The Efficacy of Manual Therapy for Rotator Cuff Tendinopathy: A Systematic Review and Meta-Analysis
Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at Seton Hall University on March 31, 2015. For personal use only. No other uses without permission. Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Ariel Desjardins-Charbonneau, PT, MSc 1 Jean-Sébastien Roy, PT, PhD 2,3 Clermont E. Dionne, OT, PhD 2,4 Pierre Frémont, MD, PhD2,5 Joy C. MacDermid, PT, PhD 6 François Desmeules, PT, PhD 1,7 1
Maisonneuve-Rosemont Hospital Research Center, University of Montreal Affiliated Research Center, Montreal, Quebec, Canada 2 Department of Rehabilitation, Faculty of Medicine, Laval University, Quebec City, Quebec, Canada 3 Center for Interdisciplinary Research in Rehabilitation and Social Integration, Quebec City, Quebec, Canada 4 Population Health Research Unit (URESP), Laval University Hospital (CHU) Research Center, Quebec City, Quebec, Canada 5 Laval University Hospital (CHU) Research Center, Quebec City, Quebec, Canada 6 School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada 7 School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada The authors declare that they have no competing interests. Financial support has been provided by the Institut de Recherche en Santé et Sécurité au Travail (IRSST) and the Réseau Provincial de Recherche en Adaptation-Réadaptation (REPAR). Ariel Desjardins-Charbonneau is supported by a fellowship of the Ordre de la Physiothérapie du Québec (OPPQ). Address for correspondence and reprints request: François Desmeules, PT, PhD Unité de recherche clinique en orthopédie/ Orthopaedic clinical research unit Centre de recherche de l’Hôpital Maisonneuve-Rosemont (CRHMR) 5415 Blvd L'Assomption, Pav. Rachel Tourigny, bureau/office 4163 Montréal, QC H1T 2M4 Téléphone / Phone: 514 252-3400, # 5607 Télécopieur/ Fax: 514 254-7455 [email protected]
1
Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at Seton Hall University on March 31, 2015. For personal use only. No other uses without permission. Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
1
Abstract
2
Study Design: Systematic review and meta-analysis.
3
Objectives: To evaluate the efficacy of manual therapy (MT) for patients with rotator cuff (RC)
4
tendinopathy.
5
Background: RC tendinopathy is a highly prevalent musculoskeletal disorder. MT is a common
6
intervention used by physiotherapists for this condition although evidence regarding its efficacy
7
is inconclusive.
8
Methods: A literature search using terms related to shoulder, RC tendinopathy, and MT was
9
conducted in 4 databases to identify randomized controlled trials (RCTs) that compared MT to
10
any other type of intervention to treat RC tendinopathy. RCTs were assessed with the Cochrane
11
Risk of Bias Tool. Meta-analyses or qualitative synthesis of evidence were performed.
12
Results: Twenty-one studies were included. The majority had a high risk of bias with only 5
13
studies having a score of 69% or greater, indicative of moderate to low risk of bias. A small but
14
statistically significant overall effect for pain reduction of MT compared with a placebo or in
15
addition to another intervention was observed (n=406) which may or may not be clinically
16
important given a mean difference of 1.1(95% confidence interval [CI]: 0.6, 1.6) on a 10 cm
17
visual analog scale (VAS). Adding manual therapy to an exercise program (n=226) significantly
18
decreased pain and this effect may or may not be clinically important (mean difference of 1.0;
19
95%CI: 0.7, 1.4 on a 10 cm VAS). Based on qualitative analyses it is unclear that MT used alone
20
or added to exercises improves function.
21
Conclusions: For patients with RC tendinopathy, based on low to moderate quality evidence,
22
MT may decrease pain but it is unclear if it could improve function. More methodologically
23
sound studies are needed before more definitive conclusions can be made.
2
Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at Seton Hall University on March 31, 2015. For personal use only. No other uses without permission. Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
24 Level of evidence: Therapy, level 1a-, J Orthop Sports Phys Ther 2015;xxxxx
25 Key words: mobilization, physiotherapy, shoulder impingement syndrome, shoulder pain
3
26
INTRODUCTION
Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at Seton Hall University on March 31, 2015. For personal use only. No other uses without permission. Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
27
Shoulder pain is highly prevalent and among musculoskeletal disorders, it is the third
28
most common reason for visiting a primary care physician.17,
29
people who have shoulder complaints receive a diagnosis of rotator cuff (RC) tendinopathy.47
30
RC tendinopathy often leads to decreased function,36 lower health-related quality of life,36 poor
31
sleep quality,48 and work absenteeism.41 RC tendinopathy is a broad diagnosis and mounting
32
evidence
33
tendinitis/tendinosis, as well as subacromial bursitis may be considered as the same clinical
34
entity.20
suggest
that
diagnoses
such
as
shoulder
35, 47
As many as two thirds of
impingement
syndrome,
RC
35
Conservative treatment of RC tendinopathy generally includes rest, non-steroidal anti-
36
inflammatory drugs, and rehabilitation interventions such as exercise.20 High level evidence
37
supports exercise as an effective treatment.21 In conjunction with exercise, physiotherapists often
38
add manual therapy (MT) interventions to address impairments potentially associated with RC
39
tendinopathy.51 MT interventions have been defined by the International Federation of
40
Orthopaedic Manipulative Physical Therapist (IFOMPT) as skilled hand movements performed
41
by a therapist.27
42
Systematic reviews on the efficacy of MT and exercises for the treatment of RC
43
tendinopathy have recently been published7, 8 with the authors concluding that there is a lack of
44
evidence concerning the efficacy of MT when used alone and that evidence regarding the
45
efficacy of the addition of MT to exercise for the treatment of RC tendinopathy was
46
inconclusive.7, 8 However, in these reviews, only qualitative synthesis of results was performed
47
without pooling of results into meta-analyses. Moreover, many relevant clinical trials were
48
excluded from these reviews1, 3, 5, 11, 13, 39, 45, 49 and, since the publication of these reviews, new
4
trials have also been published.23, 28, 30 Thus, the aim of this systematic review and meta-analysis
50
was to perform an updated review of the evidence regarding the efficacy of MT, used either
51
alone or in combination with other interventions, for the treatment of RC tendinopathy.
Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at Seton Hall University on March 31, 2015. For personal use only. No other uses without permission. Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
49
5
Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at Seton Hall University on March 31, 2015. For personal use only. No other uses without permission. Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
52
METHODS
53
Literature search
54
An electronic bibliographical search was conducted in MEDLINE, EMBASE, the Physiotherapy
55
Evidence Database (PEDro), and the Cumulative Index to Nursing & Allied Health Literature
56
(CINAHL), from their date of inception to June 2014. A combination of MESH terms and text
57
words was used to identify relevant articles. In addition, a hand search was performed of the
58
reference lists of included articles and previous published reviews (FIGURE 1).
59 60
Study selection
61
Two reviewers independently reviewed titles and abstracts to identify articles of interest.
62
Consensus of the 2 reviewers was needed to include the studies in the literature review. A third
63
reviewer was available for final determination if consensus was not achieved by the pair of initial
64
reviewers.
65 66
Articles were included if they met the following inclusion criteria: participants were diagnosed
67
with RC tendinopathy/tendinitis, shoulder impingement syndrome, or subacromial bursitis;
68
participants were adults; a MT intervention was compared with another type of treatment
69
including other MT interventions; the study design was a randomized controlled trial (RCT); the
70
article was published in English or French (FIGURE 1). MT interventions that were considered
71
for inclusion had to be specific hands-on interventions.27 Included interventions meeting this
72
definition were joint mobilisations, manipulations, specific soft tissue massage techniques,
73
neurodynamic interventions, and mobilizations with movement (MWM) of the shoulder girdle or
74
spine. All types of outcome measures were considered for inclusion. Studies that included
6
75
participants with shoulder pain without further diagnostic information were included for review
76
if it was possible to determine that the majority of participants had RC tendinopathy. Studies
77
were excluded if participants had RC full-thickness tear, calcific tendinopathy, or presented with
78
a postsurgical condition.
Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at Seton Hall University on March 31, 2015. For personal use only. No other uses without permission. Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
79 80
Data extraction
81
Data and results from the included studies were extracted using a standardized form that
82
documented: characteristics of the participants, diagnostic criteria, interventions, follow-up
83
period, outcome measures, and results (TABLES 1-3). When results were missing or not fully
84
reported, efforts were made to contact the contributing authors to retrieve missing data.
85 86
Risk of bias appraisal tool
87
The internal validity of the included studies was assessed with the Cochrane Risk of Bias Tool.25
88
This tool appraises 5 different biases (selection, performance, attrition, detection, reporting)
89
using 8 different domains (methodological items). A score on a 3-point scale was attributed to
90
each judgement of risk of bias, (0 for a high risk of bias, 1 for an unclear risk of bias, and 2 for a
91
low risk of bias), thus a maximum of 16 points was possible if the study presented a low risk of
92
bias. Two reviewers independently assessed the risk of bias of each study and met to compare
93
ratings. Disagreement was resolved by consensus. If no consensus was reached a third reviewer
94
was available to make final determination.
95 96
Data analyses
97
A pre-consensus intraclass correlation coefficient (ICC) was calculated on the total score of the
7
98
Cochrane Risk of Bias Tool and interrater agreement was calculated for the 8 risk of bias
99
domains with the kappa ( ) statistic. Statistical analyses were performed with the Statistical
100
Package for Social Sciences (IBM SPSS Statistics 21, Chicago, USA).
Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at Seton Hall University on March 31, 2015. For personal use only. No other uses without permission. Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
101 102
Results from studies with similar comparators or outcome measures were pooled into meta-
103
analyses. Only meta-analyses without a significant degree of heterogeneity (
104
60%) were retained for reporting.24 When quantitative pooling was not performed, results were
105
qualitatively synthesized. The primary analysis compared the overall efficacy of manual therapy
106
to a placebo or to another intervention. Secondary analyses included the comparisons of: 1) MT
107
alone to a placebo, 2) MT with an exercise program to an exercise program, 3) MT alone to
108
another intervention, 4) MT combined with other types of interventions to a placebo or a
109
multimodal intervention, 5) Different types of MT.
2
P>.10 and I2
Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at Seton Hall University on March 31, 2015. For personal use only. No other uses without permission. Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Ariel Desjardins-Charbonneau, PT, MSc 1 Jean-Sébastien Roy, PT, PhD 2,3 Clermont E. Dionne, OT, PhD 2,4 Pierre Frémont, MD, PhD2,5 Joy C. MacDermid, PT, PhD 6 François Desmeules, PT, PhD 1,7 1
Maisonneuve-Rosemont Hospital Research Center, University of Montreal Affiliated Research Center, Montreal, Quebec, Canada 2 Department of Rehabilitation, Faculty of Medicine, Laval University, Quebec City, Quebec, Canada 3 Center for Interdisciplinary Research in Rehabilitation and Social Integration, Quebec City, Quebec, Canada 4 Population Health Research Unit (URESP), Laval University Hospital (CHU) Research Center, Quebec City, Quebec, Canada 5 Laval University Hospital (CHU) Research Center, Quebec City, Quebec, Canada 6 School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada 7 School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada The authors declare that they have no competing interests. Financial support has been provided by the Institut de Recherche en Santé et Sécurité au Travail (IRSST) and the Réseau Provincial de Recherche en Adaptation-Réadaptation (REPAR). Ariel Desjardins-Charbonneau is supported by a fellowship of the Ordre de la Physiothérapie du Québec (OPPQ). Address for correspondence and reprints request: François Desmeules, PT, PhD Unité de recherche clinique en orthopédie/ Orthopaedic clinical research unit Centre de recherche de l’Hôpital Maisonneuve-Rosemont (CRHMR) 5415 Blvd L'Assomption, Pav. Rachel Tourigny, bureau/office 4163 Montréal, QC H1T 2M4 Téléphone / Phone: 514 252-3400, # 5607 Télécopieur/ Fax: 514 254-7455 [email protected]
1
Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at Seton Hall University on March 31, 2015. For personal use only. No other uses without permission. Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
1
Abstract
2
Study Design: Systematic review and meta-analysis.
3
Objectives: To evaluate the efficacy of manual therapy (MT) for patients with rotator cuff (RC)
4
tendinopathy.
5
Background: RC tendinopathy is a highly prevalent musculoskeletal disorder. MT is a common
6
intervention used by physiotherapists for this condition although evidence regarding its efficacy
7
is inconclusive.
8
Methods: A literature search using terms related to shoulder, RC tendinopathy, and MT was
9
conducted in 4 databases to identify randomized controlled trials (RCTs) that compared MT to
10
any other type of intervention to treat RC tendinopathy. RCTs were assessed with the Cochrane
11
Risk of Bias Tool. Meta-analyses or qualitative synthesis of evidence were performed.
12
Results: Twenty-one studies were included. The majority had a high risk of bias with only 5
13
studies having a score of 69% or greater, indicative of moderate to low risk of bias. A small but
14
statistically significant overall effect for pain reduction of MT compared with a placebo or in
15
addition to another intervention was observed (n=406) which may or may not be clinically
16
important given a mean difference of 1.1(95% confidence interval [CI]: 0.6, 1.6) on a 10 cm
17
visual analog scale (VAS). Adding manual therapy to an exercise program (n=226) significantly
18
decreased pain and this effect may or may not be clinically important (mean difference of 1.0;
19
95%CI: 0.7, 1.4 on a 10 cm VAS). Based on qualitative analyses it is unclear that MT used alone
20
or added to exercises improves function.
21
Conclusions: For patients with RC tendinopathy, based on low to moderate quality evidence,
22
MT may decrease pain but it is unclear if it could improve function. More methodologically
23
sound studies are needed before more definitive conclusions can be made.
2
Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at Seton Hall University on March 31, 2015. For personal use only. No other uses without permission. Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
24 Level of evidence: Therapy, level 1a-, J Orthop Sports Phys Ther 2015;xxxxx
25 Key words: mobilization, physiotherapy, shoulder impingement syndrome, shoulder pain
3
26
INTRODUCTION
Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at Seton Hall University on March 31, 2015. For personal use only. No other uses without permission. Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
27
Shoulder pain is highly prevalent and among musculoskeletal disorders, it is the third
28
most common reason for visiting a primary care physician.17,
29
people who have shoulder complaints receive a diagnosis of rotator cuff (RC) tendinopathy.47
30
RC tendinopathy often leads to decreased function,36 lower health-related quality of life,36 poor
31
sleep quality,48 and work absenteeism.41 RC tendinopathy is a broad diagnosis and mounting
32
evidence
33
tendinitis/tendinosis, as well as subacromial bursitis may be considered as the same clinical
34
entity.20
suggest
that
diagnoses
such
as
shoulder
35, 47
As many as two thirds of
impingement
syndrome,
RC
35
Conservative treatment of RC tendinopathy generally includes rest, non-steroidal anti-
36
inflammatory drugs, and rehabilitation interventions such as exercise.20 High level evidence
37
supports exercise as an effective treatment.21 In conjunction with exercise, physiotherapists often
38
add manual therapy (MT) interventions to address impairments potentially associated with RC
39
tendinopathy.51 MT interventions have been defined by the International Federation of
40
Orthopaedic Manipulative Physical Therapist (IFOMPT) as skilled hand movements performed
41
by a therapist.27
42
Systematic reviews on the efficacy of MT and exercises for the treatment of RC
43
tendinopathy have recently been published7, 8 with the authors concluding that there is a lack of
44
evidence concerning the efficacy of MT when used alone and that evidence regarding the
45
efficacy of the addition of MT to exercise for the treatment of RC tendinopathy was
46
inconclusive.7, 8 However, in these reviews, only qualitative synthesis of results was performed
47
without pooling of results into meta-analyses. Moreover, many relevant clinical trials were
48
excluded from these reviews1, 3, 5, 11, 13, 39, 45, 49 and, since the publication of these reviews, new
4
trials have also been published.23, 28, 30 Thus, the aim of this systematic review and meta-analysis
50
was to perform an updated review of the evidence regarding the efficacy of MT, used either
51
alone or in combination with other interventions, for the treatment of RC tendinopathy.
Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at Seton Hall University on March 31, 2015. For personal use only. No other uses without permission. Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
49
5
Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at Seton Hall University on March 31, 2015. For personal use only. No other uses without permission. Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
52
METHODS
53
Literature search
54
An electronic bibliographical search was conducted in MEDLINE, EMBASE, the Physiotherapy
55
Evidence Database (PEDro), and the Cumulative Index to Nursing & Allied Health Literature
56
(CINAHL), from their date of inception to June 2014. A combination of MESH terms and text
57
words was used to identify relevant articles. In addition, a hand search was performed of the
58
reference lists of included articles and previous published reviews (FIGURE 1).
59 60
Study selection
61
Two reviewers independently reviewed titles and abstracts to identify articles of interest.
62
Consensus of the 2 reviewers was needed to include the studies in the literature review. A third
63
reviewer was available for final determination if consensus was not achieved by the pair of initial
64
reviewers.
65 66
Articles were included if they met the following inclusion criteria: participants were diagnosed
67
with RC tendinopathy/tendinitis, shoulder impingement syndrome, or subacromial bursitis;
68
participants were adults; a MT intervention was compared with another type of treatment
69
including other MT interventions; the study design was a randomized controlled trial (RCT); the
70
article was published in English or French (FIGURE 1). MT interventions that were considered
71
for inclusion had to be specific hands-on interventions.27 Included interventions meeting this
72
definition were joint mobilisations, manipulations, specific soft tissue massage techniques,
73
neurodynamic interventions, and mobilizations with movement (MWM) of the shoulder girdle or
74
spine. All types of outcome measures were considered for inclusion. Studies that included
6
75
participants with shoulder pain without further diagnostic information were included for review
76
if it was possible to determine that the majority of participants had RC tendinopathy. Studies
77
were excluded if participants had RC full-thickness tear, calcific tendinopathy, or presented with
78
a postsurgical condition.
Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at Seton Hall University on March 31, 2015. For personal use only. No other uses without permission. Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
79 80
Data extraction
81
Data and results from the included studies were extracted using a standardized form that
82
documented: characteristics of the participants, diagnostic criteria, interventions, follow-up
83
period, outcome measures, and results (TABLES 1-3). When results were missing or not fully
84
reported, efforts were made to contact the contributing authors to retrieve missing data.
85 86
Risk of bias appraisal tool
87
The internal validity of the included studies was assessed with the Cochrane Risk of Bias Tool.25
88
This tool appraises 5 different biases (selection, performance, attrition, detection, reporting)
89
using 8 different domains (methodological items). A score on a 3-point scale was attributed to
90
each judgement of risk of bias, (0 for a high risk of bias, 1 for an unclear risk of bias, and 2 for a
91
low risk of bias), thus a maximum of 16 points was possible if the study presented a low risk of
92
bias. Two reviewers independently assessed the risk of bias of each study and met to compare
93
ratings. Disagreement was resolved by consensus. If no consensus was reached a third reviewer
94
was available to make final determination.
95 96
Data analyses
97
A pre-consensus intraclass correlation coefficient (ICC) was calculated on the total score of the
7
98
Cochrane Risk of Bias Tool and interrater agreement was calculated for the 8 risk of bias
99
domains with the kappa ( ) statistic. Statistical analyses were performed with the Statistical
100
Package for Social Sciences (IBM SPSS Statistics 21, Chicago, USA).
Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at Seton Hall University on March 31, 2015. For personal use only. No other uses without permission. Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
101 102
Results from studies with similar comparators or outcome measures were pooled into meta-
103
analyses. Only meta-analyses without a significant degree of heterogeneity (
104
60%) were retained for reporting.24 When quantitative pooling was not performed, results were
105
qualitatively synthesized. The primary analysis compared the overall efficacy of manual therapy
106
to a placebo or to another intervention. Secondary analyses included the comparisons of: 1) MT
107
alone to a placebo, 2) MT with an exercise program to an exercise program, 3) MT alone to
108
another intervention, 4) MT combined with other types of interventions to a placebo or a
109
multimodal intervention, 5) Different types of MT.
2
P>.10 and I2
