The Role of Therapeutic Exercise in the Conflicting and Unstable Shoulder

Abstract

Context: The use of therapeutic exercise and manual therapy in rehabilitation of the unstable and conflicting shoulder (UCS) is widespread. In the literature, there are several electromyographical studies that have analysed the effect of specific physical exercises and clinical trials on the effectiveness of specific rehabilitative protocols. However, it has not been established yet what is the best intervention for these disorders.

Objective: In order to establish general recommendations for the treatment of UCS, we have reviewed the results of some electromyographical studies to identify the best exercises to recruit specifically the shoulder girdle muscles and some clinical trials that have proposed the utilisation of therapeutic exercise and manual therapy for UCS.

Methods: Review of the literature of the last 10 years. We have searched Pedro, Medline and the Cochrane Library for randomised clinical trials, systematic reviews and electromyographical studies on rehabilitative protocols based on therapeutic exercise and manual therapy.

Outcomes: It is common practice for clinicians to consider the involvement of patients with shoulder instability or impingement in a programme of exercises, before proceeding to a surgical intervention. Our analysis of the literature provides evidence of the efficacy of manual therapy associated with therapeutic exercises for decrease in pain, recovery of patient's strength and restoration of abilities.

Conclusions: While the analysed studies are inconclusive, on the basis of the available data, we suggest some general rehabilitative principles for the treatment of the unstable and conflicting shoulder.     

Limited scientific evidence supports the use of conservative treatment interventions for pain and function in patients with subacromial impingement syndrome: randomized control trials

Abstract

Background: Different conservative treatment interventions are often used to decrease pain and improve function in patients with subacromial impingement syndrome (SAIS). However, the current evidence to support the use of these interventions has not been established.

Objectives: To determine the evidence for conservative treatment interventions regarding pain and function compared to any intervention for SAIS patients.

Methods: A systematic review of randomized controlled trials, published in English between 1 January 1999 and 31 May 2010, was performed using PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library and manual searching. The methodological quality (PEDro scale) and evidence grade (SBU) were rated. Eight studies were of high quality, four were medium quality, and eight were low quality. Various conservative treatment interventions were evaluated: acupuncture, electrotherapy modalities, exercises, mixed modalities, changing posture, and use of a functional brace.

Results: Limited scientific evidence (LSE) indicates positive effects of exercise and mixed modalities regarding pain and function and high-intensity laser therapy (HILT) regarding pain in SAIS patients. LSE also indicate no effect of electrotherapy modalities, apart from HILT, as treatment for SAIS.

Conclusions: The lack of high quality interventions limits the ability to draw conclusions regarding efficacy from several of the included studies. However, exercise may be as efficient as surgery, manual therapy in combination with exercise seems to be more effective than exercise alone and high-dose exercises seem to be more effective than low-dose exercises. Furthermore, there is contradictory evidence to support the use of acupuncture.     

Thoracic manual therapy in the management of non-specific shoulder pain: a systematic review

ObjectivesNon-specific shoulder pain (NSSP) is often persistent and disabling leading to high socioeconomic costs. Cervical manipulation has demonstrated improvements in patients with NSSP, although risks associated with thrust techniques are documented. Thoracic manual therapy (TMT) may utilise similar neurophysiological effects with less risk. The current evidence for TMT in treating NSSP is limited to systematic reviews of manual therapy (MT) applied to the upper quadrant. These reviews included trials that used shoulder girdle manual therapy (SG-MT) in the TMT group. This limits the scope of their conclusions with regard to the exclusive effectiveness of TMT for NSSP.MethodsThis review used a steering group for subject and methodological expertise and was reported in line with Preferred Reporting items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Key databases were searched (1990–2014) using relevant search terms and medical subject headings (MeSH); eligibility was evaluated independently by two reviewers based on pre-defined criteria. Study participants had NSSP including impingement syndrome and excluding cervical pain. Interventions included cervicothoracic junction and TMT with or without supplementary exercises. Studies that included MT applied to the shoulder girdle including the glenohumeral joint, acromioclavicular joint or sternoclavicular joint in the TMT group, without a control, were excluded. Included studies utilised outcome measures that monitored pain and disability scores. Randomized controlled trials (RCTs) and clinical studies were eligible. Using a standardised form, each reviewer independently extracted data. Risk of bias was assessed using GRADE and PEDro scale. Results were tabulated for semi-quantitative comparison.ResultsOver 912 articles were retrieved: three RCTs, one single-arm trial and three pre–post test studies were eligible. Studies varied from poor to high quality. Three RCTs demonstrated that TMT reduced pain and disability at 6, 26 and 52 weeks compared with usual care. Two pre–post test studies found between 76% and 100% of patients experienced significant pain reduction immediately post-TMT. An additional pre–post test study and a single-arm trial showed reductions in pain and disability scores 48 hours post-TMT.DiscussionThoracic manual therapy accelerated recovery and reduced pain and disability immediately and for up to 52 weeks compared with usual care for NSSP. Further, high-quality RCTs investigating the effect of TMT in isolation for the treatment of patients with NSSP are now required.     

Thoracic manual therapy in the management of non-specific shoulder pain: a systematic review

Abstract

Objectives:

Non-specific shoulder pain (NSSP) is often persistent and disabling leading to high socioeconomic costs. Cervical manipulation has demonstrated improvements in patients with NSSP, although risks associated with thrust techniques are documented. Thoracic manual therapy (TMT) may utilise similar neurophysiological effects with less risk. The current evidence for TMT in treating NSSP is limited to systematic reviews of manual therapy (MT) applied to the upper quadrant. These reviews included trials that used shoulder girdle manual therapy (SG-MT) in the TMT group. This limits the scope of their conclusions with regard to the exclusive effectiveness of TMT for NSSP.     

The effectiveness of sub-group specific manual therapy for low back pain: a systematic review

BackgroundManual therapy is frequently used to treat low back pain (LBP), but evidence of its effectiveness is limited. One explanation may be sample heterogeneity and inadequate sub-grouping of participants in randomized controlled trials (RCTs) where manual therapy has not been targeted toward those likely to respond.ObjectivesTo determine the effectiveness of specific manual therapy provided to sub-groups of participants identified as likely to respond to manual therapy.Data sourcesA systematic search of electronic databases of MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled trials (CENTRAL).Trial eligibility criteriaRCTs on manual therapy for participants identified as belonging to a sub-group of LBP likely to respond to manual therapy were included.Trial appraisal and synthesis methodsIdentified trials were assessed for eligibility. Data from included trials were extracted by two authors independently. Risk of bias in each trial was assessed using the PEDro scale and the overall quality of evidence rated according to the GRADE domains. Treatment effect sizes and 95% confidence intervals were calculated for pain and activity.ResultsSeven RCTs were included in the review. Clinical and statistical heterogeneity precluded meta-analysis. Significant treatment effects were found favouring sub-group specific manual therapy over a number of comparison treatments for pain and activity at short and intermediate follow-up. However, the overall GRADE quality of evidence was very low.ConclusionsThis review found preliminary evidence supporting the effectiveness of sub-group specific manual therapy. Further high quality research on LBP sub-groups is required.     

The fidelity of comparison intervention in manual therapy trial for patients with low back pain: a systematic review

Abstract

Background: Comparison interventions for low back pain are described in the literature utilizing different treatment interventions with various terminology. The effectiveness of these comparison groups is not well defined.

Objectives: The objective of this systematic review is to assess the fidelity of comparison interventions within randomized controlled trials assessing the effect of manual therapy on low back pain.

Methods: This systematic review utilized PubMed, CINAHL, Scopus, Cochrane, and Pedro databases. Articles were screened by two authors for eligibility criteria and then extracted, reviewed, and cross-checked for data that included sample size, patient demographics, manual therapy intervention, the control group protocol, and outcomes. The Cochrane Risk of Bias tool was used to determine disagreement among authors. A qualitative synthesis of the evidence was completed.

Results: A total of 20 articles were included in this systematic review. The comparison interventions were categorized into themes based on the terminology used by the various studies. The themes consisted of “standard care”, “sham treatment”, “control groups”, and unnamed comparison interventions. These themes were then compared to the CPG based on the interventions utilized in each study.

Conclusions: There appears to be significant variability in comparison interventions within randomized controlled trials assessing manual therapy effects on patients with low back pain. This variability may lead to inconsistent published effect sizes. It is imperative to correctly follow evidence-based practice from resources, such as the CPG, to determine the effectiveness of treatment interventions.     

Does taping in addition to physiotherapy improve the outcomes in subacromial impingement syndrome? A systematic review

Background: Taping is used with or without other interventions for many purposes, especially to manage pain and improve functional activity in patients with shoulder pain. Objectives: The aim of this review was to determine whether any taping technique in addition to physiotherapy care is more effective than physiotherapy care alone in patients with shoulder impingement syndrome. Methods: A systematic search of Cochrane Database of Systematic Review, MEDLINE (EBSCO), Physiotherapy Evidence Database (PEDro), CINAHL (EBSCO), PUBMED, AMED, EMBASE (OVID), The Kinesio Kinesio® Taping Method, Kinesio® Tex Tape UK and International websites (www.kinesiotaping.co.uk; www.kinesiotaping.com) was conducted to June 2015. The outcome measures were pain, disability, range of motion and muscle strength. As data were not suitable for meta-analysis, narrative synthesis were applied. Results: Three randomized controlled trials and one controlled trial (135 patients) were included. The results were conflicting and weak on the effectiveness of taping as an adjunct therapy for improvement of pain, disability, range of motion and muscle strength. Conclusion: Clinical taping in addition to physiotherapy interventions (e.g. exercise, electrotherapy, and manual therapy) might be an optional modality for managing patients with shoulder impingement syndrome, especially for the initial stage of the treatment; however, we need further robust, placebo controlled and consistent studies to prove whether it is more effective than physiotherapy interventions without taping.     

Spinal manipulative therapy for low back pain: A systematic review

Abstract

Objectives: Gather and analyse relevant literature on spinal manipulative therapy for low back pain through systematic review to present a balanced and impartial summary of the findings. The aim of this systematic review was to investigate the efficacy of spinal manipulative therapy in patients with low back pain.

Methods: Databases searched included COCHRANE, MEDLINE, EMBASE, PEDro, PUBMED, WEB OF KNOWLEDGE, INGENTA CONNECT and GOOGLE SCHOLAR between January 2000 and January 2008. Sixteen articles were retrieved. Standardised inclusion and exclusion criteria were applied to select articles relevant to the review question. Seven studies were excluded and nine studies were included. In the next step, the methodological quality of the included studies was assessed with the PEDro scale, which rated the studies from 0 to 10.

Results: Methodological quality scores ranged from 4 to 8 out of a possible 10. Spinal manipulative therapy can be preferred for short-term relief of low back pain when compared with general exercise and dynamic strengthening exercises, which is revealed by a high quality study, moderate quality studies and a low quality study. Spinal manipulative therapy combined with exercise is more effective than exercise alone, which is revealed by a high quality study.

Conclusions: Further studies are needed to improve the quality of the evidence. There is evidence that spinal manipulative therapy combined with exercise is more effective than other procedures like spinal manipulative therapy, exercise or physician consultation alone.     

An exercise trial targeting posterior shoulder strength in manual wheelchair users: pilot results and lessons learned

Purpose: Because wheelchair users are unable to use standard fitness equipment such as treadmills and bikes, we developed an upper body rowing ergometer (UBRE) that can be retrofitted onto a standard stationary cycle and used to perform a rowing exercise. We validated a graded exercise testing protocol utilizing the UBRE and completed a 12-week pilot intervention to compare the training effects of the UBRE to a standard arm cycle ergometer (ACE) in manual wheelchair users. Methods: Repeat graded exercise tests were compared on the two pieces of equipment. Twenty-seven manual wheelchair users participated in the intervention. Outcomes included pre- versus post-test change in shoulder pain, strength and cardiorespiratory fitness measures. Results: Testing results obtained with the UBRE were comparable to those on the ACE. In the exercise intervention, most outcome measures did not change significantly, but individuals assigned to the UBRE were able to increase their peak exercise test power by 31?W and duration by 3.6?min. Conclusion: There is biomechanical reason to believe that rowing exercises may improve shoulder muscle balance in this population, which could reduce the risk of impingement. This may be of benefit to manual wheelchair users, who are at high risk for shoulder injury.

• Implications for Rehabilitation

• Regular exercise improves cardiorespiratory fitness and did not exacerbate shoulder pain in this group of manual wheelchair users.

• Exercises that target posterior shoulder muscle groups, such as rowing, may improve muscle balance and reduce the risk of shoulder impingement.

• Participation in exercise is hindered in this population by a high rate of secondary health conditions and difficulty accessing facilities and equipment.

     

The measurement properties of pediatric observational pain scales: A systematic review of reviews

BackgroundValid observational pain scales are needed to assess pain and ensure sufficient treatment of pain in children that lack the verbal ability to self-report pain. Published reviews attempt to synthesize results from primary studies validating these scales and based on the findings recommendations may be given, for example which pain scales are the most appropriate for use in different pediatric populations.ObjectivesThe aims of this review were to describe how systematic reviews have evaluated and recommended observational pain scales for use in children aged 0–18 years and appraise the evidence underlying these recommendations.DesignSystematic review of reviews.Data sourcesThe Cochrane Library, PubMed/MEDLINE, CINAHL, Web of Science, and PsychINFO were searched from inception to September 2016. Reference lists and gray literature were searched for additional studies.Review methodsStudy selection and data extraction were performed by two reviewers independently with a disagreement procedure in place. Methodological quality or study validity was measured using the Assessment of Multiple Systematic Reviews checklist and risk of bias or internal validity was measured using the Risk of Bias in Systematic Reviews tool. The review protocol was registered with PROSPERO: registration number CRD42016035264.ResultsTwelve reviews met the inclusion criteria. Together; they included 65 different observational pain scales for use in children, of which 28 were recommended at least once. Face, Legs, Activity, Cry, Consolability/revised version of Face, Legs, Activity, Cry, Consolability, COMFORT/COMFORT behavioral scale and Children’s Hospital of Eastern Ontario Pain Scale were evaluated and recommended most frequently. Few of the included reviews assessed the methodological quality of the studies included in the review. The narrative analysis consisted mostly of a reiteration of the results from the primary studies. In general, more recent reviews showed a lower risk of bias than older ones.ConclusionsIncluded reviews exhibited low quality of evidence; thus, their recommendations regarding pain scales for use in clinical practice or research with children that lack the verbal ability to self-report pain should be interpreted with caution.     

The effectiveness of vestibular rehabilitation therapy vs conservative treatment on dizziness: a systematic review and meta-analysis

Abstract

Background: Dizziness is a common condition which may lead to loss of function and disability. Vestibular Rehabilitation Therapy (VRT) may be utilized to affect the vestibular system and reduce dizziness. However, controversy exists regarding the most effective interventions to treat dizziness.

Objectives: To examine the effectiveness of VRT compared to other conservative treatments in reducing dizziness and disability.

Methods: A literature search was performed using different combinations of the terms: dizziness, physical therapy, vertigo, vestibular, cervicogenic dizziness to identify randomized clinical trials comparing VRT to conservative treatments. The Cochrane Risk of Bias Tool was used to assess the quality of each included study. Additionally, a meta-analysis and qualitative analysis of the evidence was performed.

Results: Ten studies were included in the systematic review. Only four studies were included in the meta-analysis due to lack of adequate data reported for continuous outcomes. Eight studies scored less than a 69% on the Cochrane risk of bias tool indicating a low to moderate risk of bias. The meta-analysis revealed that VRT was found to be more effective than conservative treatment for short term outcomes (0–3?weeks) but not long-term outcomes (4 or more weeks). The results from the studies excluded from the meta-analysis but included in the systematic review are inconclusive.

Conclusions: VRT was only found to be more effective than other conservative treatments in the short term.     

Effectiveness of Conservative Nonpharmacologic Therapies for Pain,Disability, Physical Capacity,and Physical Activity Behavior in Patients With Degenerative Lumbar Spinal Stenosis: A Systematic Review and Meta-Analysis

ObjectiveTo investigate the effectiveness of conservative nonpharmacologic therapies on pain, disability, physical capacity, and physical activity outcomes in patients with degenerative lumbar spinal stenosis (LSS).Data SourcesSystematic search of MEDLINE, EMBASE, CENTRAL, and PsycINFO from inception to November 4, 2019, without language restrictions.Study SelectionPairs of review authors independently identified randomized controlled trials published in peer-reviewed scientific journals reporting on the effects of rehabilitation interventions on pain intensity (back or leg), disability, symptom severity, physical capacity, physical activity behavior, or adverse events (secondary outcome) in adults with LSS. The search identified 1718 records; data from 21 reports of 19 trials (1432 patients) were included.Data ExtractionReview author pairs independently extracted data and assessed included studies. We assessed risk of bias with the Cochrane tool, and overall study quality with the Grading of Recommendations Assessment, Development and Evaluation classification.Data SynthesisWe pooled data using random-effects meta-analyses; treatment effects were reported as mean differences (MD) and 95% confidence intervals (CI). Directed exercise and manual therapy was superior to self-directed or group exercise for improving short-term walking capacity (MD, 293.3 m; 95% CI, 61.7-524.9 m; low-quality evidence), back pain (MD, –1.1; 95% CI, –1.8 to –0.4; moderate quality evidence), leg pain (MD, –.9; 95% CI, –0.2 to –1.5; moderate-quality evidence), and symptom severity (MD, –0.3; 95% CI, –0.4 to –0.2; low quality evidence). There is very low quality evidence that rehabilitation is no better than surgery at improving intermediate- or long-term disability. Single trials provided conflicting evidence of effectiveness for a variety of therapies.ConclusionsFor patients with LSS, there is low- to moderate-quality evidence that manual therapy with supervised exercises improves short-term walking capacity and results in small improvements in pain and symptom severity compared with self-directed or group exercise. The choice between rehabilitation and surgery for LSS is very uncertain owing to the very low quality of available evidence.     

The Effects of Graded Motor Imagery and Its Components on Chronic Pain: A Systematic Review and Meta-Analysis

Graded motor imagery (GMI) is becoming increasingly used in the treatment of chronic pain conditions. The objective of this systematic review was to synthesize all evidence concerning the effects of GMI and its constituent components on chronic pain. Systematic searches were conducted in 10 electronic databases. All randomized controlled trials (RCTs) of GMI, left/right judgment training, motor imagery, and mirror therapy used as a treatment for chronic pain were included. Methodological quality was assessed using the Cochrane risk of bias tool. Six RCTs met our inclusion criteria, and the methodological quality was generally low. No effect was seen for left/right judgment training, and conflicting results were found for motor imagery used as stand-alone techniques, but positive effects were observed for both mirror therapy and GMI. A meta-analysis of GMI versus usual physiotherapy care favored GMI in reducing pain (2 studies, n = 63; effect size, 1.06 [95% confidence interval, .41, 1.71]; heterogeneity, I² = 15%). Our results suggest that GMI and mirror therapy alone may be effective, although this conclusion is based on limited evidence. Further rigorous studies are needed to investigate the effects of GMI and its components on a wider chronic pain population.PerspectiveThis systematic review synthesizes the evidence for GMI and its constituent components on chronic pain. This review may assist clinicians in making evidence-based decisions on managing patients with chronic pain conditions.     

The effects of exercise therapy on adolescent idiopathic scoliosis: An overview of systematic reviews and meta-analyses

BackgroundExercise therapy was suggested as an appealing treatment option for Adolescent Idiopathic Scoliosis (AIS) patients with less side effects, lower economic costs, and more psychological benefits. Nevertheless, no unanimous findings about the efficacy of exercise therapy have been obtained from previous systematic reviews and/or meta-analyses.ObjectiveTo provide an overview of previous systematic reviews and/or meta-analyses on the effectiveness of exercise therapy on AIS treatment.MethodsSystematic searches in Medline, Eric, CINAHL, Embase, SPORTDiscus, PsycINFO, and the Cochrane Library for systematic reviews and/or meta-analyses of randomized controlled trials (RCTs), non-randomized comparison studies (NRS) or observational studies using exercise as an intervention, and with outcome measures including Cobb angle, angle of trunk rotation (ATR), and quality of life. The methodological quality of the review articles was evaluated by A Measurement Tool to Assess Systematic Reviews (AMSTAR) checklist.ResultsTen systematic reviews and meta-analyses were included. The quality of most of the review articles is moderate with a mean score of 6/11 on the AMSTAR scale. Overall, there is increasing evidence showing the efficacy of exercise therapy on reducing the Cobb angle and angle of trunk rotation, and improving perceived quality of life.ConclusionExercise therapy was found to have potential benefits to treat physiological and psychological aspects of AIS patients. However, the findings were not conclusive given that some reviews relied on data from the trials with potential risk of bias and significant heterogeneity. More high-quality research is still needed to verify these findings.     

Effect of low-level laser therapy on postoperative endodontic pain: An updated systematic review

ObjectiveTo evaluate the influence of low-level laser therapy (LLLT) on postoperative pain after endodontic treatment.MethodsThe PICOS strategy was used to identify randomized clinical trials comparing low-level laser therapy and mock laser therapy to manage postoperative pain after endodontic treatment, retreatment, and endodontic surgery. An electronic search was performed in MEDLINE through PubMed, Web of Science, LILACS, Scopus and Cochrane Library, OpenGrey and Google Scholar. Quality assessment was performed using the Cochrane Collaboration’s tool for assessing the risk of bias. The quality of evidence was rated on the basis of the GRADE approach.ResultsTwelve studies were included in the qualitative synthesis. Within the 12 studies, 7 articles were classified as “low risk of bias,” 4 studies were considered “unclear risk of bias” and 1 study was considered "high risk of bias." Six studies evaluated the postoperative pain after primary root canal treatment, two studies after root canal retreatment and four after periapical surgery. Most of the studies reported significantly less postoperative pain after LLLT in different time periods; two studies found no differences. The certainty of evidence was classified as low and very low to treatment / retreatment and endodontic surgery, respectively.ConclusionsBased on the limited quality evidence, most of the included studies reported significantly less postoperative pain after LLLT. However, the lack of standardization in laser parameters, use of medications and the certainty of evidence classified as low and very low indicate the need for further studies.     

Shall we use cryotherapy in the treatment in surgical procedures,in acute pain or injury,or in long term pain or dysfunction? - A systematic review

PurposeThis review aimed to evaluate the certainty of evidence for the use of cryotherapy in patients with musculoskeletal disorders.MethodsPubMed, Embase, Cochrane Library and AMED were searched from January 2000 to January 2018 (update June 2019) for systematic reviews (SRs) and randomized controlled trials (RCTs) reporting outcomes on pain, swelling, range of motion (ROM), function, blood loss, analgesic use, patient satisfaction and adverse advents. The papers were categorised into: surgical procedures, acute pain or injury and long-term pain or dysfunction. Methodological quality and risk of bias were assessed using the AMSTAR and the Swedish Health Technology Assessment instruments. Level of certainty of evidence was synthesized using GRADE.Study selectionEight SRs and 50 RCTs from a total of 6027 (+839) were included. In total 34 studies evaluated cryotherapy in surgical procedures, twelve evaluated cryotherapy use in acute pain or injury and twelve studies evaluated cryotherapy in long-term pain and dysfunction.ResultsThe certainty of evidence is moderate (GRADE III) after surgical procedures to reduce pain, improve ROM, for patient satisfaction and few adverse events are reported. Cryotherapy in acute pain and injury or long-term pain and dysfunction show positive effects but have a higher number of outcomes with low certainty of evidence (GRADE II).ConclusionCryotherapy may safely be used in musculoskeletal injuries and dysfunctions. It is well tolerated by patients. More advanced forms of cryotherapy may accentuate the effect. Future research is needed where timing, temperature for cooling, dose (time) and frequency are evaluated.     

Western Massage Therapies in the Management of Neck Pain: A Systematic Review

ObjectiveThe purpose of this review was to compare types of Western massage therapy (MT) to other therapies, placebo, and no-treatment controls in neck pain (NP) in randomized and nonrandomized clinical trials.MethodsAn electronic, systematic search was performed in 7 English and 2 Turkish databases (PubMed, Web of Science, Scopus, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, SPORTDiscus, Physiotherapy Evidence-Based Database, ULAKBIM National Medical Database, and the Reference Directory of Turkey). The search terms “NP” and “massage” were used. Studies published between January 2012 and July 2021 were searched. Methodological quality was evaluated with Downs and Black Scale and version 2 of the Cochrane risk-of-bias tool.ResultsA total of 932 articles were identified; 8 of them were eligible. The Downs and Black score ranged from 15 to 26 points. Two studies were rated as “fair,” 3 studies as “good,” and 3 studies as “excellent.” According to version 2 of the Cochrane risk-of-bias tool, 3 studies had a low risk of bias, 3 studies had some concerns, and 2 studies had a high risk of bias. Fair evidence found that myofascial release therapy improved pain intensity and pain threshold compared to no intervention in the short term. Excellent evidence found that connective tissue massage with exercise improved pain intensity and pain threshold compared to exercise alone in the short term. No Western MTs were superior to other active therapies according to short-term and immediate effects.ConclusionThis review suggests that Western MTs (myofascial release therapy and connective tissue massage) may improve NP, but studies are limited. This review showed that Western MTs were not superior to other active therapies for improving NP. The reviewed studies reported only immediate and short-term effects of Western MT; thus, high-quality randomized clinical trials investigating the long-term effects of Western MT are needed.     

Use of Mobilization with Movement in the Treatment of a Patient with Subacromial Impingement: A Case Report

Abstract

Mobilization with movement (MWM) is a fairly new therapeutic technique commonly used by physical therapists. The purpose of this case report was to describe the use of MWM in the treatment of a 27-year old left-hand dominant male patient referred to physical therapy with a diagnosis of supraspinatus tendinopathy secondary to impingement. Interventions consisted of MWM and other manual therapy techniques, modalities, and therapeutic exercises. Outcome measures used included goniometric active range of motion (AROM) measurements and manual muscle tests of the shoulder, impingement tests, and the Shoulder Pain and Disability Index (SPADI) and Short Form-36 (SF-36) questionnaires. Specific outcome measures used to describe the response to MWM of the glenohumeral joint included the Numeric Pain Rating Scale (NPRS) and goniometric measurement of abduction AROM. After the first MWM treatment (session 2/12), the 6/10 pre-application NPRS score during shoulder abduction was reduced to 3/10 post-application; however, abduction AROM did not improve (95°). At the final MWM treatment (session 6/12), the pre-application NPRS score during abduction was reduced from 3/10 to 0/10 post-application; abduction AROM increased from 130° to 175°. After 12 sessions, there was a decrease from moderate pain (7/10) to little or no pain (0-1/10) during active shoulder abduction; restricted (95°) to full shoulder abduction active range of motion (180°); and an improvement in the SPADI score from 45% to 8% with no pain or ADL activity difficulty scores >2. This case report indicates that MWM may be an effective treatment intervention for patients with subacromial impingement. Future research is needed to study the efficacy and mechanisms of this treatment technique.