The adjunctive benefit of manual therapy in addition to therapeutic exercise for shoulder impingement syndrome: A systematic review X. Konstantakis¹, C. Pazaridis², N. Heneghan² ¹University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom ²University of Birmingham, School of Sport, Exercise and Rehabilitation Sciences, Birmingham, United Kingdom Background Shoulder impingement syndrome (SIS) constitutes the most common diagnostic subgroup of shoulder conditions, for which therapeutic exercise (TE) is considered as an effective treatment intervention (Green et al., 2003). Existing evidence suggests that its efficacy may be augmented when is combined with manual therapy (MT). However, the evidence regarding the effectiveness of this combined treatment intervention is inconclusive (Kuhn, 2009; Michener et al., 2004; Desmeules et al., 2003). Records identified through database searching (n =1.469) Additional records identified through other sources (n =19) Results 7 RCTs from 4 countries. Results in table 1. 3 studies had high risk of bias; 3 were at unclear risk of bias. Only one study (n=90) had low risk of bias. After 5 but not in 12 weeks, the intervention group (TE with MT) reported a minor decrease of mean weekly pain, dropped by 2.3, (TE group by 1.7); between group difference of mean pain 0.6, with a RR of 1.46 (95% CI 1.01-2.10), indicating a additional effect of MT in a TE programme. Records after duplicates removed (n =860) Records excluded (n = 847) Non English language Full-thickness RC tear Other physiotherapy interventions(acupuncture, shockwave) RC repair No intervention Osteopathy Manipulation Records screened (n = 860) Discussion MT with TE appeared superior to TE alone in improving pain and shoulder function in SIS in the short term; methodological deficits found in the majority of the studies, precluded explicit judgments. The results mirror those of previous systematic reviews (Kuhn, 2009; Michener et al., 2004; Desmeules et al., 2003). Future studies should evaluate the long term effects of this combined therapeutic approach, include larger sample sizes and use more valid clinical criteria for the diagnosis of SIS. Full-text articles assessed for eligibility (n = 15) Full-text articles excluded, with reasons (n = 8) MWM Chiropractic adjustment Injection Population criteria not satisfied : non-specific shoulder pain population/ SIS not defined Purpose To investigate whether TE combined with MT is superior to TE alone in improving patient reported outcomes of pain and shoulder function in patients with SIS. Studies included in qualitative synthesis (n = 7) Limitations Risk of publication bias due to the exclusion of non-English language published studies. Grey literature was not searched; risk of inclusion bias. Figure 1: Flow chart indicating search process Design A systematic review was designed in accordance to published guidelines and reported in line with PRISMA. Key databases: AMED (EBSCO), CINAHL plus (EBSCO), Cochrane Library, Evidence in Health and Social care, Medline (Ovid), PEDro, Scopus, Science Citation Index Expanded (ISI), were searched, using pre-defined search terms, up to November 2015. Citation lists from the included studies were scanned. No restriction regarding the publication date; only English language studies were included. Inclusion criteria Population: adults with SIS or associated diagnoses Intervention: TE and MT Comparator: A TE programme was compared to MT combined with TE Outcome measures: pain and shoulder function Study designs: Only RCTs or controlled clinical trials were included. Searching, data extraction and quality assessment was undertaken by 2 independent reviewers (XK, CP). Disagreement was resolved by consensus. The Cochrane risk-of-bias tool was used to evaluate the studies’ quality. Risk of bias was classified for individual studies (low, unclear, high). Heterogeneity in key characteristics precluded meta-analysis. A qualitative data synthesis was performed. The results were tabulated (table 1) for comparison. Table 1: Characteristic & results of n=7 studies Author/ Date Population-Intervention Outcome measures Results R O B Conroy and Hayes, (1998) N=14 Group1 n=7: TE+MT Group2 n=7: TE Duration of symptoms: not stated VAS over 24h pain; subacr. compression; Examiner-rated overhead function; 3 items using a 3-point scale Measurements: Baseline, post-treat.(within 1- 3 days) & 3 weeks TE+MT group; less pain over 24h (p= 0.008) & subacr. compression test (p = 0.032), than TE group. No functional differences. U Bang and Deyle, (2000) N = 52 Group1 n=24: TE Group2 n=28: TE+MT Duration of symptoms: 4.4, 5.6 months VAS with resisted break tests of active ABD, ER and IR Self-report pain; 6-point pt Likert scale; Owestry Low Back Disab. Quest. Measurements: Baseline 3-4 weeks (post treat.) and 60 days 1 month: TE+MT group signific. (70%) less pain than TE group (35%) 2 months:TE+MT group signific. improved in function and pain (p = 0.005) H Senbursa et al., (2007) N=30 Group1 n=15: TE Group2 n=15: TE+MT VAS with functional activities Neer’s functional questionnaire Measurements: Baseline 4 weeks and 3 months (only for pain and function) 4 weeks: TE+MT group signific. less pain (mean 6.7 to 2.0) than TE group (mean 6.6 to 3.0). Statist.functional differences (p>0.05) TE+MT group > TE group Barbosa et al., (2008) Duration of symptoms: > 6months DASH score 0–100 ; CMS (including VAS) 0–100 (100=best) Measurements: At the end of treatment=within 4 weeks after end of treatment (rate unspecified) After 4 weeks: MD (95% CI"); DASH: 15 (7.84–22.16); CMS: 10.29 (3.86–16.72) favouring TE+MT group Kachingwe et al., (2008) N=33 Group1 n=8: TE Group2 n=9: TE+MT VAS with max. pain over 24h; with Neer’s and Hawkins-Kennedy tests; SPADI Measurements: At 6 weeks TE+MT group higher % of pain improvement (44.2)>TE group (20.8); Both groups statistic. improved in pain (p<.001);statistically signific. improved in function(p<.001) Senbursa et al., (2011) N=77 Group1 n=25: TE Group2 n=30: TE+MT VAS at night, at rest and on movement; Function measurement using MASES questionnaire Measurements: At 4 and 12 weeks No signif. differences in pain (p>0.05); TE+MT group improved faster in night pain (p>0.05); in pain with movement the 4th week. After 12 weeks, TE+MT group; best pain and function results (p<0.05). Kromer et al., (2013) N=90 Group1 n=44: TE Group2 n=46: TE+MT Duration of symptoms: for at least 4 weeks Mean weekly pain score; NRS SPADI. Other outcomes: PGIC, GPSS, PST (plus FABQ and PCS) Measurements: At 5 and 12 weeks After 5 weeks: TE+MT group: pain dropped by 2.3; TE group by 1.7;between group difference of mean weekly pain 0.6 , with a RR of 1.46 (95% CI 1.01-2.10) 5 weeks: both improved in pain (p=0.000); 12 weeks: TE group improved in pain L Conclusion Limited evidence suggests that MT may enhance the effectiveness of TE in improving pain and function in SIS in the short term. Poor quality of studies coupled with heterogeneity of both interventions precludes strong conclusions. Clinical Implications More methodologically high quality studies are required to evaluate further this combined therapeutic approach and establish the optimal protocols for TE programme and MT regimen, thus allowing clinicians to take an evidence-based practice approach when treating patients with SIS. References Desmeules F., Cote C, Fremont P., (2003) Therapeutic exercise and orthopedic manual therapy for impingement syndrome: a systematic review. Clin J Sports Med. 13:176–82 Green, S., Buchbinder, R., & Hetrick, S. E. (2003) Physiotherapy interventions for shoulder pain. The Cochrane Library. Kuhn JE (2009) Exercise in the treatment of rotator cuff impingement: A systematic review and a synthesized evidence-based rehabilitation protocol, J Shoulder Elbow Surg., 18, 138-160. Michener L, Walsworth M, Burnet EN. (2004) Effectiveness of rehabilitation for patients with subacromial impingement syndrome: a systematic review. J Hand Ther. 17:152–64 Acknowledgments Authors would like to acknowledge the Musculoskeletal Association of Chartered Physiotherapists (MACP) for funding this presentation. TE; therapeutic exercise, MT; manual therapy VAS; visual analogue scale, DASH; Disabilities of the Arm Shoulder and Hand, CMS; Constant-Murley Score, MD; mean difference, CI; confidence interval, SPADI; Shoulder Pain and Disability Index, MASES; Modified American Shoulder Surgery, NRS; Numeric Rating Scale, GPSS; Generic Patient-Specific Scale, PST; Patients Satisfaction with Treatment Contact details: fon88kon@hotmail.com