Manual Therapy 14 (2009) 463–474

Contents lists available at ScienceDirect

Manual Therapy
journal homepage: www.elsevier.com/math

Systematic Review

The effectiveness of manual therapy in the management of musculoskeletal

disorders of the shoulder: A systematic review
Chung-Yee Cecilia Ho a, Gisela Sole a, *, Joanne Munn a, b
a
School of Physiotherapy, University of Otago, 325 Great King Street, Dunedin North, P.O. Box 56, Dunedin 9016, New Zealand
b
School of Physiotherapy, The University of Sydney, P.O. Box 170, Lidcombe NSW 1825, Australia

a r t i c l e i n f o a b s t r a c t

Article history: A systematic review of randomised controlled trials (RCTs) was conducted to determine the effectiveness
Received 22 July 2008 of manual therapy (MT) techniques for the management of musculoskeletal disorders of the shoulder.
Received in revised form Seven electronic databases were searched up to January 2007, and reference lists of retrieved articles and
23 March 2009
relevant MT journals were screened. Fourteen RCTs met the inclusion criteria and their methodological
Accepted 27 March 2009
qualities were assessed using the PEDro scale. Results were analyzed within diagnostic subgroups
(adhesive capsulitis (AC), shoulder impingement syndrome [SIS], non-specific shoulder pain/dysfunc-
Keywords:
tion) and a qualitative analysis using levels of evidence to define treatment effectiveness was applied. For
Shoulder
Manual therapy SIS, there was no clear evidence to suggest additional benefits of MT to other interventions. MT was not
Massage shown to be more effective than other conservative interventions for AC, however, massage and
Systematic review Mobilizations-with-Movement may be useful in comparison to no treatment for short-term outcomes for
shoulder dysfunction.
Ó 2009 Elsevier Ltd. All rights reserved.

1. Introduction conservative interventions for patients with musculoskeletal

disorders of the shoulder. Therefore, the purpose of this systematic
Various physiotherapy approaches have been suggested for review was to determine the level of evidence of the effectiveness
shoulder musculoskeletal disorders, including manual therapy of MT in the management of shoulder musculoskeletal disorders.
(MT), electrotherapy, acupuncture and exercise therapy (Brox,
2003). MT, including massage, joint mobilization and manipulation 2. Methodology
(such as Maitland, 1991), may be used with the aim of decreasing
pain and improving range of motion (ROM), thereby improving 2.1. Types of studies and participants
function.
To date, a number of systematic reviews have evaluated the Studies included randomised controlled clinical trials with
effectiveness of conservative treatment in shoulder disorders (Van language restricted to English or German (Fig. 1). Research papers
der Heijden et al., 1997; Green et al., 1998; Desmeules et al., 2003; on humans with disorders of the shoulder girdle, including frac-
Green et al., 2003; Ejnisman et al., 2004; Grant et al., 2004; Gibson tures, dislocation, degenerative/osteoarthritis and orthopedic
et al., 2004; Harniman et al., 2004; Michener et al., 2004; Faber surgery were included. Studies including subjects with systemic
et al., 2006; Trampas and Kitsios, 2006). Although there was some diseases such as rheumatoid arthritis, neurological disorders such
evidence of an additional benefit of MT with exercise in patients as stroke, or shoulder symptoms of spinal origin were excluded.
with shoulder impingement syndrome (SIS), conclusions from
these reviews (Desmeules et al., 2003; Green et al., 2003; Michener
2.2. Interventions and outcomes
et al., 2004; Faber et al., 2006; Trampas and Kitsios, 2006) were
limited due to small number of studies including MT. To our
Studies where at least one application of MT (manipulation,
knowledge, there is no systematic review specifically for the
passive joint or soft tissue mobilization techniques or massage) was
effectiveness of MT in addition or in comparison to other
applied to either the shoulder girdle, cervical or thoracic spine were
included (Paris, 2000; Vernon et al., 2007). Multi-modal interven-
tions were included if the effects of MT could be differentiated from
* Corresponding author. Tel.: þ64 3 479 7936; fax: þ64 3 479 8414. the other interventions. Studies reporting pain, ROM, functional
E-mail address: gisela.sole@otago.ac.nz (G. Sole). outcomes, patient satisfaction or recovery rate were considered.

1356-689X/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.math.2009.03.008
464 C.-Y.C. Ho et al. / Manual Therapy 14 (2009) 463–474

Step 1:

Computer database search (n = 4311): Manual search of relevant journals (n = 57):

MEDLINE (n = 936) Manual Therapy (n = 34)
PUBMED (n = 1384) Journal of Manual and Manipulative Therapy (n = 15)
AMED (n = 322) Journal of Manipulative and Physiological Therapeutic (n = 8)
CINHAL (n = 514)
EMBASE (n = 1004)
PEDro (n = 151)
Duplicate articles excluded (n = 1406)

Step 2: Unrelated articles excluded based

on title and article type (n = 2122)

Screening of title and abstract for inclusion and

exclusion (n = 840)

Irrelevant articles excluded (n = 699)

Case report (n = 52)

Uncertain-
full article retrieved (n = 58) Irrelevant articles excluded (n = 58)

Step 3:

Relevant articles full article retrieved (n = 30)

Articles excluded (n = 17):
• Laboratory studies (n = 2)
• Case studies (n = 2)
• Economic evaluation (n = 1)
• Mutli-model (n = 12)
Articles included in systematic review (n = 13)

Step 4:

Hand search of reference list for potentially

relevant articles (n = 1)

Step 5:

Quality Assessment using PEDro scale (n = 14)

Step 6:

Data extraction and analysis

Fig. 1. Flow diagram of study selection process.

2.3. Search strategy authors and institutions screened potentially relevant titles and
abstracts for inclusion. Full articles were retrieved if there was
An electronic search was performed of MEDLINE (1950 to January insufficient information from the title and abstract to determine
2007), CINAHL (1982 to January 2007), AMED (1985 to relevance. If consensus for study eligibility was not reached, a third
January 2007), EMBASE (1988 to January 2007), PUBMED (1950 to assessor (JM) was involved.
January 2007) and PEDro (1950 to January 2007), and included
a combination of search terms related to shoulder musculoskeletal
disorders and to MT (Appendix I). Supplementary searches were done 2.5. Quality assessment
on the PEDro database, and by hand searching all volumes of three
relevant MT journals and reference lists of the included studies. Randomised controlled trials (RCTs) were rated independently
by two assessors (CH and JM) using the PEDro scale. Disagreements
2.4. Study selection in scores were resolved by consensus or a third opinion (GS) where
required. A study was considered to be of high quality if the PEDro
One assessor (CH) screened all titles for relevance and duplica- score was greater than five and of low quality if the PEDro score was
tion. Two independent assessors (CH and GS) blinded to journal, five or less (Maher et al., 2003).
 C.-Y.C. Ho et al. / Manual Therapy 14 (2009) 463–474 465

Table 1 meta-analysis was not performed. A qualitative analysis using

Levels of evidence by van Tulder et al. (2003). levels of evidence to define treatment effectiveness was performed
Level of evidence Description (Table 1, van Tulder et al., 2003). These levels of evidence criteria
Strong evidence Consistent findings among multiple high-quality RCTs considers participants, interventions, controls, outcomes, both high
Moderate evidence Consistent findings among multiple low-quality RCTs and low methodological quality of the included studies and
and/or CCTs and/or one high-quality RCT consistency of findings between studies, and are widely used (Faber
Limited evidence One low-quality RCT and/or CCT
et al., 2006; Woodley et al., 2007).
Conflicting evidence Inconsistent findings among multiple trials
No evidence No RCTs or CCTs.

RCT: randomised clinical trial; CCT: clinical controlled trial. 3. Results

3.1. Selection of studies and study characteristics

2.6. Data extension and analysis
Fourteen RCTs (n ¼ 888 subjects) from 840 citation postings and
Data were extracted by one author (CH) for characteristics of hand searching results were included (Fig. 1). The studies investi-
participants, shoulder conditions, interventions and outcomes of gated patients with AC (Table 2), SIS (Table 3) and non-specific
pain, ROM and function using a standardized form (Fig. 1, Step 6). If shoulder pain/dysfunction (Table 4). Sample sizes ranged from 14
a study reported more than one measure for an outcome, the to 172 patients, averaging 64 patients per study. The mean age of
measure most commonly used between studies or deemed to be patients ranged from 44 to 65 years.
more representative of function was used. Data were extracted for
outcomes immediately following the intervention period (initial 3.1.1. Interventions
follow-up) and, where available, at the final follow-up time point Interventions included joint mobilizations (Maitland concept) of
(long-term follow-up). the shoulder girdle (Bulgen et al., 1984; Conroy and Hayes, 1998;
Pain outcomes for overall pain, functional pain, 24-h pain and Maricar and Chok, 1999; Vermeulen et al., 2006) mobilization of the
pain on movement and night pain were considered. For ROM, active upper quarter (Winters et al., 1997; Bang and Deyle, 2000; Bergman
(and passive for studies with patients with adhesive capsulitis [AC]) et al., 2004), manipulation (Winters et al., 1997; Bergman et al.,
measures of abduction in degrees were extracted. For function, 2004), Cyriax’ manipulation and deep transverse frictions (Guler-
patient satisfaction and functional outcome questionnaires were Uysal and Kozanoglu, 2004), ‘‘Mobilization-with-Movement’’
considered. For continuous variables, the mean difference (95% (MWM) (Teys et al., 2008) or soft tissue massage (Van den Dolder
confidence intervals, CI) between groups was calculated from end- and Roberts, 2003). Bang and Deyle (2000) used a pragmatic
point scores or change scores (Herbert, 2000a, Clare et al., 2004). combination of joint and soft tissue mobilization techniques based
For dichotomous outcomes, relative risks (RR, with 95% CI) were on the upper quartile movement impairment assessed for the
calculated (Herbert, 2000b). individual participant in the experimental group; whereas Conroy
Results for each study were analyzed within commonly repor- and Hayes (1998) used glenohumeral joint mobilizations for the
ted diagnostic subgroups. Trials were assessed for clinical hetero- experimental group, but included soft tissue mobilization tech-
geneity with respect to the participants, intervention and niques as part of ‘‘conventional physiotherapy’’ for both participant
outcomes. Due to the wide range of disorders and interventions, groups.

Table 2
Study characteristics: adhesive capsulitis.

Author/year Condition Participants characteristics Interventions Outcomes

Bulgen et al. MOR: Not stated n ¼ 42, 28 female, 14 male Intervention period: varied Follow-up period: weekly for the first 6 weeks then
(1984) Four groups: intra- Mobilization group: n ¼ 11 between groups. monthly for a further 6 months
articular injection; Ice therapy group: n ¼ 12 All subjects were taught pendular Outcome measures:
mobilizations; ice Steroid group: n ¼ 11 exercises 2–3 min every hour and Verbal reports of progress
therapy and no Control group: n ¼ 8 pain medication if required. Passive ROM (goniometry):
treatment Age ¼ 55.8 (44–74) y Mobilization group: Total flexion
DOS ¼ 4.8 (1–12) months Maitland’s mobilizations Total abduction
Three times weekly for 6 weeks External rotation
Ice therapy group: Glenohumeral flexion
Ice pack followed by PNF Internal rotation
Three times weekly for 6 weeks
Steroid group:
Intra-articular /subacromial injec-
tion weekly for 3 weeks
Non-treatment group:
Pendular exercises and pain
medication

Binder et al. MOR: Not stated n ¼ 40, Gender not stated Follow-up from original study Follow-up period:
(1984) Four groups: intra- Mobilization group: n ¼ 11 (Bulgen et al., 1984) 40–48 months after initial presentation
articular injection; Ice therapy group: n ¼ 11 Outcome measures:
mobilizations; ice Steroid group: n ¼ 10 Persistent or recurrent pain/or restriction of
therapy and no Control group: n ¼ 8 movement
treatment Age ¼ not stated Passive ROM (goniometry): Total flexion
DOS ¼ not stated Total abduction
External rotation
Total rotation

(continued on next page)

466 C.-Y.C. Ho et al. / Manual Therapy 14 (2009) 463–474

Table 2 (continued )

Author/year Condition Participants characteristics Interventions Outcomes

Guler-Uysal MOR: Not stated n ¼ 40 3-week intervention Follow-up period:
and Two groups: Cyriax Experimental group: n ¼ 20, Active stretching and pendulum End of 1 and 2 week
Kozanoglu approach; physical 15 female, 5 male movements were performed by Outcome measures:
(2004) modalities Age ¼ 53.6  6.9 (43–70) y both groups after each session. Pain using VAS:
DOS ¼ 7.6  3.9 (2–12) Experimental group: Spontaneous pain
months Deep transverse frictions and Night pain
Control group: n ¼ 20, 13 manipulation. Pain with motion
female, 7 male 1 h session three times weekly. Passive ROM (goniometry):
Age ¼ 58.4  9.7(44–82) y Control group: Flexion
DOS ¼ 5.6  3.9 (2–12) Hot packs and shorts wave Abduction
months diathermy. Internal rotation
1 h session 5 times weekly. External rotation
Recovery rate

Maricar and MOR: Not stated n ¼ 32 8-week intervention Follow-up period:

Chok (1999) Two groups: manual Experimental group: n ¼ 16, Experimental group: 3, 5, 7, and 8 week
therapy þ exercises 7 female, 9 male Mobilization of upper quadrant Outcome measures:
and exercises alone Age ¼ 57.9  9.5 y using Maitland Grade IIIþ and IV AROM (goniometry)
Control group: n ¼ 16, 6 and exercises Flexion
female, 10 male Once weekly for 8 weeks External rotation
Age ¼ 54.9  5.4 y Control group: Internal rotation
DOS of both groups ¼ Exercises Hand-behind-back
average: 3 months Once weekly for 8 weeks

Nicholson MOR: Toss of coin n ¼ 20 4-week intervention Follow-up period:

(1985) Two groups: joint Experimental group: n ¼ 10, Experimental group: Weekly for 4 weeks
mobilization 6 female, 4 male Gliding and distractive mobilization Outcome measures:
þ exercises and Age ¼ 51(31–70) 12.16 y techniques and exercises Pain questionnaire
exercises alone DOS ¼ 27.6  33.41 (1–104) Two to three times weekly for 4 ROM (goniometry):
weeks weeks Active internal rotation
Control group: n ¼ 10, 4 Control group: Active external rotation
female, 6 male Exercises Active abduction
Age ¼ 55  16.43 (20–77) y Repeat the exercises three times Passive abduction
DOS ¼ 30.8  31.28 (3–104) daily independently
weeks

Vermeulen MOR: Random- n ¼ 100 12-week intervention Follow-up period:

et al. (2006) number generator HG mobilizations: n ¼ 49, 32 Subjects might have further treat- 3, 6 and 12 month
Two groups: high- female, 17 male ments as suggested by orthopedic Outcome measures:
grade mobilization Age ¼ 51.6 (7.6) y surgeon following intervention Active and Passive ROM (goniometry): Abduction
(HG) and Low grade DOS ¼ 8 (5–14.5) months period Forward flexion
(LG) LG mobilizations: n ¼ 51, 34 LG mobilizations: External rotation
female, 17 male Maitland grade I and II joint Shoulder Rating Questionnaire (SRQ)
Age ¼ 51.7 (8.6) y mobilization Shoulder Disability Questionnaire (SDQ)
DOS ¼ 8(6–14) months Number of sessions 18.6  4.9 Pain using VAS: Pain at rest
HG mobilizaionts: Pain during movement
Maitland grade III and IV joint Pain during the night
mobilization General Health using SF-36
Number of sessions 21.5  2.5
2 times weekly for 30 min for
a maximum of 12 weeks
A minimal duration of exposure to
the therapy of at least 6 weeks

RCT ¼ randomized controlled trial; MOR ¼ method of randomization; DOS ¼ duration of symptoms; ROM ¼ range of motion; PNF ¼ proprioceptive neuromuscular facilitation;
MWM ¼ mobilization with movement; s ¼ seconds; min ¼ minutes; VAS ¼ visual Analogue Scale; y ¼ years; data given as means  SD (range), unless otherwise stated.

MT was used in isolation (Winters et al., 1997; Winters et al., (Nicholson, 1985; Conroy and Hayes, 1998; Maricar and Chok, 1999;
1999; Van den Dolder and Roberts, 2003; Vermeulen et al., 2006; Bang and Deyle, 2000), education, and proprioceptive neuromus-
Teys et al., 2008) or in combination with exercises (Nicholson, 1985; cular facilitation (PNF) (Citaker et al., 2005). The number of inter-
Conroy and Hayes, 1998; Maricar and Chok, 1999; Bang and Deyle, vention sessions ranged from 3 to 20 (average 11 sessions). Twelve
2000; Guler-Uysal and Kozanoglu, 2004; Citaker et al., 2005), hot studies investigated immediate effects following intervention, with
packs (Conroy and Hayes, 1998; Citaker et al., 2005) or medical care the follow-up period ranging from 3 days to 4 years. Two studies
(Bergman et al., 2004). One study compared high-grade (HG) joint also investigated long-term effects (Bergman et al., 2004; Ver-
mobilizations, defined as grade III or higher on Maitland grading meulen et al., 2006). Two studies investigated long-term results of
system (Maitland, 1991), to low grade (LG) in patients with AC subjects included in earlier reported studies (Binder et al., 1984;
(Vermeulen et al., 2006). This study was included as there was Winters et al., 1999).
consensus amongst the current authors to consider LG mobiliza-
tions a control condition as clinical lore would usually indicate the 3.1.2. Measures
use of high rather than low-grade mobilization techniques with the The most common measure was pain (such as visual analogue
aim of improving ROM in patients with AC. Control interventions scales, VAS) and goniometric ROM which were reported in 10 out
included ice therapy (Binder et al., 1984; Bulgen et al., 1984), elec- of 14 studies. Various functional outcome measures were used
trophysical modalities (Guler-Uysal and Kozanoglu, 2004), exercise (Table 2).
 C.-Y.C. Ho et al. / Manual Therapy 14 (2009) 463–474 467

Table 3
Study characteristics: shoulder impingement syndrome.

Author/year Condition Participants characteristics Interventions Outcomes

Bang and Deyle (2000) MOR: Table of random numbers n ¼ 52 3-week intervention Follow-up period:
Two groups: Manual ther- Manual therapy group: n ¼ 28, Twice weekly for a total of 6 After 6 treatment sessions
apy þ exercise and exercise 10 female, 18 male visits Outcome measures:
alone Age ¼ 42  10.1 (17–64) y Manual therapy group: Perception of shoulder func-
DOS ¼ 5.6  3.7 (1–12) months standardized flexibility and tion: Functional assessment
Exercise group: n ¼ 24, 12 strengthening program, questionnaire (9 categories):
female, 12 male Joint mobilization of upper Pain using (VAS):
Age ¼ 45  8.4 (24–60) y quarter and soft tissue massage. Overall pain intensity
DOS ¼ 4.4  2.8 (1–12) months Exercise group: Raising arm overhead
Standardized flexibility and Behind the back activities
strengthening program Reaching across body
Lifting with problem arm
Lying on shoulder
Pushing and pulling
Carrying an object with arm at
side
Performance of usual physical
activity, sport or hobby
Resisted break test: IR; ER and
abduction
Active abduction
Isometric strength using
a stabilized electronic
dynamometer:
Internal rotation
External rotation
Abduction

Citaker et al. (2005) MOR: not stated n ¼ 40, Gender not stated Length of intervention period: Follow-up period:
Two groups: Hot Mobilization group: n ¼ not Not stated Unclear, stated as after inter-
pack þ mobilization þ exercises stated 20-session treatment followed vention period
and hot pack þ PNF þ exercises Age ¼ 52.8  9.86 y by 3 weeks of theraband Outcome measures:
DOS ¼ not stated exercises Pain using VAS
PNF group: n ¼ not stated Mobilization group: ROM (goniometry):
Age ¼ 55.5  8.95 y Manual mobilization, hot packs, Flexion
DOS ¼ not stated theraband exercises and Cod- Abduction
man pendulum exercises External rotation
PNF group: Internal rotation
PNF , hot packs, theraband Hyperextension
exercises and Codman University of California at Los
pendulum exercises Angeles Shoulder Rating Scale
(UCLA)
Categorized into pain, function,
AROM, strength and patient
satisfaction
Total score: 2–35
28 or less ¼ unsatisfactory
29–33 ¼ good
34–35 ¼ excellent

Conroy and Hayes (1998) MOR: not stated n ¼ 14, 6 female, 8 male 3-week intervention Follow-up period:
Two groups: joint mobi- Experimental group: n ¼ 7 3 sessions per week 3 week
lization þ soft tissue massage Age ¼ 55  10.2 y Experimental group: Outcome measures:
and soft tissue massage only DOS ¼ not stated Joint mobilization of sub- Maximum pain over the
Control group: n ¼ 7 acromial and glenohumeral preceding 24-hr period (VAS)
Age ¼ 50.7  16.5 y joints, soft tissue mobilization, Pain with subacromial
DOS ¼ not stated hot pack, stretching and compression test (VAS)
strengthening exercise, and AROM (goniometry):
patient education Shoulder flexion
Manual therapy: oscillatory Abduction
pressure of 2–3 oscillations per Scapular plane elevation
second, each technique was Internal rotation
administered 2–4 times (30 s External rotation
each) Overhead Function (graded on
Control group: a 3-point scale):
Soft tissue mobilization, hot Reach behind head
pack, stretching and strength- Reach across and around the
ening exercise and patient upper body
education Touch a mark on the wall that
required 135 of shoulder
flexion.

RCT ¼ randomized Controlled Trial; MOR ¼ method of randomization; DOS ¼ duration of symptoms; ROM ¼ range of motion; PNF ¼ proprioceptive neuromuscular facilitation;
MWM ¼ mobilization with movement; s ¼ seconds; min ¼ minutes; VAS ¼ visual Analogue Scale; y ¼ years; data given as means  SD (range), unless otherwise stated.
468 C.-Y.C. Ho et al. / Manual Therapy 14 (2009) 463–474

Table 4
Study characteristics: non-specific shoulder pain or dysfunction.

Author/year Condition Participants characteristics Interventions Outcomes

Bergman et al. MOR: Sealed n ¼ 150 12-week intervention Follow-up period:
(2004) envelope Manipulative group: n ¼ 79, 42 female, 37 males Manipulative group: Week 6, 12 , 26 and 52
Two groups: Age ¼ 48.4  12.4 y Usual medical care and Outcome measures:
Manipulative DOS: 0–12 weeks ¼ 53, 12–26 weeks ¼ 26 mobilization or manipula- Patient-perceived recovery (7-point ordinal scale)
therapy Medical care group: n ¼ 71, 32 female, 39 males tive to cervical spine, upper Patient’s perception of ‘‘cured’’
þ medical care Age ¼ 47.8  11.8 y thoracic spine and adjacent Severity of the main complaint during preceding
and medical DOS: 0–12 weeks ¼ 50, 12–26 weeks ¼ 21 ribs week on an 11-point scale (0 ¼ best 10 ¼ worst)
care alone The mean duration of Shoulder pain (4-point ordinal scale):
a manipulative session At rest
23  13 min In motion
maximum of 6 treatments Night pain
over a 12-week period Sleeping problems caused by pain
Medical care group: Inability to lie on the painful side
Usual medical care Degree of radiation
General pain
Shoulder disability questionnaire for the func-
tional status of the shoulder in the preceding 24 h
16 items
EuroQol health:
5 items
3-point ordinal scale

Teys et al. MOR: Drawing n ¼ 24, 13 female, 11 male 3-day intervention Follow-up period:
(2008) of lots Age ¼ 46.1  9.86 (20–64) y Experimental group: Each treatment session
Three groups: DOS ¼ 1–12 months Mobilization with move- Outcome measures:
MWM; Sham ment: Postero-lateral glide Pain-free AROM (goniometry):
and control of glenohumeral joint Scapular plane elevation
during elevation Pressure pain threshold using pressure pain
3 sets of 10 repetitions with algometry and by palpating the most sensitive
a rest interval of 30 s point located over anterior aspect of the shoulder
between each set.
Sham group:
Anterior glide with minimal
pressure applied. Elevation
through half of available
pain-free range.
3 sets of 10 repetitions with
a rest interval of 30 s
between each set.
Control group:
No manual contact

Van den Dolder MOR: Sealed n ¼ 29 2-week intervention Follow-up period:

and Roberts envelope Massage group: n ¼ 15, 4 female, 11 male Massage group: 2 week
(2003) Two groups: Age ¼ 63.1  9.9 y 6 treatments of soft tissue Outcome measures:
Massage and DOS ¼ median 26 (13–26) weeks massage around the Pain intensity using Short Form McGill Pain
control Control group: n ¼ 14, 5 female, 9 male shoulder Questionnaire:
Age ¼ 65.9  9.2 y Each treatment 15–20 min 3 sections
DOS ¼ median 30 (23–91) weeks Control group: 1st: A list of 15 words to describe pain
No treatment for 2 weeks 2nd: 100 mm VAS pain experienced over last 24 h
3rd: Present pain index
Functional disability using a Patient Specific
Functional Disability Measure:
Active ROM using photographs:
Flexion
Abduction
Hand-behind-back

Winters et al. MOR: Not n ¼ 172 Up to 11-week intervention Follow-up period:

(1997) stated Shoulder girdle groups: Manipulation group: 2, 6 and 11 weeks
2 categories: Manipulation: n ¼ 29, 15 female, 14 male mobilization and manipu- Outcome measures:
Shoulder girdle Age ¼ 43.9  12.6 y lation of the cervical spine, Shoulder pain score (4-point scale):
and synovial DOS ¼ median 3 weeks upper thoracic spine, upper Pain at rest
Shoulder Physiotherapy: n ¼ 29, 18 female, 11 male ribs, acromioclavicular Pain during motion
girdle: Manipu- Age ¼ 46.4  11.2 y joints and glenohumeral Pain during the night
lation and DOS ¼ median 4 weeks joint Sleeping problems because of pain
physiotherapy Synovial groups: Once a week with Inability to lie on affected side
Synovial: Corti- Manipulation: n ¼ 32, 17 female, 15 male a maximum of 6 treatments Presence of radiated pain
costeroid injec- Age ¼ 46.7  12.1 y Physiotherapy group: Together with a 101 point numerical pain scale
tion; manipula- DOS ¼ median 9 weeks Exercise therapy, massage Patient’s perception of ‘‘cured’’
tion and Physiotherapy: n ¼ 35, 14 female, 21 male and physical applications
physiotherapy Age ¼ 53.1  12.6 y Twice a week
DOS ¼ median 4 weeks Injection group:
Corticosteroid injection: n ¼ 47, 32 female, 15 male 1–3 injections
Age ¼ 53.5  12.5 y
DOS ¼ median 8 weeks
 C.-Y.C. Ho et al. / Manual Therapy 14 (2009) 463–474 469

Table 4 (continued )

Author/year Condition Participants characteristics Interventions Outcomes

Winters et al. MOR: not Questionnaire sent to all 172 subjects, 130 (76%) Follow-up from original Follow-up period:
(1999) stated could be evaluated study (Winters et al., 1997) 2–3 years after original study
2 categories: Gender ¼ not stated Outcome measures:
Shoulder girdle Age ¼ not stated Persisting, recurrent or new shoulder complaints
and synovial DOS ¼ not stated Patient’s perception of ‘‘cured’’
Shoulder Shoulder girdle groups:
girdle: Manipu- Manipulation: n ¼ 18
lation and Physiotherapy: n ¼ 22
physiotherapy Synovial groups:
Synovial: Corti- Injection: n ¼ 38
costeroid injec- Manipulation: n ¼ 26
tion; manipula- Physiotherapy: n ¼ 26
tion and
physiotherapy

RCT ¼ randomized Controlled Trial; MOR ¼ method of randomization; DOS ¼ duration of symptoms; ROM ¼ range of motion; PNF ¼ proprioceptive neuromuscular facilitation;
MWM ¼ mobilization with movement; s ¼ seconds; min ¼ minutes; VAS ¼ visual Analogue Scale; y ¼ years; data given as means  SD (range), unless otherwise stated.

3.2. Methodological quality 3.3.1. Adhesive capsulitis

3.3.1.1. Pain. No differences were found between HG MT and LG MT
PEDro quality scores ranged from 3 to 8 out of 10 (Fig. 2). Eight of with respect to pain at initial or long-term follow-up in one high-
the 14 studies scored 6 or more. The most common sources of bias quality trial (Fig. 3) (Vermeulen et al., 2006). These findings are
were failure to blind therapists (100% of studies), failure to blind consistent with the high-quality trial of Guler-Uysal and Kozanoglu
subjects (86% of studies), failure to conceal allocation (79% of (2004) (for initial follow-up), comparing MT using the Cyriax
studies) and lack of analysis by intention-to-treat (71% of studies). approach (Cyriax, 1984) to hot packs and short wave diathermy
Thirteen of 154 (8%) quality criteria assessed across studies required (Fig. 3).
discussion to reach consensus between assessors. Three criteria
required an opinion from the third assessor. 3.3.1.2. Range of motion. For active ROM, two studies (Nicholson,
1985; Maricar and Chok, 1999) showed that mobilization with
exercise was no more effective than exercise alone in the short-
3.3. Effects of manual therapy term. Vermeulen et al. (2006) found in a high-quality trial that HG
joint mobilizations were more effective than LG mobilizations
All results are reported as mean differences (95% CI) for the when active ROM was measured both immediately and 12 months
effect of MT compared to control for outcome measures of pain, following the intervention period (Fig. 3).
ROM and function unless otherwise stated. For passive ROM, Nicholson (1985) showed that mobilization
with exercise was more effective than exercise alone. In contrast,
Study PEDro scale item number Total score Guler-Uysal and Kozanoglu (2004) found that manipulation with
/10 deep transverse frictions following the Cyriax approach (Cyriax,
a
1 2 3 4 5 6 7 8 9 10 11
Bang and Deyle 2000 6 1984) was no more effective than the application of physical
modalities. When long-term effects of MT were investigated,
Bergman et al. 2004 8
Binder et al. (1984) showed in a low-quality trial that MT was no
Binder et al. 1984 3
more effective than intra-articular steroid injection, ice therapy or
Bulgen et al. 1984 3
no treatment. Vermeulen et al. (2006) found HG mobilizations
Citaker et al. 2005 4 were more effective than LG mobilizations at initial and long-term
Conroy and Hayes 1998 7 follow-up.
Guler-Uysal and Kozanoglu 6
2004
Maricar and Chok 1999 4 3.3.1.3. Function. Guler-Uysal and Kozanoglu (2004) did not show
Nicholoson 1985 6
a better recovery rate (number of patients who reached 80% of
normal shoulder ROM) for patients receiving deep massage and
Teys et al. 2008 8
manipulation than patients receiving physical modalities [Relative
van den Dolder and Roberts 7
2003 Risk (95% CI) ¼ 1.5 (1.0–2.0)]. HG mobilizations were more effective
Vermeulen et al. 2006 7 in improving shoulder function when compared to LG mobiliza-
Winters et al. 1997 5 tions for long-term outcomes but not short-term outcomes (Fig. 3)
Winters et al. 1999 3 (Vermeulen et al., 2006).
The qualitative analysis defining treatment effectiveness (Table
Fig. 2. Pedro score table. aCriteria 1 was not used to calculate the PEDro score. 5) showed moderate evidence that MT was no more effective than
, ¼ criteria not met. ¼ criteria met. Pedro Scale item. 1. Eligibility criteria were other interventions in decreasing pain measures and improving
specified. 2. Subjects were randomly allocated to groups. 3. Allocation was concealed. ROM and function. However, there was moderate evidence that HG
4. The groups were similar at baseline regarding the most important prognostic
MT compared to LG MT was more effective for increasing ROM and
indicators. 5. There was blinding of all subjects. 6. There was blinding of all therapists
who administered the therapy. 7. There was blinding of all assessors who measured at long-term functional outcomes.
least one key outcome. 8. Measures of at least one key outcome were obtained from
more than 85% of the subjects initially allocated to groups. 9. All subjects for whom 3.3.2. Shoulder impingement syndrome
outcome measures were available received the treatment or control condition as 3.3.2.1. Pain. The addition of pragmatic MT was shown to be
allocated or, where this was not the case, data for at least one key outcome was
analyzed by ‘‘intention to treat’’. 10. The results of between-group statistical compar-
effective in reducing pain compared to exercise alone (Bang and
isons are reported for at least one key outcome. 11. The study provides both point Deyle, 2000) and when joint mobilizations were compared to
measures and measures of variability for at least one key outcome. ‘‘conventional’’ physiotherapy alone (Conroy and Hayes, 1998) in
470 C.-Y.C. Ho et al. / Manual Therapy 14 (2009) 463–474

Fig. 3. Distribution of estimates from five studies for the mean difference in effect of manual therapy compared to control (or placebo) on pain (-), AROM (:), PROM (6) and
function (A) for patients with adhesive capsulitis. The size of each estimate symbol is proportional to the study’s sample size. The horizontal bars report 95% confidence intervals.
Pain and function are measured on a 0–100 scale, ROM is measured in degrees. Positive results indicate a beneficial effect of manual therapy over control. Mob ¼ mobilization;
AROM ¼ active range of motion; PROM ¼ passive range of motion. aVermeulen et al. (2006) compared high-grade to low-grade mobilization techniques. Low-grade mobilization
techniques were considered as a control condition for the purpose of the systematic review as these grades would not be applied for the aim of increasing ROM.

high-quality trials. Converseley, Citaker et al. (2005), a low-quality no treatment. Long-term, effects of MT was no more greater than
trial, reported that joint mobilizations in addition to exercise and usual medical care (Bergman et al., 2004).
modalities were no more effective than exercise, modalities and
PNF in improving pain (Fig. 4). 3.3.3.2. Range of motion. MWM were effective for improving short-
term active ROM compared to sham or no treatment in a high-
3.3.2.2. Range of motion. Joint mobilizations were no more effec- quality trial (Teys et al., 2008). Similarly, massage of the shoulder
tive in improving active ROM than conventional physiotherapy was effective compared to no treatment in a high-quality trial
alone (Conroy and Hayes, 1998) and PNF (Citaker et al., 2005) for (Fig. 5, Van den Dolder and Roberts, 2003).
short-term outcomes (Fig. 4).
3.3.3.3. Function. Massage was effective for improving function
3.3.2.3. Function. Bang and Deyle (2000) found that pragmatic compared to no treatment (Fig. 5) (Van den Dolder and Roberts,
MT was effective in improving function compared to exercise 2003). However, the addition of MT to usual medical care was no
alone. Similarly, Citaker et al. (2005) showed that joint mobili- more effective for improving function at initial and long-term
zations were effective in comparison to PNF. Assessment of follow-up (Bergman et al., 2004).
function on overhead reaching (Conroy and Hayes, 1998) showed Winters et al. (1997, 1999) investigated patients’ perception of
that there was no additional benefit of joint mobilizations to recovery following an 11-week intervention and also 2–3 years
physiotherapy which included soft tissue mobilization techniques later. Manipulation was more effective than traditional physio-
(Fig. 4). therapy for treating shoulder complaints originating from the
In summary, there was no clear evidence to suggest additional shoulder girdle [RR (95% CI): 6.7 (2.2–20)]. In the group with
benefits of MT to other interventions in the management of synovial shoulder complaints, manipulation was no more effective
patients with SIS (Table 5). than traditional physiotherapy. Further, it was ineffective when
compared to corticosteroid injection for synovial shoulder
3.3.3. Non-specific shoulder pain/dysfunction complaints [RR (95% CI): 2 (0.9–4.4); 0.5 (0.3–0.9), respectively]. At
3.3.3.1. Pain. The additional effect of MT of the upper quarter to the 2–3 year follow-up, manipulation was shown to be no more
medical care was shown to be effective in reducing pain originating effective in improving function than traditional physiotherapy and
from the shoulder girdle at initial follow-up in a high-quality trail injection in both groups [RR (95% CI): 1.2 (0.8–1.8); 0.9 (0.7–1.2); 1
(Bergman et al., 2004). In a low-quality trial (Winters et al., 1997) (0.7–1.3), respectively] (Winters et al., 1999).
manipulation was beneficial compared to traditional physiotherapy For non-specific shoulder pain/dysfunction, there was moderate
at initial follow-up. However, manipulation was ineffective in evidence to suggest MT was effective in the short-term for
treating shoulder complaints where shoulder disorders were clas- increasing ROM when compared to sham type treatment and
sified as originated from synovial structures when compared to control groups, and massage was effective when compared to no
traditional physiotherapy or corticosteroid injection (Winters et al., treatment (Table 5). Moderate evidence suggests that MT is no
1997) (Fig. 5). In addition, Van den Dolder and Roberts (2003) found more effective in improving function in the long-term compared to
two-weeks of massage more effective for pain relief compared to other interventions.
 C.-Y.C. Ho et al. / Manual Therapy 14 (2009) 463–474 471

Table 5
Table of level of evidence for the effectiveness of manual therapy for musculoskeletal disorders of the shoulder.

Shoulder pathology Outcome Follow-up Evidence

measures
Adhesive capsulitisa Painb Initial Moderate evidence exists to suggest that MT is no more effective for improving pain when compared
to other interventions.
Moderate evidence exists to suggest that high-grade MT is no more effective than low-grade MT for
improving pain.
Long-term Moderate evidence exists to suggest that high-grade MT is no more effective than low-grade MT for
improving pain.
PROM Initial Conflicting evidence exists regarding the effect of MT on PROM when compared to other
interventions.
Moderate evidence exists to suggest that high-grade MT is more effective for improving PROM than
low-grade manual therapy.
Long-term Limited evidence exists to suggest that MT is no more effective for improving PROM when compared
to other interventions.
Moderate evidence exists to suggest that high-grade MT is more effective for improving PROM than
low-grade MT.
AROM Initial Moderate evidence exists to suggest that MT is no more effective for improving AROM when
compared to other interventions.
Moderate evidence exists to suggest that high-grade MT is more effective for improving AROM than
high-grade MT.
Long-term Moderate evidence exists to suggest that high-grade MT is more effective for improving AROM when
compared to low-grade MT.
Function Initial Moderate evidence exists to suggest that MT is no more effective for improving recovery when
compared to other interventions.
Moderate evidence exists to suggest that high-grade MT is no more effective for improving shoulder
function than low-grade MT.
Long-term Moderate evidence exists to suggest that high-grade MT is more effective for improving shoulder
function than low-grade MT.

Shoulder impingement Pain Initial Conflicting evidence exists regarding the effect of MT on pain when compared to other interventions.
syndrome AROM Initial Moderate evidence exists to suggest that MT is no more effective for improving AROM when
compared to other interventions.
Function Initial Conflicting evidence exists regarding the effect of MT on function when compared to other
interventions.

Shoulder pain/dysfunction Pain Initial Conflicting evidence exists regarding the effect of MT on pain when compared to other interventions.
Moderate evidence exists to suggest that massage is more effective for improving pain compared to
no treatment.
Long-term Moderate evidence exists to suggest that MT is no more effective for improving pain when compared
to other interventions.
AROM Initial Moderate evidence exists to suggest that MT is more effective for improving AROM compared to
sham or no treatment.
Moderate evidence exists to suggest that massage is effective for improving AROM compared to no
treatment.
Function Initial Conflicting evidence exists regarding the effect of MT on function compared to other interventions.
Moderate evidence exists to suggest that massage is effective for improving function compared to no
treatment.
Long-term Moderate evidence exists to suggest that MT is no more effective in improving function or recovery
when compared to other interventions.

AROM ¼ active range of motion; PROM ¼ passive range of motion; MT ¼ manual therapy.
a
Effect statement for adhesive capsulitis does not include study by Bulgen et al. (1984), because insufficient statistical data of study outcomes were given. They reported ‘‘at
the end of treatment, the groups were significantly different at the 2% level, but by the end of the study there was no significant difference between the groups’’.
b
Effect statement for adhesive capsulitis does not include the study by Nicholson (1985), because the pain scale used was not specified, so the score could not be converted
to the scale of 0–100 for effect size calculation. The author reported the change pain score in mean degrees (standard deviation): experimental group ¼ 5.10 (4.56) and control
group ¼ 2.90 (4.41) and P value ¼ 0.7201.

4. Discussion found a pragmatic approach, including joint and soft tissue mobi-
lizations to the individual-specific movement impairment of the
This review found inconsistent evidence for the effectiveness of upper quadrant to be more effective than therapeutic exercise
MT for various shoulder disorders compared to control interven- alone. Conroy and Hayes (1998) included soft tissue mobilizations
tions and no treatment, contrasting with other published reviews in both the experimental and the control group, adding joint
regarding treatment efficacy for SIS. Green et al. (2003), Michener mobilizations to the former. Different forms of MT may have similar
et al. (2004) and Faber et al. (2006) reported limited evidence neurophysiological effects, despite differences in mechanical
suggesting that MT combined with exercise was more effective applications (Bialosky et al., 2009). It is thus possible, that these
than exercise alone in patients with SIS, whereas here there was common effects contributed to the lack of significant differences for
conflicting evidence for the benefit of MT on pain and function. The between-group outcomes by Conroy and Hayes (1998). Based on
current inclusion of the study by Citaker et al. (2005), finding that findings of our review, clinicians should consider incorporating soft
the addition of MT yielded no added benefit in SIS, is likely to have tissue and joint mobilization techniques in addition to therapeutic
contributed to our differing findings. exercises for patients with SIS, based on an individual assessment.
Conflicting evidence for effects on pain and function in SIS may Future RCTs should investigate pragmatic approaches to determine
be explained by variable definitions of MT. Bang and Deyle (2000) the effectiveness of MT in the management of patients with SIS.
472 C.-Y.C. Ho et al. / Manual Therapy 14 (2009) 463–474

Fig. 4. Distribution of estimates from three studies for the mean difference in the effects of manual therapy compared to control (or placebo) on pain (-), AROM (:) and function
(A) for patients with shoulder impingement syndrome. The size of each estimate symbol is proportional to the study’s sample size. The horizontal bars report 95% confidence
intervals. Pain and function are measured on a 0–100 scale, ROM is measured in degrees. Positive results indicate a beneficial effect of manual therapy over the control.
AROM ¼ active range of motion.

Our findings indicate that MT may not be more effective for the The lack of clear description and wide range of MT, further
management of pain and improving ROM and function for patients compounded by the difficulty of consistent sub-grouping of
with AC than other interventions. However, the studies had a Pedro patients with unspecific shoulder pain/dysfunction make it difficult
rating of 6 or less (Binder et al., 1984; Nicholson, 1985; Maricar and to provide clear guidelines for the clinician. The evidence was
Chok, 1999; Guler-Uysal and Kozanoglu, 2004). Vermeulen et al. conflicting or moderate that MT may be more effective than other
(2006) found that when comparing high-grade to low-grade joint interventions for pain management and improving ROM and
mobilizations, the former was more effective in improving ROM in the function for patients in this large group.
short and the long term, and ROM and function in the long term. In the One study investigated the effect of massage alone on shoulder pain
absence of higher quality RCT, the use of MT in patients with AC still with beneficial short-term effects (Van den Dolder and Roberts, 2003).
relies predominantly on clinical reasoning, with more support for the The control group of patients received no treatment, thus the positive
aim of improving ROM and function, than for pain management. findings for the experimental group may have, in part, indicated

Fig. 5. Distribution of estimates from four studies for the mean difference in the effects of manual therapy compared to control (or placebo) on pain (-), AROM (:) and function
(A) for patients with non-specific shoulder pain/dysfunction. The size of each estimate symbol is proportional to the study’s sample size. The horizontal bars report 95% confidence
intervals. Pain and function are measured on a 0–100 scale, ROM is measured in degrees. Positive results indicate a beneficial effect of manual therapy over control.
Exp ¼ experimental; Mani ¼ manipulation; Physio ¼ physiotherapy; AROM ¼ active range of motion.
 C.-Y.C. Ho et al. / Manual Therapy 14 (2009) 463–474 473

placebo effects. However, the authors (Van den Dolder and Roberts, Appendix I (continued)
2003) proposed that the decrease in pain with the massage was greater Phase 1 Phase 2 Phase 3 Phase 4
than what was previously considered to be decrease of pain as a result 6. Adhesive capsulitis 22. Manual 38. Rheumatoid
of placebo effects of treatment (Hrobjartsson and Gotzsche, 2001). therapy arthritis
A qualitative analysis of levels of evidence according to specific 7. Frozen shoulder 23. Joint 39. Hemiplegia
criteria van Tulder et al. (2003) was performed to define treatment mobilization
8. Joint instability 24. Spinal 40. Cancer or
effectiveness as meta-analysis was inappropriate because of clinical
mobilization neoplasm
heterogeneity with respect to the interventions and population 9. Sternoclavicular 25. Osteopathic 41. Celebral palsy
groups. The average methodological quality of the included studies joint manipulation
was defined as high (mean score  6). The most common sources of 10. Acromioclavicular 26. Chiropractic 42. Reflex
bias were failure to blind therapists and subjects. It is difficult to joint manipulation sympathetic
dystrophy
administer MT treatment without distinguishing between the 11. Glenohumeral 27. Acupressure 43. Acupuncture
treatments. Blinding of patients is also difficult when divergent joint
treatment techniques are compared. Inability to blind patients may 28. Traction 44. or/33–43
change their responses to treatment and may be affected by the 29. Physical 45. or/16, 2–11
therapy
expectations of the assessors, thereby potentially producing biases
30. physiotherapy 46. or/17–27,31,32
(Trampas and Kitsios, 2006). When the allocation is not concealed, 31. or/29,30 47. and/45,46
decisions about participant inclusion may be influenced by knowl- 32. and/28,31 48. 47 not 44
edge of whether or not the patient receives the treatment condition, 49. limit 48 to
potentially producing systematic bias (Trampas and Kitsios, 2006). English or German

Lack of analysis of intention-to-treat was another common problem

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