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Manual Therapy Techniques

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Manual therapy interventions for the shoulder have been associated with improvements in pain and function in individuals with shoulder impingement syndrome (SIS) and adhesive capsulitis (AC).  Often rotator cuff tendinopathy can also be diagnostically synonymous with shoulder impingement syndrome.

Rotator Cuff Tendinopathy:
One moderate quality RCT compared  a protocol-driven comprehensive intervention consisting soft-tissue massage, glenohumeral mobilizations, thoracic and cervical spine mobilization, scapular re-training exercises, postural taping, and home exercise programs to a placebo group receiving inactive ultrasound. At 11 weeks there were no difference between the groups, but at the final 22-week follow-up the treatment group had significantly better improvements than the placebo group.
Bennel, 2010, BMJ

Shoulder Impingement Syndrome (SIS):
One high quality randomized trial has investigated the effectiveness of manual therapy interventions for the shoulder on patients with SIS. Bang and Deyle compared a program of strengthening and stretching exercises to that same program with the addition of manual therapy interventions primarily directed to the shoulder. At 30 days following the end of the treatment period, individuals receiving manual therapy + exercise demonstrated greater improvements in pain and function than those receiving exercise alone. Additionally, only individuals in the manual therapy + exercise group demonstrated improvements in strength.
Bang, 2000, J Orthop Phys Ther
Senbursa, 2007, Knee Surg Sports Traumatol Arthrosc
Ho, 2009, Man Ther
Surenkok, 2009, J Sport Rehabil

Adhesive Capsulitis (AC):
There is considerable controversy surrounding the effectiveness of manual therapy for AC. While some studies have shown MT interventions to be of benefit, several studies have found MT interventions to be no more effective than other interventions or to a “wait and see” approach in improving pain and function in individuals with frozen shoulder. However, several systematic reviews have concluded that because of the poor methodological quality of the research, it is impossible to discern what role, if any, MT should play in the management of individuals with AC. 
Bulgen, 1984, Ann Rheum Dis
Vermuelen, 2006, Phys Ther
Green, 2008, Cochrane Database Syst. Rev
Ho, 2009, Man Ther

Translational Manipulation Under Anesthesia (MUA) For Adhesive Capsulitis
To reduce the risk of injury associated with traditional glenohumeral manipulation, Roubal and colleagues developed a novel technique of translational manipulation following interscalene brachial plexus block. This procedure utilizes modifications of Kaltenborn and Maitland joint gliding mobilizations/manipulations. Forty-three patients treated with translational MUA have been reported in the medical literature. The initial study by Roubal followed eight patients for one month post MUA and observed significant improvements in ROM, function, and pain levels for all patients receiving the intervention. A second study by Placzek et al. investigated the long-term effectiveness of translational MUA on 31 individuals and found the positive outcomes post manipulation remained at the 14 month mark for all subjects. Boyles et al followed four patients treated with translational MUA and evaluated glenohumeral arthrokinematic motion pre and post manipulation using video fluoroscopy. Improvements in clinical outcomes were similar to previous findings. Additionally, increased caudal translation of the humeral head during active shoulder abduction was noted when comparing pre- and post-manipulation video fluoroscopic images. No adverse events or injuries were observed in any of the three studies.

While these initial results have been promising, all of the research published to date on translational MUA for AC has been in the form of case-series and cohort studies. These study designs preclude the establishment of a cause and effect relationship between the interventions delivered and the outcomes observed. Future research, in the form of randomized controlled trials, will be needed to determine whether translational MUA is truly an effective intervention for individuals with AC. 
Roubal, 1996, J Orthop Sports Phys Ther
Placzek, 1998, J Orthop Sports Phys Ther
Boyles, 2005, Man Ther


Non-Specific Shoulder Pain:
Pribicevic, 2010, J Manipulative Physiol Ther
Yiasemides, 2011, Phys Ther

Adhesive Capsulitis:
Placzek, 2004, Am J Orthop
Johnson, 2007, J Orthop Sports Phys Ther
Mitra, 2009, PM&R
Ng, 2009, Scott Med J

Shoulder Impingement Syndrome:
Tate, 2010, J Orthop Sports Phys Ther

Rotator Cuff Tendinopathy:
Bialoszewski, 2011, Ortop Traumatol Rehabil


Muraki, 2007, Man Ther
Hsu, 2009, Man Ther
Ho, 2009, Man Ther
Bergman, 2010, BMC Musculoskel Dis


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