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The Cochrane Database of Systematic... Sep 2021Low back pain has been the leading cause of disability globally for at least the past three decades and results in enormous direct healthcare and lost productivity costs. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Low back pain has been the leading cause of disability globally for at least the past three decades and results in enormous direct healthcare and lost productivity costs.
OBJECTIVES
The primary objective of this systematic review is to assess the impact of exercise treatment on pain and functional limitations in adults with chronic non-specific low back pain compared to no treatment, usual care, placebo and other conservative treatments.
SEARCH METHODS
We searched CENTRAL (which includes the Cochrane Back and Neck trials register), MEDLINE, Embase, CINAHL, PsycINFO, PEDro, SPORTDiscus, and trials registries (ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform), and conducted citation searching of relevant systematic reviews to identify additional studies. The review includes data for trials identified in searches up to 27 April 2018. All eligible trials have been identified through searches to 7 December 2020, but have not yet been extracted; these trials will be integrated in the next update.
SELECTION CRITERIA
We included randomised controlled trials that assessed exercise treatment compared to no treatment, usual care, placebo or other conservative treatment on the outcomes of pain or functional limitations for a population of adult participants with chronic non-specific low back pain of more than 12 weeks' duration.
DATA COLLECTION AND ANALYSIS
Two authors screened and assessed studies independently, with consensus. We extracted outcome data using electronic databases; pain and functional limitations outcomes were re-scaled to 0 to 100 points for meta-analyses where 0 is no pain or functional limitations. We assessed risk of bias using the Cochrane risk of bias (RoB) tool and used GRADE to evaluate the overall certainty of the evidence. When required, we contacted study authors to obtain missing data. To interpret meta-analysis results, we considered a 15-point difference in pain and a 10-point difference in functional limitations outcomes to be clinically important for the primary comparison of exercise versus no treatment, usual care or placebo.
MAIN RESULTS
We included 249 trials of exercise treatment, including studies conducted in Europe (122 studies), Asia (38 studies), North America (33 studies), and the Middle East (24 studies). Sixty-one per cent of studies (151 trials) examined the effectiveness of two or more different types of exercise treatment, and 57% (142 trials) compared exercise treatment to a non-exercise comparison treatment. Study participants had a mean age of 43.7 years and, on average, 59% of study populations were female. Most of the trials were judged to be at risk of bias, including 79% at risk of performance bias due to difficulty blinding exercise treatments. We found moderate-certainty evidence that exercise treatment is more effective for treatment of chronic low back pain compared to no treatment, usual care or placebo comparisons for pain outcomes at earliest follow-up (MD -15.2, 95% CI -18.3 to -12.2), a clinically important difference. Certainty of evidence was downgraded mainly due to heterogeneity. For the same comparison, there was moderate-certainty evidence for functional limitations outcomes (MD -6.8 (95% CI -8.3 to -5.3); this finding did not meet our prespecified threshold for minimal clinically important difference. Certainty of evidence was downgraded mainly due to some evidence of publication bias. Compared to all other investigated conservative treatments, exercise treatment was found to have improved pain (MD -9.1, 95% CI -12.6 to -5.6) and functional limitations outcomes (MD -4.1, 95% CI -6.0 to -2.2). These effects did not meet our prespecified threshold for clinically important difference. Subgroup analysis of pain outcomes suggested that exercise treatment is probably more effective than education alone (MD -12.2, 95% CI -19.4 to -5.0) or non-exercise physical therapy (MD -10.4, 95% CI -15.2 to -5.6), but with no differences observed for manual therapy (MD 1.0, 95% CI -3.1 to 5.1). In studies that reported adverse effects (86 studies), one or more adverse effects were reported in 37 of 112 exercise groups (33%) and 12 of 42 comparison groups (29%). Twelve included studies reported measuring adverse effects in a systematic way, with a median of 0.14 (IQR 0.01 to 0.57) per participant in the exercise groups (mostly minor harms, e.g. muscle soreness), and 0.12 (IQR 0.02 to 0.32) in comparison groups.
AUTHORS' CONCLUSIONS
We found moderate-certainty evidence that exercise is probably effective for treatment of chronic low back pain compared to no treatment, usual care or placebo for pain. The observed treatment effect for the exercise compared to no treatment, usual care or placebo comparisons is small for functional limitations, not meeting our threshold for minimal clinically important difference. We also found exercise to have improved pain (low-certainty evidence) and functional limitations outcomes (moderate-certainty evidence) compared to other conservative treatments; however, these effects were small and not clinically important when considering all comparisons together. Subgroup analysis suggested that exercise treatment is probably more effective than advice or education alone, or electrotherapy, but with no differences observed for manual therapy treatments.
Topics: Adult; Exercise; Exercise Therapy; Female; Humans; Low Back Pain; Mind-Body Therapies; Musculoskeletal Manipulations
PubMed: 34580864
DOI: 10.1002/14651858.CD009790.pub2 -
International Orthopaedics Feb 2022Systematic review and meta-analysis to assess the effectiveness of manual therapy in improving carpal tunnel syndrome (CTS) symptoms, physical function, and nerve... (Meta-Analysis)
Meta-Analysis Review
AIM OF THE STUDY
Systematic review and meta-analysis to assess the effectiveness of manual therapy in improving carpal tunnel syndrome (CTS) symptoms, physical function, and nerve conduction studies.
METHOD
MEDLINE, Web of Science, SCOPUS, Cochrane Library, TRIP database, and PEDro databases were searched from the inception to September 2021. PICO search strategy was used to identify randomized controlled trials applying manual therapy on patients with CTS. Eligible studies and data extraction were conducted independently by two reviewers. Methodology quality and risk of bias were assessed by PEDro scale. Outcomes assessed were pain intensity, physical function, and nerve conduction studies.
RESULTS
Eighty-one potential studies were identified and six studies involving 401 patients were finally included. Pain intensity immediately after treatment showed a pooled standard mean difference (SMD) of - 2.13 with 95% confidence interval (CI) (- 2.39, - 1.86). Physical function with Boston Carpal Tunnel Syndrome Questionnaire (BCTS-Q) showed a pooled SMD of - 1.67 with 95% CI (- 1.92, - 1.43) on symptoms severity, and a SMD of - 0.89 with 95% CI (- 1.08, - 0.70) on functional status. Nerve conduction studies showed a SMD of - 0.19 with 95% CI (- 0.40, - 0.02) on motor conduction and a SMD of - 1.15 with 95% CI (- 1.36, - 0.93) on sensory conduction.
CONCLUSIONS
This study highlights the effectiveness of manual therapy techniques based on soft tissue and neurodynamic mobilizations, in isolation, on pain, physical function, and nerve conduction studies in patients with CTS.
Topics: Carpal Tunnel Syndrome; Humans; Musculoskeletal Manipulations; Neural Conduction; Pain; Pain Measurement; Treatment Outcome
PubMed: 34862562
DOI: 10.1007/s00264-021-05272-2 -
International Journal of Environmental... Jul 2021Primary dysmenorrhea (PD) refers to painful cramps before and/or during menstruation. There is a need for emphasis on alternative methods of conservative treatment, so... (Meta-Analysis)
Meta-Analysis Review
Primary dysmenorrhea (PD) refers to painful cramps before and/or during menstruation. There is a need for emphasis on alternative methods of conservative treatment, so as to reduce the dependence on drugs for alleviating the symptoms. The aim was to find out the effectiveness of some physiotherapy techniques in the treatment of PD. A systematic review and meta-analysis was conducted according to PRISMA standards. The descriptors were "dysmenorrhea", "physical the-rapy", "physiotherapy", and "manual therapy". The search was performed in five databases: Scopus, PubMed, PEDro, Web of Science, and Medline, in February 2021. The inclusion criteria were randomized controlled trials over the last six years. Articles not related to the treatment of PD or using pharmacology as the main treatment were excluded. Nine articles met the objectives and criteria, with a total of 692 participants. The most used scale to measure pain was the VAS (visual analogue scale). The main techniques were isometric exercises, massage therapy, yoga, electrotherapy, connective tissue manipulation, stretching, kinesio tape, progressive relaxation exercises and aerobic dance. Meta-analysis shows benefits of physiotherapy treatment for pain relief compared with no intervention or placebo (MD: -1.13, 95% CI: -1.61 to -0.64, I: 88%). The current low-quality evidence suggests that physiotherapy may provide a clinically significant reduction in menstrual pain intensity. Given the overall health benefits of physiotherapy and the low risk of side effects reported, women may consider using it, either alone or in conjunction with other therapeutic modalities.
Topics: Dysmenorrhea; Electric Stimulation Therapy; Exercise Therapy; Female; Humans; Massage; Physical Therapy Modalities
PubMed: 34360122
DOI: 10.3390/ijerph18157832 -
Schmerz (Berlin, Germany) Aug 2022The treatment of carpal tunnel syndrome (CTS) usually involves surgical decompression of the nerve or splinting and additional medication. Physiotherapy and sports... (Review)
Review
BACKGROUND
The treatment of carpal tunnel syndrome (CTS) usually involves surgical decompression of the nerve or splinting and additional medication. Physiotherapy and sports therapy could be non-invasive and alternative treatment approaches with a simultaneous low risk of side effects.
OBJECTIVE
The review systematically summarizes the current studies on the effectiveness of physiotherapy and sports therapeutic interventions for treatment of CTS and focuses on the reduction of symptoms and, as a secondary outcome, improvement of hand function.
MATERIAL AND METHODS
The systematic review includes randomized controlled trials reporting on physiotherapy or sports therapy interventions published prior to February 2021 in the electronic databases PubMed, CINAHL and Web of Science. Following the guidelines of preferred reporting items for systematic reviews and meta-analyses (PRISMA) and the Cochrane Collaboration, a systematic search of the literature, data extraction and evaluation of the risk of bias using the Cochrane risk of bias tool were conducted by two independent researchers.
RESULTS
Out of 461 identified studies 26 were included in the qualitative analysis. The risk of bias in the individual studies was graded as moderate to low. Potential bias might arise due to inadequate blinding of patients and study personnel in some cases as well as due to selective reporting of study results and procedures. Manual therapy proved to be faster and equally effective in reducing pain and improving function in the long term compared to surgery. Mobilization techniques, massage techniques, kinesiotaping and yoga as therapeutic interventions also showed positive effects on symptoms.
CONCLUSION
For the management of mild to moderate CTS, physiotherapy and sports therapeutic interventions are characterized primarily by success after as little as 2 weeks of treatment as well as comparable success to surgery and 3 months of postoperative treatment. In addition, patients are not exposed to surgical risks. The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) with the number 42017073839.
Topics: Carpal Tunnel Syndrome; Humans; Medicine; Musculoskeletal Manipulations; Physical Therapy Modalities
PubMed: 35286465
DOI: 10.1007/s00482-022-00637-x -
The Cochrane Database of Systematic... Sep 2015Low-back pain (LBP) is one of the most common and costly musculoskeletal problems in modern society. It is experienced by 70% to 80% of adults at some time in their... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Low-back pain (LBP) is one of the most common and costly musculoskeletal problems in modern society. It is experienced by 70% to 80% of adults at some time in their lives. Massage therapy has the potential to minimize pain and speed return to normal function.
OBJECTIVES
To assess the effects of massage therapy for people with non-specific LBP.
SEARCH METHODS
We searched PubMed to August 2014, and the following databases to July 2014: MEDLINE, EMBASE, CENTRAL, CINAHL, LILACS, Index to Chiropractic Literature, and Proquest Dissertation Abstracts. We also checked reference lists. There were no language restrictions used.
SELECTION CRITERIA
We included only randomized controlled trials of adults with non-specific LBP classified as acute, sub-acute or chronic. Massage was defined as soft-tissue manipulation using the hands or a mechanical device. We grouped the comparison groups into two types: inactive controls (sham therapy, waiting list, or no treatment), and active controls (manipulation, mobilization, TENS, acupuncture, traction, relaxation, physical therapy, exercises or self-care education).
DATA COLLECTION AND ANALYSIS
We used standard Cochrane methodological procedures and followed CBN guidelines. Two independent authors performed article selection, data extraction and critical appraisal.
MAIN RESULTS
In total we included 25 trials (3096 participants) in this review update. The majority was funded by not-for-profit organizations. One trial included participants with acute LBP, and the remaining trials included people with sub-acute or chronic LBP (CLBP). In three trials massage was done with a mechanical device, and the remaining trials used only the hands. The most common type of bias in these studies was performance and measurement bias because it is difficult to blind participants, massage therapists and the measuring outcomes. We judged the quality of the evidence to be "low" to "very low", and the main reasons for downgrading the evidence were risk of bias and imprecision. There was no suggestion of publication bias. For acute LBP, massage was found to be better than inactive controls for pain ((SMD -1.24, 95% CI -1.85 to -0.64; participants = 51; studies = 1)) in the short-term, but not for function ((SMD -0.50, 95% CI -1.06 to 0.06; participants = 51; studies = 1)). For sub-acute and chronic LBP, massage was better than inactive controls for pain ((SMD -0.75, 95% CI -0.90 to -0.60; participants = 761; studies = 7)) and function (SMD -0.72, 95% CI -1.05 to -0.39; 725 participants; 6 studies; ) in the short-term, but not in the long-term; however, when compared to active controls, massage was better for pain, both in the short ((SMD -0.37, 95% CI -0.62 to -0.13; participants = 964; studies = 12)) and long-term follow-up ((SMD -0.40, 95% CI -0.80 to -0.01; participants = 757; studies = 5)), but no differences were found for function (both in the short and long-term). There were no reports of serious adverse events in any of these trials. Increased pain intensity was the most common adverse event reported in 1.5% to 25% of the participants.
AUTHORS' CONCLUSIONS
We have very little confidence that massage is an effective treatment for LBP. Acute, sub-acute and chronic LBP had improvements in pain outcomes with massage only in the short-term follow-up. Functional improvement was observed in participants with sub-acute and chronic LBP when compared with inactive controls, but only for the short-term follow-up. There were only minor adverse effects with massage.
Topics: Acute Pain; Adult; Bias; Chronic Pain; Humans; Low Back Pain; Manipulation, Spinal; Massage; Randomized Controlled Trials as Topic
PubMed: 26329399
DOI: 10.1002/14651858.CD001929.pub3 -
Physical Therapy Jan 2016Manual therapy (MT) and exercise have been extensively used to treat people with musculoskeletal conditions such as temporomandibular disorders (TMD). The evidence... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Manual therapy (MT) and exercise have been extensively used to treat people with musculoskeletal conditions such as temporomandibular disorders (TMD). The evidence regarding their effectiveness provided by early systematic reviews is outdated.
PURPOSE
The aim of this study was to summarize evidence from and evaluate the methodological quality of randomized controlled trials that examined the effectiveness of MT and therapeutic exercise interventions compared with other active interventions or standard care for treatment of TMD.
DATA SOURCES
Electronic data searches of 6 databases were performed, in addition to a manual search.
STUDY SELECTION
Randomized controlled trials involving adults with TMD that compared any type of MT intervention (eg, mobilization, manipulation) or exercise therapy with a placebo intervention, controlled comparison intervention, or standard care were included. The main outcomes of this systematic review were pain, range of motion, and oral function. Forty-eight studies met the inclusion criteria and were analyzed.
DATA EXTRACTION
Data were extracted in duplicate on specific study characteristics.
DATA SYNTHESIS
The overall evidence for this systematic review was considered low. The trials included in this review had unclear or high risk of bias. Thus, the evidence was generally downgraded based on assessments of risk of bias. Most of the effect sizes were low to moderate, with no clear indication of superiority of exercises versus other conservative treatments for TMD. However, MT alone or in combination with exercises at the jaw or cervical level showed promising effects.
LIMITATIONS
Quality of the evidence and heterogeneity of the studies were limitations of the study.
CONCLUSIONS
No high-quality evidence was found, indicating that there is great uncertainty about the effectiveness of exercise and MT for treatment of TMD.
Topics: Exercise Therapy; Humans; Musculoskeletal Manipulations; Pain Measurement; Range of Motion, Articular; Temporomandibular Joint Disorders
PubMed: 26294683
DOI: 10.2522/ptj.20140548 -
Medicina (Kaunas, Lithuania) Jul 2021: Osteoarthritis (OA) is among the most common degenerative diseases that induce pain, stiffness and reduced functionality. Various physiotherapy techniques and methods... (Review)
Review
: Osteoarthritis (OA) is among the most common degenerative diseases that induce pain, stiffness and reduced functionality. Various physiotherapy techniques and methods have been used for the treatment of OA, including soft tissue techniques, therapeutic exercises, and manual techniques. The primary aim of this systemic review was to evaluate the short-and long-term efficacy of manual therapy (MT) in patients with knee OA in terms of decreasing pain and improving knee range of motion (ROM) and functionality. : A computerised search on the PubMed, PEDro and CENTRAL databases was performed to identify controlled randomised clinical trials (RCTs) that focused on MT applications in patients with knee OA. The keywords used were 'knee OA', 'knee arthritis', 'MT', 'mobilisation', 'ROM' and 'WOMAC'. : Six RCTs and randomised crossover studies met the inclusion criteria and were included in the final analysis. The available studies indicated that MT can induce a short-term reduction in pain and an increase in knee ROM and functionality in patients with knee OA. MT techniques can contribute positively to the treatment of patients with knee OA by reducing pain and increasing functionality. Further research is needed to strengthen these findings by comparing the efficacy of MT with those of other therapeutic techniques and methods, both in the short and long terms.
Topics: Exercise Therapy; Humans; Knee Joint; Musculoskeletal Manipulations; Osteoarthritis, Knee; Range of Motion, Articular
PubMed: 34356977
DOI: 10.3390/medicina57070696 -
The Journal of Manual & Manipulative... Jun 2021Patients with myofascial pain syndrome of the neck and upper back have active trigger points and may present with pain and decreased function. Dry needling (DN) and... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Patients with myofascial pain syndrome of the neck and upper back have active trigger points and may present with pain and decreased function. Dry needling (DN) and trigger point manual therapy (TMPT) techniques are often used to manage MPS.
OBJECTIVE
To compare DN and TPMT for reducing pain on the Visual Analog Scale (VAS) and Pressure Pain Threshold (PPT) scores and improving function on the Neck Disability Index (NDI) in patients with neck and upper back MPS.
METHODS
PubMed, PEDro, and CINAHL were searched for randomized controlled trials within the last 10 years comparing a group receiving DN and the other receiving TPMT. Studies were assessed using PEDro scale and Cochrane risk-of-bias tool to assess methodological quality. Meta-analyses were performed using random-effect model. Standardized mean differences (Cohen's d) and confidence intervals were calculated to compare DN to TPMT for effects on VAS, PPT, and NDI.
RESULTS
Six randomized controlled trials with 241 participants total were included in this systematic review. The effect size of difference between DN and TPMT was non-significant for VAS [d = 0.41 (-0.18, 0.99)], for PPT [d = 0.64 (-0.19, 1.47)], and for NDI [d = -0.66 (-1.33, 0.02)].
CONCLUSIONS
Both DN and TPMT improve pain and function in the short to medium term. Neither is more superior than the other.
Topics: Dry Needling; Humans; Musculoskeletal Manipulations; Myofascial Pain Syndromes; Neck Pain; Trigger Points
PubMed: 32962567
DOI: 10.1080/10669817.2020.1822618 -
Chiropractic & Manual Therapies Nov 2022Cervicogenic headache is a secondary headache, and manual therapy is one of the most common treatment choices for this and other types of headache. Nonetheless, recent... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Cervicogenic headache is a secondary headache, and manual therapy is one of the most common treatment choices for this and other types of headache. Nonetheless, recent guidelines on the management of cervicogenic headache underlined the lack of trials comparing manual and exercise therapy to sham or no-treatment controls. The main objective of this systematic review and meta-analysis was to assess the effectiveness of different forms of manual and exercise therapy in people living with cervicogenic headache, when compared to other treatments, sham, or no treatment controls.
METHODS
Following the PRISMA guidelines, the literature search was conducted until January 2022 on MEDLINE, CENTRAL, DOAJ, and PEDro. Randomized controlled trials assessing the effects of manual or exercise therapy on patients with cervicogenic headache with headache intensity or frequency as primary outcome measures were included. Study selection, data extraction and Risk of Bias (RoB) assessment were done in duplicate. GRADE was used to assess the quality of the evidence.
RESULTS
Twenty studies were included in the review, with a total of 1439 patients. Common interventions were spinal manipulation, trigger point therapy, spinal mobilization, scapulo-thoracic and cranio-cervical exercises. Meta-analysis was only possible for six manual therapy trials with sham comparators. Data pooling showed moderate-to-large effects in favour of manual therapy for headache frequency and intensity at short-term, small-to-moderate for disability at short-term, small-to-moderate for headache intensity and small for headache frequency at long-term. A sensitivity meta-analysis of low-RoB trials showed small effects in favor of manual therapy in reducing headache intensity, frequency and disability at short and long-term. Both trials included in the sensitivity meta-analysis studied spinal manipulation as the intervention of interest. GRADE assessment showed moderate quality of evidence.
CONCLUSION
The evidence suggests that manual and exercise therapy may reduce headache intensity, frequency and disability at short and long-term in people living with cervicogenic headache, but the overall RoB in most included trials was high. However, a sensitivity meta-analysis on low-RoB trials showed moderate-quality evidence supporting the use of spinal manipulation compared to sham interventions. More high-quality trials are necessary to make stronger recommendations, ideally based on methodological recommendations that enhance comparability between studies. Trial registration The protocol for this meta-analysis was pre-registered on PROSPERO under the registration number CRD42021249277.
Topics: Humans; Post-Traumatic Headache; Headache; Exercise Therapy; Manipulation, Spinal; Exercise
PubMed: 36419164
DOI: 10.1186/s12998-022-00459-9 -
The Cochrane Database of Systematic... Aug 2014Adhesive capsulitis (also termed frozen shoulder) is commonly treated by manual therapy and exercise, usually delivered together as components of a physical therapy... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Adhesive capsulitis (also termed frozen shoulder) is commonly treated by manual therapy and exercise, usually delivered together as components of a physical therapy intervention. This review is one of a series of reviews that form an update of the Cochrane review, 'Physiotherapy interventions for shoulder pain.'
OBJECTIVES
To synthesise available evidence regarding the benefits and harms of manual therapy and exercise, alone or in combination, for the treatment of patients with adhesive capsulitis.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL Plus, ClinicalTrials.gov and the WHO ICTRP clinical trials registries up to May 2013, unrestricted by language, and reviewed the reference lists of review articles and retrieved trials, to identify potentially relevant trials.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) and quasi-randomised trials, including adults with adhesive capsulitis, and comparing any manual therapy or exercise intervention versus placebo, no intervention, a different type of manual therapy or exercise or any other intervention. Interventions included mobilisation, manipulation and supervised or home exercise, delivered alone or in combination. Trials investigating the primary or adjunct effect of a combination of manual therapy and exercise were the main comparisons of interest. Main outcomes of interest were participant-reported pain relief of 30% or greater, overall pain (mean or mean change), function, global assessment of treatment success, active shoulder abduction, quality of life and the number of participants experiencing adverse events.
DATA COLLECTION AND ANALYSIS
Two review authors independently selected trials for inclusion, extracted the data, performed a risk of bias assessment and assessed the quality of the body of evidence for the main outcomes using the GRADE approach.
MAIN RESULTS
We included 32 trials (1836 participants). No trial compared a combination of manual therapy and exercise versus placebo or no intervention. Seven trials compared a combination of manual therapy and exercise versus other interventions but were clinically heterogeneous, so opportunities for meta-analysis were limited. The overall impression gained from these trials is that the few outcome differences between interventions that were clinically important were detected only up to seven weeks. Evidence of moderate quality shows that a combination of manual therapy and exercise for six weeks probably results in less improvement at seven weeks but a similar number of adverse events compared with glucocorticoid injection. The mean change in pain with glucocorticoid injection was 58 points on a 100-point scale, and 32 points with manual therapy and exercise (mean difference (MD) 26 points, 95% confidence interval (CI) 15 points to 37 points; one RCT, 107 participants), for an absolute difference of 26% (15% to 37%). Mean change in function with glucocorticoid injection was 39 points on a 100-point scale, and 14 points with manual therapy and exercise (MD 25 points, 95% CI 35 points to 15 points; one RCT, 107 participants), for an absolute difference of 25% (15% to 35%). Forty-six per cent (26/56) of participants reported treatment success with manual therapy and exercise compared with 77% (40/52) of participants receiving glucocorticoid injection (risk ratio (RR) 0.6, 95% CI 0.44 to 0.83; one RCT, 108 participants), with an absolute risk difference of 30% (13% to 48%). The number reporting adverse events did not differ between groups: 56% (32/57) reported events with manual therapy and exercise, and 53% (30/57) with glucocorticoid injection (RR 1.07, 95% CI 0.76 to 1.49; one RCT, 114 participants), with an absolute risk difference of 4% (-15% to 22%). Group differences in improvement in overall pain and function at six months and 12 months were not clinically important.We are uncertain of the effect of other combinations of manual therapy and exercise, as most evidence is of low quality. Meta-analysis of two trials (86 participants) suggested no clinically important differences between a combination of manual therapy, exercise, and electrotherapy for four weeks and placebo injection compared with glucocorticoid injection alone or placebo injection alone in terms of overall pain, function, active range of motion and quality of life at six weeks, six months and 12 months (though the 95% CI suggested function may be better with glucocorticoid injection at six weeks). The same two trials found that adding a combination of manual therapy, exercise and electrotherapy for four weeks to glucocorticoid injection did not confer clinically important benefits over glucocorticoid injection alone at each time point. Based on one high quality trial (148 participants), following arthrographic joint distension with glucocorticoid and saline, a combination of manual therapy and supervised exercise for six weeks conferred similar effects to those of sham ultrasound in terms of overall pain, function and quality of life at six weeks and at six months, but provided greater patient-reported treatment success and active shoulder abduction at six weeks. One trial (119 participants) found that a combination of manual therapy, exercise, electrotherapy and oral non-steroidal anti-inflammatory drug (NSAID) for three weeks did not confer clinically important benefits over oral NSAID alone in terms of function and patient-reported treatment success at three weeks.On the basis of 25 clinically heterogeneous trials, we are uncertain of the effect of manual therapy or exercise when not delivered together, or one type of manual therapy or exercise versus another, as most reported differences between groups were not clinically or statistically significant, and the evidence is mostly of low quality.
AUTHORS' CONCLUSIONS
The best available data show that a combination of manual therapy and exercise may not be as effective as glucocorticoid injection in the short-term. It is unclear whether a combination of manual therapy, exercise and electrotherapy is an effective adjunct to glucocorticoid injection or oral NSAID. Following arthrographic joint distension with glucocorticoid and saline, manual therapy and exercise may confer effects similar to those of sham ultrasound in terms of overall pain, function and quality of life, but may provide greater patient-reported treatment success and active range of motion. High-quality RCTs are needed to establish the benefits and harms of manual therapy and exercise interventions that reflect actual practice, compared with placebo, no intervention and active interventions with evidence of benefit (e.g. glucocorticoid injection).
Topics: Adult; Bursitis; Exercise Therapy; Female; Glucocorticoids; Humans; Injections, Intra-Articular; Male; Middle Aged; Musculoskeletal Manipulations; Randomized Controlled Trials as Topic; Shoulder Pain
PubMed: 25157702
DOI: 10.1002/14651858.CD011275