1136104

research-article2022
SPHXXX10.1177/19417381221136104Paraskevopoulos et al.SPORTS HEALTH

vol. 15 • no. 5 SPORTS HEALTH

Effectiveness of Combined Program of

Manual Therapy and Exercise Vs Exercise
Only in Patients With Rotator Cuff-related
Shoulder Pain: A Systematic Review and
Meta-analysis
Eleftherios Paraskevopoulos, PhD,*† George Plakoutsis, MSc,† Efstathios Chronopoulos, PhD,‡
and Papandreou Maria, PhD†

Context: 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.
Objective: To evaluate the additional benefits of MT with exercise compared with exercise in isolation for the management
of RCRSP.
Data Sources: 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. Standardized mean differences
(SMDs) and 95% CIs 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 grading of
recommendations assessment, development and evaluation approach.
Study Design: Meta-analysis of randomized controlled trials.
Level of Evidence: Level 2.
Results: Twelve articles were found eligible and 8 of them demonstrated high methodological quality. Eleven articles were
included for quantitative analysis. Pain with movement was not significantly different between MT and exercise versus
exercise alone (SMD [95% CI] = −0.15 [−0.41 to 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 to 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 to 0.69]; I2 = 88%) or the long term (SMD [95% CI] = −0.02 [−0.21 to 0.16]; I2 = 2%).
Conclusion: Adding MT to exercise interventions for the management of RCRSP is not more effective than exercise alone
for pain and function in adult patients.
Keywords: shoulder; rotator cuff; manual therapy; outcomes; pain; function

From †Department of Physiotherapy, University of West Attica, Athens, Greece, ‡Second Department of Orthopaedics, Medical School, National and Kapodistrian University
of Athens, Athens, Greece
*Address correspondence to Eleftherios Paraskevopoulos, PhD, Department of Physiotherapy, University of West Attica, Ag. Spiridonos 28, Athens, Greece, 12243 (email:
[email protected]).
The authors report no potential conflicts of interest in the development and publication of this article.
DOI: 10.1177/19417381221136104
© 2022 The Author(s)

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S
houlder pain is one of the most common musculoskeletal fulfilled the eligibility criteria, and searched the gray literature
symptoms, with an estimated prevalence of 15% to 30% for eligible articles. The keywords that were used for the search
of the population at any one time.49 Furthermore, rotator were shoulder impingement, subacromial pain, tendinopathy,
cuff-related shoulder pain (RCRSP) is evaluated in rotator cuff tears, manual therapy, mobilization, manipulation,
approximately 70% of the patients who experience shoulder exercise, function, strength, range of motion, and similar
pain.49 RCRSP is an over-arching term that encompasses a combinations of words. All studies were downloaded into
spectrum of shoulder conditions including subacromial pain, Endnote X8 for screening. A detailed explanation of our search
(impingement) syndrome, rotator cuff tendinopathy, and strategy for each database is listed in Appendix Table A1
symptomatic partial and full-thickness rotator cuff tears.32 It has (available in the online version of this article).
been argued that the term RCRSP is more appropriate than
more traditional diagnoses that were related to pathoanatomic Study Selection
and structural pathologies because it remains almost impossible Articles were initially screened for eligibility by title and abstract
to identify a specific structure as the primary contributor to a and then by full text. The search and full inclusion process was
patient’s shoulder pain.32,41 performed by 2 independent reviewers using the PICOS
Conservative management of RCRSP entails strengthening framework (P = participants; I = interventions; C = comparison;
exercise, stretching, and mobility exercise of the shoulder, the O = outcomes, S = study design). Full texts of potentially
thoracic and cervical spine. Exercise is considered the mainstay relevant articles were retrieved for final evaluation. The
of management of shoulder pathology, with several systematic selection process for the selected studies was conducted by
reviews highlighting the statistical and clinical superiority of consensus, and when a consensus was not achieved, a third
exercise interventions on pain and function.1,31,51 However, reviewer was available to assist the process for a final judgment.
previous research trials have shown beneficial effects from the
addition of manual therapy (MT) in exercise interventions for Eligibility Criteria Based on the
PICOS Framework
patients with RCRSP.3,5,13,35,53 It has been proposed that MT may
Participants
induce hypoalgesia40,50 or restore normal biomechanics by
increasing the range of motion in the shoulder region.33,55 Studies were eligible for inclusion if they recruited adult
The benefits of MT in RCRSP have been mostly investigated in participants (≥18 years). Only studies that recruited symptomatic
isolation in previous systematic reviews.6,7,17 Moreover, the patients diagnosed with RCRSP, including subacromial pain
results of the aforementioned reviews suggested that there was (impingement) syndrome, rotator cuff tendinopathy, and
a lack of evidence concerning the efficacy of MT when used symptomatic partial, full-thickness rotator cuff tears, subacromial
alone and that evidence regarding the efficacy of the addition of bursitis or disorders that affect tissues and result in shoulder
MT to exercise for the treatment of rotator cuff tendinopathy pain, were included in the final selection. In addition, studies
was not conclusive. However, the possible adjunctive benefits of with nonspecific shoulder pain were included. Only articles that
MT with exercise interventions when compared with exercise clearly stated that diagnosis was made based on physical
alone have not previously been investigated in a systematic examination were included. Studies that evaluated patients only
review. Furthermore, since then, new studies have been through diagnostic imaging were excluded. Studies that
published that investigated the additional benefits of MT with recruited patients with a history of traumatic injury, surgery or
exercise compared with exercise alone and not only in rotator systemic diseases, or diseases related to other areas such as the
cuff tendinopathies but also in a variety of clinical populations cervical spine were excluded.
that are now under the umbrella term RCRSP. Thus, this
systematic review aimed to perform an updated review of the Intervention
evidence regarding the efficacy of MT with exercise, compared Studies that evaluated the effectiveness of MT and exercise
with exercise alone, for the treatment of RCRSP. versus exercise alone were eligible. We considered MT the
following interventions: massage therapy, mobilization, and
manipulation. Additionally, we considered as exercise the
Methods following interventions: mobility and strengthening exercises,
This systematic review was conducted by the criteria set out in aerobic exercises, and motor control exercises performed
the preferred reporting items for systematic reviews and meta- on the ground, on machines, or in water, with or without
analyses (PRISMA) statement, and it was prospectively supervision.
registered on PROSPERO (CRD42021288224).
Comparison Groups
Search Methods The comparator was groups of patients who received only
International electronic databases were used for the literature exercise. We considered as exercise the following: mobility and
search, including PubMed, Scopus, PEDro, and EBSCO from strengthening exercises, aerobic exercises, and motor control
inception up to April 20, 2022. We consulted with experts in the exercises performed on the ground, on machines, or in water
field, manually reviewed the reference lists of articles that with or without supervision.

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Outcome Measures The review manager software (RevMan 5.3) was used to
Studies were considered eligible if they analyzed at least 1 of summarize the effects of MT and exercise versus exercise alone
the following outcome measures at baseline and final follow-up when sufficient common outcomes were available for a
assessment: pain with a subjective measurement, function with meta-analysis. Outcome data were transformed to 0 to 100 point
a shoulder-specific questionnaire (ie, shoulder pain and scales for the meta-analysis. Subgroup analysis was performed
disability index; SPADI), range of motion, and strength. The for each outcome based on follow-up duration. The length of
primary outcomes considered were pain and function, whereas follow-up was divided into short-term (≤3 months), intermediate
all the others were considered secondary outcomes. (4 and 5 months), and long-term (≥6 months) follow-up. Mean
differences for the same outcome or standardized mean
Study Design differences (SMDs) (when necessary) with 95% CIs for
English-written articles and randomized controlled trials were continuous data were calculated. Due to clinical and
considered eligible for this review. Articles that were not full methodological heterogeneity between studies, a random-effects
text and pilot studies were excluded. model was selected to pool studies’ outcomes. According to
Cohen's criteria, SMD values were classified as small (≤0.20),
Methodological Quality Assessment moderate (between 0.21 and 0.79), and large (≥0.80).12 In
The methodological quality and risk of bias of the included addition, heterogeneity was assessed using the I2 statistic and
studies was assessed with the PEDro scale, which consists of 11 we interpreted I2 values >50% as significant heterogeneity.27
items related to the validity of the articles assessed.16 The first Whenever possible, the overall treatment effect was compared
item concerned the external validity; however, this was not with its minimum clinically important difference (MCID).
included in the final score. The remaining items concerned Sensitivity analysis was conducted by excluding studies with
internal validity. These items were related to the random ‘low’ or ‘moderate quality’ (PEDro score <7) or large treatment
allocation, allocation concealment, baseline comparability, effect sizes.
blinding of therapists, patients, and raters, experimental Quality of Evidence
mortality, intention-to-treat analysis, statistical comparisons and
point measures, and measures of variability. These items could To evaluate the overall quality of evidence and strength of
assist the readers to identify studies that were likely to be recommendations, we applied the grading of recommendations
internally valid (items 2-9) and studies with sufficient statistical assessment, development and evaluation (GRADE) in the meta-
information to make their results interpretable (items 10 and analysis for each outcome.23 Meta-analyses of studies were
11).52 The final score of the PEDro may have ranged from 0 initially categorized as high-quality evidence and were
(low quality) to 10 (high quality). downgraded by 1 level for each serious flaw present in the
Previously indexed studies in the PEDro database maintained following overall domains: risk of bias (we downgraded quality
their scores, whereas nonindexed studies were assessed by 2 of evidence when >25% of the studies in each comparison was
independent reviewers, and with the assistance of a third considered as low quality), inconsistency (we downgraded
reviewer, when needed, to resolve any discrepancies. Based on quality of evidence when significant heterogeneity [I2 value
the protocol of previous studies, studies that scored ≥7 in the >50%], minimal or no overlap of confidence intervals and wide
PEDro were classified as studies with high methodological variance of point estimates across studies was detected),
quality, 5 or 6 with moderate quality, and ≤4 as poor. indirectness (we downgraded quality of evidence when
participants, interventions, or outcomes measures from included
Data Extraction studies were essentially different), imprecision (we downgraded
Data were extracted independently by 2 reviewers using a quality of evidence when the pooled sample was <400
standardized form that collected information regarding participants and/or wide confidence intervals were evident
participant characteristics, study design, follow-up, interventions indicating no benefit from the intervention under study),
(type, duration, and the number of sessions), comparison group publication bias (we downgraded quality of evidence in meta-
characteristics, and outcomes. analyses that included >10 studies that presented with
asymmetrical funnel plots, sponsored studies or the authors
Data Synthesis and Analysis reported conflict of interest). Based on the above criteria, the
Interrater agreement for reviewers’ assessments of study quality of evidence was classified as very low, low, moderate, or
eligibility was calculated with Cohen’s kappa (κ) coefficient. A κ high.27
of 0 to 0.2 represented slight agreement; 0.21 to 0.40, fair
agreement; 0.41 to 0.60, moderate agreement; and 0.61 to 0.80,
Results
substantial agreement.17 A value greater than 0.80 was
considered as complete agreement. Interrater agreement for Study Selection
assessments of methodological quality was calculated with the We identified 42,295 trials after removal of duplicates that were
intraclass correlation coefficient (ICC). The κ and ICC were potentially relevant and after reading the titles and abstracts 20
calculated using SPSS software version 26 (IBM Corp). articles were found as potentially eligible for review. Full texts

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Identification
PubMed Scopus PEDro EBSCO
(n =236) (n = 42,295) (n = 508) (n = 664)

Records aer duplicates removed

(n = 42,295)
Screening

Titles and abstracts Records excluded

assessed for eligibility (n = 42,274)
(n = 42,295)

Full-text arcles excluded, with

reasons (n = 8)
Eligibility

Full-text arcles assessed Not the intended comparison

for eligibility Frozen shoulder paents (n=1)
(n = 20) Breast cancer paents (n=1)
Dry needling (n=1)
Ultrasound (n=1)
Ultrasound-guided applicaon of
percutaneous electrolysis (n=1)
Studies included in Inferenal current (n=1)
qualitave synthesis No comparison group (n=1)
Included

(n = 12) Control group (n=1)

Studies included in Studies excluded from quantave

quantave synthesis synthesis
(n = 11) (n = 1)

Figure 1. Flow chart of literature search results.

of the 20 articles were scrutinized for eligibility based on our for 2 studies that recruited younger patients between the ages of
inclusion and exclusion criteria and 8 articles were excluded. 21 and 35 years.8,46 Also, the majority of the studies recruited
The reasons for the removal of the studies can be found in more women than men; however, 1 study45 did not mention the
Figure 1, and these were related to the pathology of the female:male ratio, and thus it was impossible to estimate the
participants,9,20,37 or the interventions that were pooled sample of women separately. All the studies assessed
compared.14,15,18,22,28,54 Finally, 12 articles were found appropriate patients with physical examination, and the majority of the
for a qualitative synthesis.2,8,10,19,24,29,30,36,45–47,55 After excluding 1 studies used common orthopaedic special tests to identify signs
article47 due to a lack of relevant data available in the full text of impingement, except for 2 studies that recruited patients with
and even after a request from the primary authors, the painful shoulder during physiological and accessory movements
remaining 11 were found appropriate for quantitative synthesis. in the shoulder region.10,55
There was almost complete agreement between the 2 reviewers
at the title/abstract screening stage (κ = 0.80) and at the full-text Interventions
screening stage (κ = 0.82). In all studies, exercise programs consisted of strengthening and
mobility exercises for the shoulder, whereas 4 provided
Participants supervision2,8,30,36 and 1 provided extra advice on how to avoid
The characteristics of the participants from the included studies or minimize painful shoulder movements during activities of
are listed in Appendix Table A2 (available online). The final daily living.55 Furthermore, 4 studies incorporated exercises that
sample in our qualitative synthesis was 574 participants after 52 targeted the scapula2,36,46,55 and motor control exercises.36,46,55 As
dropouts (9%). The vast majority of the studies included for the MT techniques, 4 studies used techniques that targeted
samples with mean ages that ranged from 42 to 65 years, except the lower cervical or the thoracic spine,2,8,24,36 5 studies targeted

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Table 1. Methodological quality assessment using the PEDro scale

Studies 1 2 3 4 5 6 7 8 9 10 11 Total Score

2
Bang and Deyle (2000) Y Y N Y N N Y Y N Y Y 6
Senbursa et al (2007)45 Y Y N Y N N N N N Y Y 4
Chen et al (2009)10 Y Y Y Y N N Y Y Y Y Y 8
55
Yiasemides et al (2011) Y Y Y Y N N Y Y Y Y Y 8
Kromer et al (2013)29 Y Y Y Y N N N Y Y Y Y 7
Kromer et al (2014)30 N Y Y Y N N N Y Y Y Y 7
Camargo et al (2015)8 N Y Y Y N N Y Y Y Y Y 8
36
Mintken et al (2016) Y Y Y Y N N Y Y Y Y Y 8
Haider et al (2018)24 N Y N Y N N N Y N Y Y 5
Sharma et al (2021)46 Y Y Y Y Y N N Y N Y Y 7
47
Sharma et al (2021) Y Y N Y N N Y Y N Y Y 6
Eliason et al (2021)19 Y Y Y Y N N Y Y Y Y Y 8
≥7/10 8/12

N, no; Y, yes.
1. Eligibility criteria; 2. Random allocation; 3. Concealed allocation; 4. Baseline comparability; 5. Blinding of individuals; 6. Blinding of therapists; 7. Blinding
of assessors; 8. Adequate follow-up; 9. Intention-to-treat analysis; 10. Between-group comparisons; 11. Point estimates and variability.
Item 1 (eligibility criteria) does not contribute to the total score.

the shoulder regions, including the glenohumeral, shoulder strength2 and 2 measured shoulder range of
acromioclavicular, and sternoclavicular joints,2,8,10,45,55 1 the motion,10,45 although the values were available only in 1 of
scapula directly45 and 1 study targeted both the spine (thoracic them.10 In outcomes that were used only once, a pooled
and cervical) and the glenohumeral joint.29 Of the included estimate of effect was not possible. These were the self-rated
studies, 2 used grade III and IV mobilizations,2,8 1 study used questionnaire for symptom change,55 scapular kinematic
high-velocity mobilizations,36 2 studies used low velocity measurement and mechanical sensitivity,8 the QuickDASH,36 the
mobilizations,10,55 1 study used 1 nonthrust mobilization and 3 global rating of change,36 and the patient acceptable symptom
different thrust manipulation techniques directed at the thoracic state.36
spine.24 One study did not clearly define the force of the
mobilization but commented only on the direction of the Risk of Bias
mobilization.30 A summary of the risk of bias across the included studies is
listed in Table 1. Based on the PEDro criteria, 67% of the studies
Outcome Measures were classified as studies with high methodological quality. The
Pain with activity in the short term was assessed in 4 scoring of studies for the risk of bias ranged from 4 to 8.
studies2,8,45,55 and the long term only in 1.55 Pain at rest in the Blinding of therapists was not feasible in any trial, while almost
short term was assessed in 6 studies2,8,24,30,36,45 and in the long all of them did not satisfy the fifth criterion that is related to
term only in 1.36 Shoulder function was assessed with the SPADI blinding of individuals. A significant proportion of the eligible
in the short term in 5 studies,10,24,30,36,46,55 and with the Constant studies (42%) did not include an intention-to-treat analysis.
Murley score,19 the disabilities of the arm, shoulder and hand
(DASH) questionnaire,8 and the functional assessment score.2 Meta-analysis
Shoulder function was also assessed in the long term in 3 Pain
studies.10,36,55 A pooled estimate of effect was generated for the The adjunctive effects of MT with exercise versus exercise alone
aforementioned outcomes. Furthermore, 2 studies assessed pain on pain during movement were examined by 4 studies2,8,45,55 in
levels with the SPADI in the long term.30,55 One study measured the short term (≤3 months) from a pooled sample of 224

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Figure 2. Forest plot showing the effects of exercise compared with manual therapy (MT) and exercise for pain in patients with
rotator cuff-related shoulder pain. Data are depicted according to measurement conditions. IV, inverse variance.

subjects (Figure 2). Overall, on completion of the interventions, [95% CI] = −0.02 [−0.21 to 0.16]; I2 = 2%), with no substantial
pain with movement was not significantly different between MT heterogeneity, based on high-quality evidence (Appendix Table
and exercise versus exercise alone (SMD [95% CI] = −0.15 [−0.41 A4 [available online]). Sensitivity analysis demonstrated that the
to 0.12]; I2 = 0%), with no substantial heterogeneity, based on inclusion of studies that used only the SPADI did not change
moderate-quality evidence (Appendix Table A3 [available the significance of the overall result, either in the short term
online]). Furthermore, the adjunctive effects of MT with exercise (MD [95% CI] = 5.21 [−0.73 to 11.15]; I2 = 82%) or the long term
versus exercise alone on pain at rest were examined by 6 (MD [95% CI] = 2.24 [−2.19 to 6.68]; I2 = 0%).
studies2,8,24,30,36,45 in the short term (≤3 months) from a pooled
sample of 394 subjects. Overall, on completion of the SPADI Pain Scale
interventions, pain at rest was significantly improved in the The pain scale of the SPADI was used separately on 2
groups that used exercise only when compared with the groups occasions30,55 to examine the effects of MT with exercise against
that also used MT, with a moderate effect size (SMD [95% CI] = exercise only, in the long term from a pooled sample of 175
0.47 [0.04 to 0.89]; I2 = 75%) and substantial heterogeneity, subjects (Figure 4). Overall, pain was not significantly different
based on low-quality evidence (Appendix Table A3 [available between MT and exercise versus exercise alone (SMD
online]). [95% CI] = −0.14 [−0.44 to 0.16]; I2 = 0%), with no substantial
heterogeneity, based on low-quality evidence (Appendix Table
Shoulder Function A5 [available online]).
The adjunctive effects of MT with exercise versus exercise alone
on function were assessed with the SPADI,10,24,30,36,46,55 the
Discussion
Constant-Murley score,19 the DASH,8 and the functional
assessment score.2 The results in the short term (≤3 months) The purpose of this systematic review was to determine the
were examined by 9 studies2,8,10,19,24,30,36,46,55 from a pooled additional benefits of MT with exercise in patients with RCRSP
sample of 699 subjects (Figure 3). Overall, on completion of the when compared with exercise only for pain, function, range of
interventions, shoulder function was not significantly different motion, and strength. From our literature search, we found
between MT and exercise versus exercise alone (SMD [95% enough studies for a meta-analysis, only for our primary
CI] = 0.23 [-0.22 to 0.69]; I2 = 88%), with substantial outcomes of pain and function. The results of this systematic
heterogeneity, based on moderate-quality evidence (Appendix review cannot support the superiority of a combined
Table A4 [available online]). The adjunctive effects of MT with intervention that includes MT and exercise for the management
exercise versus exercise alone on function with the SPADI in the of RCRSP.
long term (≥ 6 months) were examined by 5 studies10,19,30,36,55 In contrast to previous systematic reviews6,7,17,51 that examined
from a pooled sample of 482 subjects. Overall, on completion MT and exercise interventions for the management of shoulder
of the interventions, shoulder function was not significantly pathology, this review provides more evidence for the lack of
different between MT and exercise versus exercise alone (SMD statistically important effectiveness of MT, in addition to exercise

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Figure 3. Forest plot showing the effects of exercise compared with manual therapy (MT) and exercise for shoulder function in
patients with rotator cuff-related shoulder pain. Data are depicted according to follow-up time. IV, inverse variance.

Figure 4. Forest plot showing the effects of exercise compared with manual therapy and exercise for pain with the shoulder pain
and disability index in patients with rotator cuff-related shoulder pain. Data are depicted according to measurement conditions. IV,
inverse variance.

for RCRSP. Although when looking at the results from the when MT was used as an adjunctive intervention with exercise
meta-analysis, MT and exercise resulted in a superior reduction (MCID >13.1).46
of pain at rest in the short term, and the results were not Previous reviews, including a Cochrane review, have proposed
statistically significant. Also, previous research has supported that MT with exercise may be more effective than exercise alone
that a minimum reduction of 14 of 100 for patients with in the short term for patients with shoulder impingement.6,7,38,51
shoulder pain is a clinically significant reduction.43 Although all However, this is the first systematic review with a meta-analysis
studies except 1 of moderate quality8 demonstrated a clinically that examined only studies that directly compared the
important reduction in pain for both groups that received MT effectiveness of adding MT in exercise interventions against
with exercise or exercise alone, the between-group difference in exercise only for a variety of disorders that fall under the
all studies was not clinically important (<14 MCID). Previous umbrella of RCRSP. Interestingly, this meta-analysis failed to
research has shown that a minimum change of 13.1 of 100 show the superiority of MT in pain or function, by including
points in function for the SPADI, for patients with shoulder pain, studies that incorporated a variety of MT techniques, including
is clinically significant.42 Although all studies demonstrated a high- or low-velocity mobilizations in the shoulder region or the
clinically important improvement in function with the SPADI, spine. Joint-based MT has been shown to activate pain
only 1 moderate quality study showed clinically superior inhibitory cortical systems,48 and thus a reduction of pain, at
functional improvements between groups in the short term, least in the short term, should be expected. However, the results

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of our meta-analysis showed that exercise only, was statically English articles. Also, we considered MT interventions as several
more effective than exercise with MT in the short term, with a techniques such as mobilization, manipulations, and soft tissue
moderate effect size. It should be noted though, that the results massage based on previous research.26 However, there is
did not demonstrate the clinical superiority of exercise in currently no ideal classification of MT techniques as MT is broad
isolation. by nature.25 Finally, only a limited number of studies assessed
Moreover, combined interventions were not more effective pain in the long term. Although there are limitations in this
than single interventions. The addition of MT in exercise review, an important strength of this study was that we reduced
interventions has failed to show superiority in previous the confounding effects of other interventions by including only
systematic reviews for patients with hip osteoarthiritis44 and studies that compared MT and exercise with exercise in
neck pain.21 Combined interventions may result in antagonistic isolation. Furthermore, the findings of this review are based on
interactions between treatments, but also patients who receive moderate- and high-quality studies, except for 1 low-quality
MT and exercise may spend less time on each exercise, which study.
could affect the overall outcome of the treatment. Furthermore,
the variety of different MT techniques that were used in the Conclusion
trials may have compromised the effectiveness of the
Based on high- to low-quality evidence, MT and exercise are
interventions. For example, several different MT techniques
not more effective than exercise in isolation for the management
were used based on clinical judgment, although the
of shoulder pain and function in adult patients with RCRSP.
symptomatology of the subjects was similar in all studies. Using
clinical judgment of course in clinical practice is a necessity;
however, in research, it is difficult to draw any conclusions. References
Moreover, some studies recruited treating therapists with a 1. Abdulla SY, Southerst D, Côté P, et al. Is exercise effective for the management
variety of experience and qualifications, which may have of subacromial impingement syndrome and other soft tissue injuries of the
affected the proper delivery of the interventions in shoulder? A systematic review by the Ontario Protocol for Traffic Injury
Management (OPTIMa) Collaboration. Man Ther. 2015;20:646-656.
nonpharmacological interventions.4 More importantly, the 2. Bang MD, Deyle GD. Comparison of supervised exercise with and without
majority of the included studies used more than 1 therapist for manual physical therapy for patients with shoulder impingement syndrome.
the delivery of the MT techniques, which could also have J Orthop Sports Phys Ther. 2000;30:126-137.
3. Bergman GJ, Winters JC, Groenier KH, et al. Manipulative therapy in addition
compromised the results. Finally, MT dosage was under- to usual medical care for patients with shoulder dysfunction and pain: a
reported on many occasions2,8,10,29,45,47 in terms of duration. As randomized, controlled trial. Ann Intern Med. 2004;141:432-439.
limited research exists on the optimal dosage of MT for 4. Boutron I, Tubach F, Giraudeau B, Ravaud P. Methodological differences in
clinical trials evaluating nonpharmacological and pharmacological treatments of
shoulder pathology, research is necessary to establish the hip and knee osteoarthritis. JAMA. 2003;290:1062-1070.
minimally effective dose of MT before examining its 5. Boyles RE, Ritland BM, Miracle BM, et al. The short-term effects of thoracic spine
effectiveness. thrust manipulation on patients with shoulder impingement syndrome. Man
Ther. 2009;14:375-380.
Another factor that needs to be considered when evaluating 6. Braun C, Bularczyk M, Heintsch J, Hanchard NCA. Manual therapy and exercises
the adjunctive benefits of MT in exercise interventions for for shoulder impingement revisited. Phys Ther Rev. 2013;18:263-284.
patients with RCRSP is the psychology of patients. Psychological 7. Braun C, Hanchard NCA. Manual therapy and exercise for impingement related
shoulder pain. Phys Ther Rev. 2010;15:62-83.
factors may influence the perpetuation of pain intensity and 8. Camargo PR, Alburquerque-Sendín F, Avila MA, et al. Effects of stretching
disability in patients with shoulder pain.34 Also, personal and and strengthening exercises, with and without manual therapy, on scapular
work-related factors may contribute to the development of kinematics, function, and pain in individuals with shoulder impingement: a
randomized controlled trial. J Orthop Sports Phys Ther. 2015;45:984-997.
shoulder pain.11 Thus, the exercise interventions used and the 9. Çelik D, Kaya Mutlu E. Does adding mobilization to stretching improve
therapeutic alliance that is created between patients and outcomes for people with frozen shoulder? A randomized controlled clinical trial.
therapists during the rehabilitation process might result in Clin Rehabil. 2016;30:786-794.
10. Chen JF, Ginn KA, Herbert RD. Passive mobilisation of shoulder region joints
important changes in shoulder pathology and patients’ behavior plus advice and exercise does not reduce pain and disability more than advice
that are together effective enough.39 As has been highlighted and exercise alone: a randomised trial. Aust J Physiother. 2009;55:17-23.
previously21 adding MT is not expected to attribute to the 11. Chu P-C, Wang T-G, Guo YL. Work-related and personal factors in shoulder
disorders among electronics workers: findings from an electronics enterprise in
patient-therapist relationship leading to no additional benefits Taiwan. BMC Public Health. 2021;21:1525.
for the patient. Clinicians may consider the findings of this study 12. Cohen J. Statistical power analysis for the behavioral sciences. Academic Press;
in light of treatment costs, which are bound to increase when New York, NY: New York University: 2013.
13. Conroy DE, Hayes KW. The effect of joint mobilization as a component of
more interventions are provided without evidence that proves comprehensive treatment for primary shoulder impingement syndrome.
efficacy. J Orthop Sports Phys Ther. 1998;28:3-14.
14. Coronado RA, Bialosky JE, Bishop MD, et al. The comparative effects of spinal
Limitations and peripheral thrust manipulation and exercise on pain sensitivity and the
relation to clinical outcome: a mechanistic trial using a shoulder pain model.
Our investigation should be interpreted in light of its limitations. J Orthop Sports Phys Ther. 2015;45:252-264.
Initially, this study included a limited number of studies, and 15. de Miguel Valtierra L, Salom Moreno J, Fernández-de-Las-Peñas C, Cleland JA,
Arias-Buría JL. Ultrasound-guided application of percutaneous electrolysis as
thus publication bias could not be assessed. It is likely that an adjunct to exercise and manual therapy for subacromial pain syndrome:
eligible studies were not located because we included only a randomized clinical trial. J Pain. 2018;19:1201-1210.

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16. de Morton NA. The PEDro scale is a valid measure of the methodological quality with shoulder pain: a multicenter randomized controlled trial. J Orthop Sports
of clinical trials: a demographic study. Aust J Physiother. 2009;55:129-133. Phys Ther. 2016;46:617-628.
17 Desjardins-Charbonneau A, Roy JS, Dionne CE, et al. The efficacy of manual 37. Pace do Amaral MT, Freire de Oliveira MM, Ferreira Nde O, et al. Manual
therapy for rotator cuff tendinopathy: a systematic review and meta-analysis. therapy associated with upper limb exercises vs. exercises alone for shoulder
J Orthop Sports Phys Ther. 2015;45:330-350. rehabilitation in postoperative breast cancer. Physiother Theory Pract.
18. Ebadi S, Forogh B, Fallah E, Babaei Ghazani A. Does ultrasound therapy add to 2012;28:299-306.
the effects of exercise and mobilization in frozen shoulder? A pilot randomized 38. Page MJ, Green S, McBain B, et al. Manual therapy and exercise for rotator cuff
double-blind clinical trial. J Bodyw Mov Ther. 2017;21:781-787. disease. Cochrane Database Syst Rev. 2016;6:CD012224.
19. Eliason A, Harringe M, Engström B, Werner S. Guided exercises with or without 39. Paraskevopoulos E, Gioftsos G, Georgoudis G, Papandreou M. Perceived barriers
joint mobilization or no treatment in patients with subacromial pain syndrome: and facilitators of sports rehabilitation adherence in injured volleyball athletes: a
a clinical trial. J Rehabil Med. 2021;53:00190. qualitative study from Greece. J Clin Sport Psychol. 2021;1:1-20.
20. Fathollahnejad K, Letafatkar A, Hadadnezhad M. The effect of manual therapy 40. Paungmali A, O’Leary S, Souvlis T, Vicenzino B. Hypoalgesic and
and stabilizing exercises on forward head and rounded shoulder postures: a six- sympathoexcitatory effects of mobilization with movement for lateral
week intervention with a one-month follow-up study. BMC Musculoskel Disord. epicondylalgia. Phys Ther. 2003;83:374-383.
2019;20:86. 41. Powell JK, Lewis JS. Rotator cuff-related shoulder pain: is it time to reframe
21. Fredin K, Lorås H. Manual therapy, exercise therapy or combined treatment in the advice, “You need to strengthen your shoulder”? J Orthop Sports Phys Ther.
the management of adult neck pain—a systematic review and meta-analysis. 2021;51:156-158.
Musculoskel Sci Pract. 2017;31:62-71. 42. Roy JS, MacDermid JC, Woodhouse LJ. Measuring shoulder function: a systematic
22. Gomes C, Dibai-Filho AV, Moreira WA, et al. Effect of adding interferential review of four questionnaires. Arthritis Rheum. 2009;61:623-632.
current in an exercise and manual therapy program for patients with unilateral 43. Saito H, Harrold ME, Cavalheri V, McKenna L. Scapular focused interventions
shoulder impingement syndrome: a randomized clinical trial. J Manipul Physiol to improve shoulder pain and function in adults with subacromial pain: a
Ther. 2018;41:218-226. systematic review and meta-analysis. Physiother Theory Pract. 2018;34:653-670.
23. Guyatt G, Oxman AD, Akl EA, et al. GRADE guidelines: 1. Introduction—GRADE 44. Sampath KK, Mani R, Miyamori T, Tumilty S. The effects of manual therapy or
evidence profiles and summary of findings tables. J Clin Epidemiol. 2011;64:383-394. exercise therapy or both in people with hip osteoarthritis: a systematic review
24. Haider R, Bashir MS, Adeel M, Ijaz MJ, Ayub A. Comparison of conservative and meta-analysis. Clin Rehabil. 2016;30:1141-1155.
exercise therapy with and without Maitland thoracic manipulative therapy in 45. Senbursa G, Baltaci G, Atay A. Comparison of conservative treatment with
patients with subacromial pain: clinical trial. JPMA. 2018;68:381-387. and without manual physical therapy for patients with shoulder impingement
25. Hidalgo B, Hall T, Bossert J, et al. The efficacy of manual therapy and exercise syndrome: a prospective, randomized clinical trial. Knee Surg Sports Traumatol
for treating non-specific neck pain: a systematic review. J Back Musculoskel Arthrosc. 2007;15:915-921.
Rehabil. 2017;30:1149-1169. 46. Sharma S, Ejaz Hussain M, Sharma S. Effects of exercise therapy plus manual
26. Ho CY, Sole G, Munn J. The effectiveness of manual therapy in the management therapy on muscle activity, latency timing and SPADI score in shoulder
of musculoskeletal disorders of the shoulder: a systematic review. Man Ther. impingement syndrome. Complement Ther Clin Pract. 2021;44:101390.
2009;14:463-474. 47. Sharma S, Ghrouz AK, Hussain ME, et al. Progressive resistance exercises plus
27. Kamonseki DH, Christenson P, Rezvanifar SC, Calixtre LB. Effects of manual manual therapy is effective in improving isometric strength in overhead athletes
therapy on fear avoidance, kinesiophobia and pain catastrophizing in individuals with shoulder impingement syndrome: a randomized controlled trial. BioMed Res
with chronic musculoskeletal pain: systematic review and meta-analysis. Intl. 2021;2021:9945775.
Musculoskel Sci Pract. 2021;51:102311. 48. Skyba DA, Radhakrishnan R, Rohlwing JJ, Wright A, Sluka KA. Joint
28. Kaya DO, Baltaci G, Toprak U, Atay AO. The clinical and sonographic effects of manipulation reduces hyperalgesia by activation of monoamine receptors but
kinesiotaping and exercise in comparison with manual therapy and exercise for not opioid or GABA receptors in the spinal cord. Pain. 2003;106:159-168.
patients with subacromial impingement syndrome: a preliminary trial. J Manipul 49. Smythe A, Rathi S, Pavlova N, et al. Self-reported management among people
Physiol Ther. 2014;37:422-432. with rotator cuff related shoulder pain: an observational study. Musculoskel Sci
29. Kromer TO, de Bie RA, Bastiaenen CH. Physiotherapy in patients with clinical Pract. 2021;51:102305.
signs of shoulder impingement syndrome: a randomized controlled trial. 50. Sterling M, Jull G, Wright A. Cervical mobilisation: concurrent effects on pain,
J Rehabil Med. 2013;45:488-497. sympathetic nervous system activity and motor activity. Man Ther. 2001;6:72-81.
30. Kromer TO, de Bie RA, Bastiaenen CH. Effectiveness of physiotherapy and costs 51. Steuri R, Sattelmayer M, Elsig S, et al. Effectiveness of conservative interventions
in patients with clinical signs of shoulder impingement syndrome: one-year including exercise, manual therapy and medical management in adults with
follow-up of a randomized controlled trial. J Rehabil Med. 2014;46:1029-1036. shoulder impingement: a systematic review and meta-analysis of RCTs.
31. Kromer TO, Tautenhahn UG, de Bie RA, Staal JB, Bastiaenen CH. Effects of Br J Sports Med. 2017;51:1340-1347.
physiotherapy in patients with shoulder impingement syndrome: a systematic 52. Stoop R, Clijsen R, Leoni D, et al. Evolution of the methodological quality of
review of the literature. J Rehabil Med. 2009;41:870-880. controlled clinical trials for myofascial trigger point treatments for the period
32. Lewis J. Rotator cuff related shoulder pain: assessment, management and 1978-2015: a systematic review. Musculoskel Sci Pract. 2017;30:1-9.
uncertainties. Man Ther. 2016;23:57-68. 53. Strunce JB, Walker MJ, Boyles RE, Young BA. The immediate effects of thoracic
33. Maitland GD. Vertebral manipulation. Elsevier Health Sciences; Butterworth, spine and rib manipulation on subjects with primary complaints of shoulder
London: 1986. pain. J Man Manip Ther. 2009;17:230-236.
34. Martinez-Calderon J, Meeus M, Struyf F, et al. The role of psychological factors in 54. Tejera-Falcón E, Toledo-Martel NDC, Sosa-Medina FM, et al. Dry needling
the perpetuation of pain intensity and disability in people with chronic shoulder in a manual physiotherapy and therapeutic exercise protocol for patients
pain: a systematic review. BMJ Open. 2018;8:e020703. with chronic mechanical shoulder pain of unspecific origin: a protocol for a
35. Mintken PE, Cleland JA, Carpenter KJ, et al. Some factors predict successful randomized control trial. BMC Musculoskel Disord. 2017;18:400.
short-term outcomes in individuals with shoulder pain receiving cervicothoracic 55. Yiasemides R, Halaki M, Cathers I, Ginn KA. Does passive mobilization of
manipulation: a single-arm trial. Phys Ther. 2010;90:26-42. shoulder region joints provide additional benefit over advice and exercise alone
36. Mintken PE, McDevitt AW, Cleland JA, et al. Cervicothoracic manual therapy plus for people who have shoulder pain and minimal movement restriction?
exercise therapy versus exercise therapy alone in the management of individuals A randomized controlled trial. Phys Ther. 2011;91:178-189.

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