In this month’s Manual Therapy Research Review, comment is provided by Dr Helen French (manipulative Physiotherapist, lecturer and researcher at the Royal College of Surgeons in Ireland), Dr Rob Sillevis (a Dutch trained manipulative physiotherapist now residing in Cape Coral, USA and is adjunct faculty at the University of St. Augustine for Health Sciences, St. Augustine, FL) and Duncan Reid (Vice President, IFOMPT). You can read their thoughts on articles on manual therapy for lateral ankle sprains and neck pain, risk stratification in low back pain, cognitive functional therapy and biopsychosocial predictors for success in low back pain.
Read the full review here or read the summary below.
Desjardins-Charbonneau A, Roy J-S, Dionne CE, Frémont P, Macdermid JC, Desmeules F. The Efficacy of Manual Therapy for Rotator Cuff Tendinopathy: A Systematic Review and Meta-analysis. J Orthop Sports Phys Ther. 2015; 45(5):330-350.
This is a well conducted systematic review which aimed to update the evidence regarding the role of manual therapy for RC tendinopathy due to the publication of new randomised controlled trials since the last systematic review on this topic (Braun et al, 2013). Some points are worth noting when considering the results of this review. The definition of RC tendinopathy was quite broad with the inclusion of patients with RC tendinopathy/tendinitis, shoulder impingement syndrome or subacromial bursitis. Studies were excluded if participant had a full-thickness RC tear, calcific tendinopathy or post-surgery.
The manual therapy (MT) interventions were also broad and were defined as ‘hands on’ techniques which included joint mobilisations, manipulations, neurodynamic techniques, specific soft tissue massage techniques and mobilisations with movement (MWMs) of the shoulder girdle or spine. Outcomes of interest were also varied as all kind of outcomes were considered for inclusion. The characteristics of the included studies are also important to review (as presented in Tables 1 and 2), where a description of the diagnostic criteria is explained for each study. Clinical tests for RC tendinopathy/impingement syndrome are fraught with errors and although a cluster of tests is recommended to determine a clinical diagnosis of shoulder impingement (Michener et al, 2009; Hegedus et al, 2008), these tests still do not provide an accurate structural diagnosis (Lewis, 2008). Just 5 of the 21 included studies has a low risk of bias, therefore caution should be applied when interpreting results. The primary analysis focused on the overall efficacy of manual therapy either alone or conjunction with another intervention compared with placebo or other intervention. Secondary analyses included comparing MT added to exercise with exercise, MT combined with other interventions to a placebo or other interventions and different types of MT.
Results differed to previous reviews, which had found conflicting evidence for the efficacy of MT. In this review, which included more clinical trials, a small significant but unclear clinical improvement in pain but not function was found for MT used alone or in conjunction with other therapy. Adding MT to a multimodal programme did not appear to improve pain, function or shoulder ROM any further, but heterogeneity of the 6 studies included in this analysis limited the conclusions. Two subgroups of patients who may respond well to MT include those with posteroinferior capsular tightness and those with reduced cervicothoracic extension.
Overall, the review does add some evidence for the role of MT in improvement of pain, but not function in RC tendinopathy, but the methodological weakness, in particular the small sample sizes which varied between 7 and 60 participants compromises the possibility of detecting a true effect if one exists. The usual challenges of blinding both participants and treatment providers in MT research also poses some risk of bias to the results. However, random allocation, allocation concealment, use of intention-to-treat analysis and trial adherence should be achievable in RCT’s if researchers want to ensure results are meaningful and impactful.
- Braun C, Bularcyzk M, Heinstch J, Hanchard NCA. Manual therapy and exercises for shoulder impingement revisited. Physical Therapy Reviews. 2013;18: 263-284.
- Hegedus EJ, Goode A, Campbell S, Morin A, Tamaddoni M, Moorman CT, Cook C (2008). Physical ex-amination tests of the shoulder: a systematic review with meta-analysis of individual tests. Br J Sports Med. 2008;42(2):80-92.
- Lewis JS. Rotator cuff tendinopathy/subacromial impingement syndrome: is it time for a new meth-od of assessment? Br J Sports Med. 2009;43(4):259-264.
- Michener LA, Walsworth Mk, Doukas WC, Murphy KP. Reliability and diagnostic accuracy of 5 physical examination tests and combination of tests for subacromial impingement. Arch Phys Med Rehab. 2009;90(11):1898-903.
Helen French PhD, MSc, B.Physio, MISCP
Loudon JK, Reiman MP, Sylvain J. The efficacy of manual joint mobilisation/manipulation in treatment of lateral ankle sprains: a systematic review. Br J Sports Med. 2014 Mar;48(5):365-70.
We can applaud the efforts of Loudon and colleagues who presented a current review of the literature evaluating the effect of MT on lateral ankle sprains. Lateral ankle sprains are common in all population groups especially in the athlete group and often encountered in the clinic. Previously, it has been reported that manual therapy is beneficial for this subject group to prevent the development of chronic ankle issues. Only 8 studies satisfied the study criteria with a relative low combined total number of 244 subjects. This low subject number and the fact that all studies included young adults <32 years of age limits the generalisability of their findings. This review evaluated the benefit from joint mobilisation/manipulation as a single intervention. This seems not comparable to standard clinical practice in which MT is combined with other interventions to augment and carry over its effects. Although it appeared that there was some benefit using MT in both the acute and subacute groups, this study doesn’t provide evidence supporting either a manipulation or mobilisation approach.
Rob Sillevis, PT, DPT, PhD, OCS, FAAOMPT, MTC, PCC, CFC
Snodgrass SJ, Rivett DA, Sterling M, Vicenzino B. Dose optimization for spinal treatment effectiveness: a randomized controlled trial investigating the effects of high and low mobilization forces in patients with neck pain. J Orthop Sports Phys Ther. 2014 Mar;44(3):141-52.
It has been previously postulated that the effectiveness of joint mobilisation/ manipulation techniques depends on several variables such as: amplitude, direction, speed, and force. Snodgrass and colleagues have provided us with a great study looking at the force component of joint mobilisation in cases of chronic neck pain. The authors have done a great job in describing the intervention and how this was controlled. The PPT outcome measure was validated and shown to be reliable, but there was no clear justification of the three measurement locations. Spinal stiffness at the most painful segment was related to the stiffness of C7 in PA direction, which seems an interesting choice because this typically is not the most mobile cervical segment. It was interesting to note that the high force group reported an increase in pain after the intervention but a decrease in pain at follow up (not significantly different from the placebo group). There was no significant change in ROM between all three groups and only at reassessment was there a significant decrease in stiffness in the high force group. The take home message from this study is the fact that the force component of joint mobilisation does not seem to support the older mechanical model and should be further investigated to help clinicians determine the best mobilisation force while working with subjects with chronic neck pain.
Rob Sillevis, PT, DPT, PhD, OCS, FAAOMPT, MTC, PCC, CFC
- Rodeghero JR, Cook CE, Cleland JA, Mintken PE. Risk stratification of patients with low back pain seen in physical therapy practice. Man Ther. 2015 Apr 15. pii: S1356-689X(15)00076-4.
- O’Sullivan K, Dankaerts W, O’Sullivan L, O’Sullivan PB. Cognitive Functional Therapy for Disabling, Nonspecific Chronic Low Back Pain: Multiple Case-Cohort Study. Phys Ther. 2015 Apr 30.
- Bath B, Lovo Grona S. Biopsychosocial predictors of short-term success among people with low back pain referred to a physiotherapy spinal triage service. J Pain Res. 2015 Apr 23;8:189-202.
I recently attended the WCPT conference in Singapore. There was a great symposium led by Nadine Foster on stratified care in the management of low back pain. The key presenters were Jonathon Hill, Peter O’Sullivan, John Childs and Mark Hancock. The main features of the presenta-tion were that recognition of key factors that influence the prognosis and guide the management of the patient are critical to improved success. I have grouped these three papers above together as all have features of this. The paper by Rodeghero and colleagues indicates that a good or bad prognosis for the outcomes of treatment for low back pain can be predicted from important demographic features deter-mined at baseline. The study O’Sullivan et al indicates that a cognitive functional approach to improve aberrant pain patterns in patients with low back pain is required, and that these are individualised to that patients’ needs. The last paper by Bath and Grona once again indicates that identifying the biopsychosocial features of the pain presentation are important in the screening of patients. These three papers also fit well with the processes and outcomes evident in the STarT Back trial undertaken by Hill et al (2012). This study used a stratified approach based on identifying patients as high, medium, or low risk with acute and sub-acute low back pain. A nine item questionnaire is used with patients to clarify the risk sta-tus then the care is delivered based on this stratification. This approach has been shown to be clinically effective as well as cost effective!! I would recommend clinicians look strongly at this research and other studies as indicated above that show stratified and individually tailored care based on risk assessment to be very effective.
- Hill JC, Whitehurst DGT, Lewis M, Bryan S, Dunn KM, Foster NE, Konstantinou K, Main CJ, Mason E, Somerville S, Sowden G, Vohora K, Hay EM. Comparison of stratified primary care management for low back pain with current best practice (STarT Back):a randomised controlled trial. Lancet 2011;378:1560–71 .
Duncan Reid DHSc PT
Thanks to Rob and Helen for taking the plunge and providing reviews for this June edition. I look forward to others following suit! If you’re interested in contributing to future issues of the Manual Therapy Research Review please contact Dr Duncan Reid on [email protected]