progressive exercise with advice or telerehabilitation yielded modest improvements. The multimodal meta-analysis for DASH scores showed significant improvement (mean difference of -1.06, 95% CI: -1.51 to -0.60). In conclusion, therapeutic exercise is the cornerstone of shoulder pain treatment, with the addition of laser therapy showing substantial benefits. Manual therapy and educational interventions offer some benefits but are not consistently superior. More rigorous studies are needed.

Is exercise therapy the right treatment for rotator cuff-related shoulder pain? Uncertainties, theory, and practice

BACKGROUND

Exercise therapy is a popular non-surgical treatment to help manage individuals with rotator cuff-related shoulder pain (RCRSP) and is recommended in all clinical practice guidelines. Due to modest effect sizes, low quality evidence, uncertainty relating to efficacy, and mechanism(s) of benefit, exercise as a therapeutic intervention has been the subject of increasing scrutiny.

AIMS

The aim of this critical review is to lay out where the purported uncertainties of exercise for RCRSP exist by exploring the relevant quantitative and qualitative literature. We conclude by offering theoretical and practical considerations to help reduce the uncertainty of delivering exercise therapy in a clinical environment.

RESULTS AND DISCUSSION

Uncertainty underpins much of the theory and practice of delivering exercise therapy for individuals with RCRSP. Nonetheless, exercise is an often-valued treatment by individuals with RCRSP, when provided within an appropriate clinical context. We encourage clinicians to use a shared decision-making paradigm and embrace a pluralistic model when prescribing therapeutic exercise. This may take the form of using exercise experiments to trial different exercise approaches, adjusting, and adapting the exercise type, load, and context based on the individual's symptom irritability, preferences, and goals.

CONCLUSION

We contend that providing exercise therapy should remain a principal treatment option for helping individuals with RCRSP. Limitations notwithstanding, exercise therapy is relatively low cost, accessible, and often valued by individuals with RCRSP. The uncertainty surrounding exercise therapy requires ongoing research and emphasis could be directed towards investigating causal mechanisms to better understand how exercise may benefit an individual with RCRSP.

Is there 'trustworthy' evidence for using manual therapy to treat patients with shoulder dysfunction?: A systematic review

The primary objective of this review was to create a 'trustworthy,' living systematic review and meta-analysis for the application of manual therapy interventions in treating patients with shoulder dysfunction. Included studies were English-language randomized controlled trials published between 1/1/2010 and 8/3/2023, with searches performed in: PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), CINHAL, ProQuest Nursing & Allied Health, EBSCO Medline, and PEDro. The population of focus included adults 18 years and older with musculoskeletal impairments related to shoulder dysfunction. Our primary outcomes included pain and region-specific outcome measures. We excluded trials, including participants having shoulder dysfunction resulting from surgery, radicular pain, instability/dislocation, fracture, lymphedema, and radiation. Our screening methodology was based upon a previously published 'trustworthy' systematic review protocol. This included the application of our PICOTS criteria in addition to screening for prospective clinical trial registration and following of prospective intent, as well as assessment of PEDro scores, risk-of-bias ratings, GRADE scoring, and examination of confidence in estimated effects. Twenty-six randomized controlled trials met our PICOTS criteria; however, only 15 of these were registered. Only three were registered prospectively. Two of these did not have discussions and conclusions that aligned with their primary outcome. The remaining single study was found to have a high risk-of-bias, meaning the remainder of the protocol could not be employed and that no randomized controlled trials could undergo further assessment or meta-analysis. The results of this systematic review indicate there are no 'trustworthy' randomized controlled trials examining the effectiveness of manual therapy interventions for the treatment of patients with shoulder dysfunction, as defined by the prospectively established methodology. Therefore, these findings signal that creating a 'trustworthy,' living systematic review on this clinically relevant topic is not yet possible due to a lack of 'trustworthy' randomized controlled trials.

Effectiveness of the Rehabilitation Training Combined with Maitland Mobilization for the Treatment of Chronic Ankle Instability: A Randomized Controlled Trial

The study aims to determine whether routine rehabilitation training combined with the Maitland mobilization is more effective than routine rehabilitation training alone in patients with chronic ankle instability, intending to provide a novel rehabilitation strategy for chronic ankle instability. A total of 48 subjects were divided into three groups: EG (Maitland mobilization and routine rehabilitation), CG (routine rehabilitation), and SG (sham mobilization and routine rehabilitation). The intervention was performed three times each week for 4 weeks, for a total of 12 sessions. Before and after the intervention, the muscle strength, star excursion balance test (SEBT), weight-bearing dorsiflexion range of motion (WB-DFROM), ankle range of movement, Cumberland ankle instability tool (CAIT), self-comfort visual analog scale (SCS-VAS), and self-induced stability scale (SISS-VAS) were assessed. The results showed that the improvement of SEBT, WB-DFROM, and active ankle range of movement without the pain in EG was more obvious than CG and SG, but the improvement of the self-report of ankle severity and muscle strength was not. Compared with routine rehabilitation training alone, routine rehabilitation training combined with Maitland mobilization for patients with chronic ankle instability may provide more benefit in terms of balance and ankle range of movement than routine rehabilitation alone, but the improvement in muscle strength was not evident enough.