MANUAL THERAPY DOES NOT PROVIDE ADDITIONAL BENEFITS WHEN COMBINED WITH EXERCISE IN PATIENTS WITH ROTATOR CUFF RELATED SHOULDER PAIN

E. Paraskevopoulos¹, G. Plakoutsis¹, E. Chronopoulos², M. Papandreou¹

¹University of West Attica, Physiotherapy, Athens, Greece, ²National and Kapodistrian University of Athens, Medicine, Athens, Greece

Background: Therapeutic exercise is considered the mainstay in the management of Rotator Cuff Related Shoulder Pain (RCRSP). Manual Therapy (MT) interventions have also shown to be effective in RCRSP. However, the benefits of adding MT along with exercise interventions for the management of RCRSP remain unknown.

Purpose: To evaluate the additional benefits of MT with exercise compared to exercise in isolation for the management of RCRSP.

Methods: A search of PubMed, Scopus, PEDro, and EBSCO from the inception date of each database through April 20, 2022, was conducted for randomized trials comparing the additional effects of MT in exercise interventions compared with exercise alone for pain management and function in patients with RCRSP. Inter-rater agreement for reviewers’ assessments of study eligibility was calculated with Cohen’s kappa (κ) coefficient. Inter-rater agreement for assessments of methodological quality was calculated with the intraclass correlation coefficient (ICC). Standardized Mean Differences (SMD) and 95% confidence interval (CI) were calculated using a random-effects inverse variance model according to the outcome of interest and comparison group. Methodological quality was assessed with PEDro and quality of evidence with the GRADE approach. Also, heterogeneity was assessed using the I² statistic and we interpreted I²values >50% as significant heterogeneity. Whenever possible, the overall treatment effect was compared with its minimum clinically important difference (MCID).

Results: Twelve articles were found eligible and 8 of them demonstrated high methodological quality. Eleven articles were included for quantitative analysis. There was almost complete agreement between the 2 reviewers at the title/ abstract screening stage (κ=0.80) and at the full-text screening stage (κ=0.82). Pain with movement was not significantly different between MT and exercise versus exercise alone (SMD [95% CI] = -0.15 [−0.41, 0.12], I²=0%), whereas, pain at rest was significantly improved in the groups that used exercise only with a moderate effect size (SMD [95% CI]=0.47 [0.04, 0.89], I²=75%). Furthermore, shoulder function was not significantly different between MT and exercise versus exercise alone in the short-term (SMD [95% CI]=0.23 [−0.22, 0.69], I²=88%) or the long-term (SMD [95% CI]=-0.02 [−0.21, 0.16], I²=2%). Although studies demonstrated a clinically important reduction in pain for either MT with exercise or exercise alone, the between-group difference (MT with exercise vs exercise only) in all studies was not clinically important for pain (<14 MCID) or function when using the SPADI (MCID>13.1).

Conclusions: Based on high to low-quality evidence it is concluded that MT and exercise do not seem to be more effective than exercise in isolation for the management of shoulder pain and function in adult patients with RCRSP. More research is necessary on the optimal dosage of MT in RCRSP before conducting larger trials for the adjunctive benefits of MT with exercise, to ensure the lack of efficacy of MT.

Implications: The results of this systematic review cannot support the superiority of combined interventions that include MT and exercise for the management of RCRSP. Combined interventions were not more effective than single interventions. Thus, we cannot propose the inclusion of MT techniques for the management of RCRSP.

Funding acknowledgements: This research study received no specific grant from funding agencies in the public, commercial, or not-for-profit sector.

Keywords:
Shoulder
Rotator cuff
Manual therapy

Topics:
Musculoskeletal: upper limb

Did this work require ethics approval? No

Reason: This is a systematic review and thus ethical approval was not required