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Joshua A Cleland - One of the best experts on this subject based on the ideXlab platform.
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effectiveness of Manual Therapy versus surgery in pain processing due to carpal tunnel syndrome a randomized clinical trial
European Journal of Pain, 2017Co-Authors: Cesar Fernandezdelaspenas, Joshua A Cleland, Maria Palacioscena, Stella Fuensalidanovo, Cristina Alonsoblanco, J A Pareja, Francisco AlburquerquesendinAbstract:Background People with carpal tunnel syndrome (CTS) exhibit widespread pressure pain and thermal pain hypersensitivity as a manifestation of central sensitization. The aim of our study was to compare the effectiveness of Manual Therapy versus surgery for improving pain and nociceptive gain processing in people with CTS. Methods The trial was conducted at a local regional Hospital in Madrid, Spain from August 2014 to February 2015. In this randomized parallel-group, blinded, clinical trial, 100 women with CTS were randomly allocated to either Manual Therapy (n = 50), who received three sessions (once/week) of Manual therapies including desensitization manoeuvres of the central nervous system, or surgical intervention (n = 50) group. Outcomes including pressure pain thresholds (PPT), thermal pain thresholds (HPT or CPT), and pain intensity which were assessed at baseline, and 3, 6, 9 and 12 months after the intervention by an assessor unaware of group assignment. Analysis was by intention to treat with mixed ANCOVAs adjusted for baseline scores. Results At 12 months, 95 women completed the follow-up. Patients receiving Manual Therapy exhibited higher increases in PPT over the carpal tunnel at 3, 6 and 9 months (all, p < 0.01) and higher decrease of pain intensity at 3 month follow-up (p < 0.001) than those receiving surgery. No significant differences were observed between groups for the remaining outcomes. Conclusions Manual Therapy and surgery have similar effects on decreasing widespread pressure pain sensitivity and pain intensity in women with CTS. Neither Manual Therapy nor surgery resulted in changes in thermal pain sensitivity. Significance The current study found that Manual Therapy and surgery exhibited similar effects on decreasing widespread pressure pain sensitivity and pain intensity in women with carpal tunnel syndrome at medium- and long-term follow-ups investigating changes in nociceptive gain processing after treatment in carpal tunnel syndrome.
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Manual Therapy exercise and traction for patients with cervical radiculopathy a randomized clinical trial
Physical Therapy, 2009Co-Authors: Ian A. Young, Arnold J Aguilera, Lori A Michener, Joshua A Cleland, Alison R SnyderAbstract:Background: To date, optimal strategies for the management of patients with cervical radiculopathy remain elusive. Preliminary evidence suggests that a multimodal treatment program consisting of Manual Therapy, exercise, and cervical traction may result in positive outcomes for patients with cervical radiculopathy. However, limited evidence exists to support the use of mechanical cervical traction in patients with cervical radiculopathy. Objective: The purpose of this study was to examine the effects of Manual Therapy and exercise, with or without the addition of cervical traction, on pain, function, and disability in patients with cervical radiculopathy. Design: This study was a multicenter randomized clinical trial. Setting: The study was conducted in orthopedic physical Therapy clinics. Patients: Patients diagnosed with cervical radiculopathy (N=81) were randomly assigned to 1 of 2 groups: a group that received Manual Therapy, exercise, and intermittent cervical traction (MTEXTraction group) and a group that received Manual Therapy, exercise, and sham intermittent cervical traction (MTEX group). Intervention: Patients were treated, on average, 2 times per week for an average of 4.2 weeks. Measurements: Outcome measurements were collected at baseline and at 2 weeks and 4 weeks using the Numeric Pain Rating Scale (NPRS), the Patient-Specific Functional Scale (PSFS), and the Neck Disability Index (NDI). Results: There were no significant differences between the groups for any of the primary or secondary outcome measures at 2 weeks or 4 weeks. The effect size between groups for each of the primary outcomes was small (NDI=1.5, 95% confidence interval [CI]=−6.8 to 3.8; PSFS=0.29, 95% CI=−1.8 to 1.2; and NPRS=0.52, 95% CI=−1.8 to 1.2). Limitations: The use of a nonvalidated clinical prediction rule to diagnose cervical radiculopathy and the lack of a control group without treatment were limitations of this study. Conclusions: The results suggest that the addition of mechanical cervical traction to a multimodal treatment program of Manual Therapy and exercise yields no significant additional benefit to pain, function, or disability in patients with cervical radiculopathy.
Rachelle Buchbinder - One of the best experts on this subject based on the ideXlab platform.
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SAT0508 Manual Therapy and Exercise for Rotator Cuff Disease: A Cochrane Review
Annals of the Rheumatic Diseases, 2016Co-Authors: Matthew J Page, Sally Green, Brodwen Mcbain, Stephen J Surace, Jessica Deitch, Nicolette Lyttle, Marshall A Mrocki, Rachelle BuchbinderAbstract:Background Initial management of rotator cuff disease often includes Manual Therapy and exercise, usually delivered together as components of a physical Therapy intervention. To best inform current practice, an up-to-date review which incorporates the most recently available evidence is needed. Objectives To systematically identify and synthesise the available evidence regarding the benefits and harms of Manual Therapy and exercise, alone or in combination, for the treatment of rotator cuff disease. Methods We included randomised controlled trials, including adults with rotator cuff disease, and comparing any Manual Therapy or exercise intervention with placebo, no intervention, a different type of Manual Therapy or exercise or any other intervention. Interventions included mobilisation, manipulation and supervised or home exercises, delivered alone or in combination. Trials investigating the primary or add-on effect of Manual Therapy plus exercise were the main comparisons of interest. Main outcomes of interest were overall pain, function, pain on motion, patient-reported global assessment of treatment success, quality of life and the number of participants experiencing adverse events. We searched CENTRAL, MEDLINE, EMBASE, CINAHL Plus, ClinicalTrials.gov and the WHO ICTRP clinical trials registries up to March 2015, unrestricted by language. Two review authors independently selected trials for inclusion, extracted data, performed risk of bias assessment and assessed the quality of the body of evidence for the main outcomes using the GRADE approach. Results We included 60 trials (3620 participants). Only one trial compared Manual Therapy plus exercise with placebo (inactive ultrasound Therapy) (120 participants; high quality evidence). At 22 weeks, there were no between-group differences in mean change in overall pain (placebo: 17.3 points on a 100-point scale; Manual Therapy plus exercise: 24.1 points; adjusted mean difference (MD) 6.8 points, 95% CI -0.7 to 14.3 points) and similar findings for function, pain on motion, treatment success and quality of life. More participants reported adverse events with Manual Therapy plus exercise (17/55, 31%) versus placebo (5/61, 8%): RR 3.77 (95% CI 1.49 to 9.54)) but these were mild and short-lived (short-term pain following treatment). Five trials (low quality evidence) found no important differences between Manual Therapy plus exercise compared with glucocorticoid injection and one trial (low quality evidence) showed no important differences between Manual Therapy plus exercise and arthroscopic subacromial decompression. Conclusions Despite identifying 60 eligible trials, only one trial has compared a combination of Manual Therapy and exercise reflective of common current practice to placebo. It was judged of high quality and found no clinically important differences between groups in any outcome. Effects of Manual Therapy plus exercise may be similar to those of other active interventions (e.g. glucocorticoid injecton, surgery), but this is based on low quality evidence. Disclosure of Interest None declared
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Manual Therapy and exercise for rotator cuff disease
Cochrane Database of Systematic Reviews, 2016Co-Authors: Matthew J Page, Sally Green, Brodwen Mcbain, Stephen J Surace, Jessica Deitch, Nicolette Lyttle, Marshall A Mrocki, Rachelle BuchbinderAbstract:Background Management of rotator cuff disease often includes 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 people with rotator cuff disease. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 3), Ovid MEDLINE (January 1966 to March 2015), Ovid EMBASE (January 1980 to March 2015), CINAHL Plus (EBSCO, January 1937 to March 2015), ClinicalTrials.gov and the WHO ICTRP clinical trials registries up to March 2015, unrestricted by language, and reviewed the reference lists of review articles and retrieved trials, to identify potentially relevant trials. Selection criteria We included randomised and quasi-randomised trials, including adults with rotator cuff disease, and comparing any Manual Therapy or exercise intervention with placebo, no intervention, a different type of Manual Therapy or exercise or any other intervention (e.g. glucocorticoid injection). Interventions included mobilisation, manipulation and supervised or home exercises. Trials investigating the primary or add-on effect of Manual Therapy and exercise were the main comparisons of interest. Main outcomes of interest were overall pain, function, pain on motion, patient-reported global assessment of treatment success, 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 60 trials (3620 participants), although only 10 addressed the main comparisons of interest. Overall risk of bias was low in three, unclear in 14 and high in 43 trials. We were unable to perform any meta-analyses because of clinical heterogeneity or incomplete outcome reporting. One trial compared Manual Therapy and exercise with placebo (inactive ultrasound Therapy) in 120 participants with chronic rotator cuff disease (high quality evidence). At 22 weeks, the mean change in overall pain with placebo was 17.3 points on a 100-point scale, and 24.8 points with Manual Therapy and exercise (adjusted mean difference (MD) 6.8 points, 95% confidence interval (CI) -0.70 to 14.30 points; absolute risk difference 7%, 1% fewer to 14% more). Mean change in function with placebo was 15.6 points on a 100-point scale, and 22.4 points with Manual Therapy and exercise (adjusted MD 7.1 points, 95% CI 0.30 to 13.90 points; absolute risk difference 7%, 1% to 14% more). Fifty-seven per cent (31/54) of participants reported treatment success with Manual Therapy and exercise compared with 41% (24/58) of participants receiving placebo (risk ratio (RR) 1.39, 95% CI 0.94 to 2.03; absolute risk difference 16% (2% fewer to 34% more). Thirty-one per cent (17/55) of participants reported adverse events with Manual Therapy and exercise compared with 8% (5/61) of participants receiving placebo (RR 3.77, 95% CI 1.49 to 9.54; absolute risk difference 23% (9% to 37% more). However adverse events were mild (short-term pain following treatment). Five trials (low quality evidence) found no important differences between Manual Therapy and exercise compared with glucocorticoid injection with respect to overall pain, function, active shoulder abduction and quality of life from four weeks up to 12 months. However, global treatment success was more common up to 11 weeks in people receiving glucocorticoid injection (low quality evidence). One trial (low quality evidence) showed no important differences between Manual Therapy and exercise and arthroscopic subacromial decompression with respect to overall pain, function, active range of motion and strength at six and 12 months, or global treatment success at four to eight years. One trial (low quality evidence) found that Manual Therapy and exercise may not be as effective as acupuncture plus dietary counselling and Phlogenzym supplement with respect to overall pain, function, active shoulder abduction and quality life at 12 weeks. We are uncertain whether Manual Therapy and exercise improves function more than oral non-steroidal anti-inflammatory drugs (NSAID), or whether combining Manual Therapy and exercise with glucocorticoid injection provides additional benefit in function over glucocorticoid injection alone, because of the very low quality evidence in these two trials. Fifty-two trials investigated effects of Manual Therapy alone or exercise alone, and the evidence was mostly very low quality. There was little or no difference in patient-important outcomes between Manual Therapy alone and placebo, no treatment, therapeutic ultrasound and kinesiotaping, although Manual Therapy alone was less effective than glucocorticoid injection. Exercise alone led to less improvement in overall pain, but not function, when compared with surgical repair for rotator cuff tear. There was little or no difference in patient-important outcomes between exercise alone and placebo, radial extracorporeal shockwave treatment, glucocorticoid injection, arthroscopic subacromial decompression and functional brace. Further, Manual Therapy or exercise provided few or no additional benefits when combined with other physical Therapy interventions, and one type of Manual Therapy or exercise was rarely more effective than another. Authors' conclusions Despite identifying 60 eligible trials, only one trial compared a combination of Manual Therapy and exercise reflective of common current practice to placebo. We judged it to be of high quality and found no clinically important differences between groups in any outcome. Effects of Manual Therapy and exercise may be similar to those of glucocorticoid injection and arthroscopic subacromial decompression, but this is based on low quality evidence. Adverse events associated with Manual Therapy and exercise are relatively more frequent than placebo but mild in nature. Novel combinations of Manual Therapy and exercise should be compared with a realistic placebo in future trials. Further trials of Manual Therapy alone or exercise alone for rotator cuff disease should be based upon a strong rationale and consideration of whether or not they would alter the conclusions of this review.
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The Cochrane Library - Manual Therapy and exercise for rotator cuff disease.
Cochrane Database of Systematic Reviews, 2016Co-Authors: Matthew J Page, Sally Green, Brodwen Mcbain, Stephen J Surace, Jessica Deitch, Nicolette Lyttle, Marshall A Mrocki, Rachelle BuchbinderAbstract:Background Management of rotator cuff disease often includes 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 people with rotator cuff disease. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 3), Ovid MEDLINE (January 1966 to March 2015), Ovid EMBASE (January 1980 to March 2015), CINAHL Plus (EBSCO, January 1937 to March 2015), ClinicalTrials.gov and the WHO ICTRP clinical trials registries up to March 2015, unrestricted by language, and reviewed the reference lists of review articles and retrieved trials, to identify potentially relevant trials. Selection criteria We included randomised and quasi-randomised trials, including adults with rotator cuff disease, and comparing any Manual Therapy or exercise intervention with placebo, no intervention, a different type of Manual Therapy or exercise or any other intervention (e.g. glucocorticoid injection). Interventions included mobilisation, manipulation and supervised or home exercises. Trials investigating the primary or add-on effect of Manual Therapy and exercise were the main comparisons of interest. Main outcomes of interest were overall pain, function, pain on motion, patient-reported global assessment of treatment success, 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 60 trials (3620 participants), although only 10 addressed the main comparisons of interest. Overall risk of bias was low in three, unclear in 14 and high in 43 trials. We were unable to perform any meta-analyses because of clinical heterogeneity or incomplete outcome reporting. One trial compared Manual Therapy and exercise with placebo (inactive ultrasound Therapy) in 120 participants with chronic rotator cuff disease (high quality evidence). At 22 weeks, the mean change in overall pain with placebo was 17.3 points on a 100-point scale, and 24.8 points with Manual Therapy and exercise (adjusted mean difference (MD) 6.8 points, 95% confidence interval (CI) -0.70 to 14.30 points; absolute risk difference 7%, 1% fewer to 14% more). Mean change in function with placebo was 15.6 points on a 100-point scale, and 22.4 points with Manual Therapy and exercise (adjusted MD 7.1 points, 95% CI 0.30 to 13.90 points; absolute risk difference 7%, 1% to 14% more). Fifty-seven per cent (31/54) of participants reported treatment success with Manual Therapy and exercise compared with 41% (24/58) of participants receiving placebo (risk ratio (RR) 1.39, 95% CI 0.94 to 2.03; absolute risk difference 16% (2% fewer to 34% more). Thirty-one per cent (17/55) of participants reported adverse events with Manual Therapy and exercise compared with 8% (5/61) of participants receiving placebo (RR 3.77, 95% CI 1.49 to 9.54; absolute risk difference 23% (9% to 37% more). However adverse events were mild (short-term pain following treatment). Five trials (low quality evidence) found no important differences between Manual Therapy and exercise compared with glucocorticoid injection with respect to overall pain, function, active shoulder abduction and quality of life from four weeks up to 12 months. However, global treatment success was more common up to 11 weeks in people receiving glucocorticoid injection (low quality evidence). One trial (low quality evidence) showed no important differences between Manual Therapy and exercise and arthroscopic subacromial decompression with respect to overall pain, function, active range of motion and strength at six and 12 months, or global treatment success at four to eight years. One trial (low quality evidence) found that Manual Therapy and exercise may not be as effective as acupuncture plus dietary counselling and Phlogenzym supplement with respect to overall pain, function, active shoulder abduction and quality life at 12 weeks. We are uncertain whether Manual Therapy and exercise improves function more than oral non-steroidal anti-inflammatory drugs (NSAID), or whether combining Manual Therapy and exercise with glucocorticoid injection provides additional benefit in function over glucocorticoid injection alone, because of the very low quality evidence in these two trials. Fifty-two trials investigated effects of Manual Therapy alone or exercise alone, and the evidence was mostly very low quality. There was little or no difference in patient-important outcomes between Manual Therapy alone and placebo, no treatment, therapeutic ultrasound and kinesiotaping, although Manual Therapy alone was less effective than glucocorticoid injection. Exercise alone led to less improvement in overall pain, but not function, when compared with surgical repair for rotator cuff tear. There was little or no difference in patient-important outcomes between exercise alone and placebo, radial extracorporeal shockwave treatment, glucocorticoid injection, arthroscopic subacromial decompression and functional brace. Further, Manual Therapy or exercise provided few or no additional benefits when combined with other physical Therapy interventions, and one type of Manual Therapy or exercise was rarely more effective than another. Authors' conclusions Despite identifying 60 eligible trials, only one trial compared a combination of Manual Therapy and exercise reflective of common current practice to placebo. We judged it to be of high quality and found no clinically important differences between groups in any outcome. Effects of Manual Therapy and exercise may be similar to those of glucocorticoid injection and arthroscopic subacromial decompression, but this is based on low quality evidence. Adverse events associated with Manual Therapy and exercise are relatively more frequent than placebo but mild in nature. Novel combinations of Manual Therapy and exercise should be compared with a realistic placebo in future trials. Further trials of Manual Therapy alone or exercise alone for rotator cuff disease should be based upon a strong rationale and consideration of whether or not they would alter the conclusions of this review.
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Manual Therapy and exercise for adhesive capsulitis frozen shoulder
Cochrane Database of Systematic Reviews, 2014Co-Authors: Matthew J Page, Sally Green, Brodwen Mcbain, Sharon Kramer, Renea V Johnston, Marisa Chau, Rachelle BuchbinderAbstract: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).
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The Cochrane Library - Manual Therapy and exercise for adhesive capsulitis (frozen shoulder)
Cochrane Database of Systematic Reviews, 2014Co-Authors: Matthew J Page, Sally Green, Brodwen Mcbain, Sharon Kramer, Renea V Johnston, Marisa Chau, Rachelle BuchbinderAbstract: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).
Matthew J Page - One of the best experts on this subject based on the ideXlab platform.
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SAT0508 Manual Therapy and Exercise for Rotator Cuff Disease: A Cochrane Review
Annals of the Rheumatic Diseases, 2016Co-Authors: Matthew J Page, Sally Green, Brodwen Mcbain, Stephen J Surace, Jessica Deitch, Nicolette Lyttle, Marshall A Mrocki, Rachelle BuchbinderAbstract:Background Initial management of rotator cuff disease often includes Manual Therapy and exercise, usually delivered together as components of a physical Therapy intervention. To best inform current practice, an up-to-date review which incorporates the most recently available evidence is needed. Objectives To systematically identify and synthesise the available evidence regarding the benefits and harms of Manual Therapy and exercise, alone or in combination, for the treatment of rotator cuff disease. Methods We included randomised controlled trials, including adults with rotator cuff disease, and comparing any Manual Therapy or exercise intervention with placebo, no intervention, a different type of Manual Therapy or exercise or any other intervention. Interventions included mobilisation, manipulation and supervised or home exercises, delivered alone or in combination. Trials investigating the primary or add-on effect of Manual Therapy plus exercise were the main comparisons of interest. Main outcomes of interest were overall pain, function, pain on motion, patient-reported global assessment of treatment success, quality of life and the number of participants experiencing adverse events. We searched CENTRAL, MEDLINE, EMBASE, CINAHL Plus, ClinicalTrials.gov and the WHO ICTRP clinical trials registries up to March 2015, unrestricted by language. Two review authors independently selected trials for inclusion, extracted data, performed risk of bias assessment and assessed the quality of the body of evidence for the main outcomes using the GRADE approach. Results We included 60 trials (3620 participants). Only one trial compared Manual Therapy plus exercise with placebo (inactive ultrasound Therapy) (120 participants; high quality evidence). At 22 weeks, there were no between-group differences in mean change in overall pain (placebo: 17.3 points on a 100-point scale; Manual Therapy plus exercise: 24.1 points; adjusted mean difference (MD) 6.8 points, 95% CI -0.7 to 14.3 points) and similar findings for function, pain on motion, treatment success and quality of life. More participants reported adverse events with Manual Therapy plus exercise (17/55, 31%) versus placebo (5/61, 8%): RR 3.77 (95% CI 1.49 to 9.54)) but these were mild and short-lived (short-term pain following treatment). Five trials (low quality evidence) found no important differences between Manual Therapy plus exercise compared with glucocorticoid injection and one trial (low quality evidence) showed no important differences between Manual Therapy plus exercise and arthroscopic subacromial decompression. Conclusions Despite identifying 60 eligible trials, only one trial has compared a combination of Manual Therapy and exercise reflective of common current practice to placebo. It was judged of high quality and found no clinically important differences between groups in any outcome. Effects of Manual Therapy plus exercise may be similar to those of other active interventions (e.g. glucocorticoid injecton, surgery), but this is based on low quality evidence. Disclosure of Interest None declared
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Manual Therapy and exercise for rotator cuff disease
Cochrane Database of Systematic Reviews, 2016Co-Authors: Matthew J Page, Sally Green, Brodwen Mcbain, Stephen J Surace, Jessica Deitch, Nicolette Lyttle, Marshall A Mrocki, Rachelle BuchbinderAbstract:Background Management of rotator cuff disease often includes 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 people with rotator cuff disease. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 3), Ovid MEDLINE (January 1966 to March 2015), Ovid EMBASE (January 1980 to March 2015), CINAHL Plus (EBSCO, January 1937 to March 2015), ClinicalTrials.gov and the WHO ICTRP clinical trials registries up to March 2015, unrestricted by language, and reviewed the reference lists of review articles and retrieved trials, to identify potentially relevant trials. Selection criteria We included randomised and quasi-randomised trials, including adults with rotator cuff disease, and comparing any Manual Therapy or exercise intervention with placebo, no intervention, a different type of Manual Therapy or exercise or any other intervention (e.g. glucocorticoid injection). Interventions included mobilisation, manipulation and supervised or home exercises. Trials investigating the primary or add-on effect of Manual Therapy and exercise were the main comparisons of interest. Main outcomes of interest were overall pain, function, pain on motion, patient-reported global assessment of treatment success, 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 60 trials (3620 participants), although only 10 addressed the main comparisons of interest. Overall risk of bias was low in three, unclear in 14 and high in 43 trials. We were unable to perform any meta-analyses because of clinical heterogeneity or incomplete outcome reporting. One trial compared Manual Therapy and exercise with placebo (inactive ultrasound Therapy) in 120 participants with chronic rotator cuff disease (high quality evidence). At 22 weeks, the mean change in overall pain with placebo was 17.3 points on a 100-point scale, and 24.8 points with Manual Therapy and exercise (adjusted mean difference (MD) 6.8 points, 95% confidence interval (CI) -0.70 to 14.30 points; absolute risk difference 7%, 1% fewer to 14% more). Mean change in function with placebo was 15.6 points on a 100-point scale, and 22.4 points with Manual Therapy and exercise (adjusted MD 7.1 points, 95% CI 0.30 to 13.90 points; absolute risk difference 7%, 1% to 14% more). Fifty-seven per cent (31/54) of participants reported treatment success with Manual Therapy and exercise compared with 41% (24/58) of participants receiving placebo (risk ratio (RR) 1.39, 95% CI 0.94 to 2.03; absolute risk difference 16% (2% fewer to 34% more). Thirty-one per cent (17/55) of participants reported adverse events with Manual Therapy and exercise compared with 8% (5/61) of participants receiving placebo (RR 3.77, 95% CI 1.49 to 9.54; absolute risk difference 23% (9% to 37% more). However adverse events were mild (short-term pain following treatment). Five trials (low quality evidence) found no important differences between Manual Therapy and exercise compared with glucocorticoid injection with respect to overall pain, function, active shoulder abduction and quality of life from four weeks up to 12 months. However, global treatment success was more common up to 11 weeks in people receiving glucocorticoid injection (low quality evidence). One trial (low quality evidence) showed no important differences between Manual Therapy and exercise and arthroscopic subacromial decompression with respect to overall pain, function, active range of motion and strength at six and 12 months, or global treatment success at four to eight years. One trial (low quality evidence) found that Manual Therapy and exercise may not be as effective as acupuncture plus dietary counselling and Phlogenzym supplement with respect to overall pain, function, active shoulder abduction and quality life at 12 weeks. We are uncertain whether Manual Therapy and exercise improves function more than oral non-steroidal anti-inflammatory drugs (NSAID), or whether combining Manual Therapy and exercise with glucocorticoid injection provides additional benefit in function over glucocorticoid injection alone, because of the very low quality evidence in these two trials. Fifty-two trials investigated effects of Manual Therapy alone or exercise alone, and the evidence was mostly very low quality. There was little or no difference in patient-important outcomes between Manual Therapy alone and placebo, no treatment, therapeutic ultrasound and kinesiotaping, although Manual Therapy alone was less effective than glucocorticoid injection. Exercise alone led to less improvement in overall pain, but not function, when compared with surgical repair for rotator cuff tear. There was little or no difference in patient-important outcomes between exercise alone and placebo, radial extracorporeal shockwave treatment, glucocorticoid injection, arthroscopic subacromial decompression and functional brace. Further, Manual Therapy or exercise provided few or no additional benefits when combined with other physical Therapy interventions, and one type of Manual Therapy or exercise was rarely more effective than another. Authors' conclusions Despite identifying 60 eligible trials, only one trial compared a combination of Manual Therapy and exercise reflective of common current practice to placebo. We judged it to be of high quality and found no clinically important differences between groups in any outcome. Effects of Manual Therapy and exercise may be similar to those of glucocorticoid injection and arthroscopic subacromial decompression, but this is based on low quality evidence. Adverse events associated with Manual Therapy and exercise are relatively more frequent than placebo but mild in nature. Novel combinations of Manual Therapy and exercise should be compared with a realistic placebo in future trials. Further trials of Manual Therapy alone or exercise alone for rotator cuff disease should be based upon a strong rationale and consideration of whether or not they would alter the conclusions of this review.
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The Cochrane Library - Manual Therapy and exercise for rotator cuff disease.
Cochrane Database of Systematic Reviews, 2016Co-Authors: Matthew J Page, Sally Green, Brodwen Mcbain, Stephen J Surace, Jessica Deitch, Nicolette Lyttle, Marshall A Mrocki, Rachelle BuchbinderAbstract:Background Management of rotator cuff disease often includes 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 people with rotator cuff disease. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 3), Ovid MEDLINE (January 1966 to March 2015), Ovid EMBASE (January 1980 to March 2015), CINAHL Plus (EBSCO, January 1937 to March 2015), ClinicalTrials.gov and the WHO ICTRP clinical trials registries up to March 2015, unrestricted by language, and reviewed the reference lists of review articles and retrieved trials, to identify potentially relevant trials. Selection criteria We included randomised and quasi-randomised trials, including adults with rotator cuff disease, and comparing any Manual Therapy or exercise intervention with placebo, no intervention, a different type of Manual Therapy or exercise or any other intervention (e.g. glucocorticoid injection). Interventions included mobilisation, manipulation and supervised or home exercises. Trials investigating the primary or add-on effect of Manual Therapy and exercise were the main comparisons of interest. Main outcomes of interest were overall pain, function, pain on motion, patient-reported global assessment of treatment success, 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 60 trials (3620 participants), although only 10 addressed the main comparisons of interest. Overall risk of bias was low in three, unclear in 14 and high in 43 trials. We were unable to perform any meta-analyses because of clinical heterogeneity or incomplete outcome reporting. One trial compared Manual Therapy and exercise with placebo (inactive ultrasound Therapy) in 120 participants with chronic rotator cuff disease (high quality evidence). At 22 weeks, the mean change in overall pain with placebo was 17.3 points on a 100-point scale, and 24.8 points with Manual Therapy and exercise (adjusted mean difference (MD) 6.8 points, 95% confidence interval (CI) -0.70 to 14.30 points; absolute risk difference 7%, 1% fewer to 14% more). Mean change in function with placebo was 15.6 points on a 100-point scale, and 22.4 points with Manual Therapy and exercise (adjusted MD 7.1 points, 95% CI 0.30 to 13.90 points; absolute risk difference 7%, 1% to 14% more). Fifty-seven per cent (31/54) of participants reported treatment success with Manual Therapy and exercise compared with 41% (24/58) of participants receiving placebo (risk ratio (RR) 1.39, 95% CI 0.94 to 2.03; absolute risk difference 16% (2% fewer to 34% more). Thirty-one per cent (17/55) of participants reported adverse events with Manual Therapy and exercise compared with 8% (5/61) of participants receiving placebo (RR 3.77, 95% CI 1.49 to 9.54; absolute risk difference 23% (9% to 37% more). However adverse events were mild (short-term pain following treatment). Five trials (low quality evidence) found no important differences between Manual Therapy and exercise compared with glucocorticoid injection with respect to overall pain, function, active shoulder abduction and quality of life from four weeks up to 12 months. However, global treatment success was more common up to 11 weeks in people receiving glucocorticoid injection (low quality evidence). One trial (low quality evidence) showed no important differences between Manual Therapy and exercise and arthroscopic subacromial decompression with respect to overall pain, function, active range of motion and strength at six and 12 months, or global treatment success at four to eight years. One trial (low quality evidence) found that Manual Therapy and exercise may not be as effective as acupuncture plus dietary counselling and Phlogenzym supplement with respect to overall pain, function, active shoulder abduction and quality life at 12 weeks. We are uncertain whether Manual Therapy and exercise improves function more than oral non-steroidal anti-inflammatory drugs (NSAID), or whether combining Manual Therapy and exercise with glucocorticoid injection provides additional benefit in function over glucocorticoid injection alone, because of the very low quality evidence in these two trials. Fifty-two trials investigated effects of Manual Therapy alone or exercise alone, and the evidence was mostly very low quality. There was little or no difference in patient-important outcomes between Manual Therapy alone and placebo, no treatment, therapeutic ultrasound and kinesiotaping, although Manual Therapy alone was less effective than glucocorticoid injection. Exercise alone led to less improvement in overall pain, but not function, when compared with surgical repair for rotator cuff tear. There was little or no difference in patient-important outcomes between exercise alone and placebo, radial extracorporeal shockwave treatment, glucocorticoid injection, arthroscopic subacromial decompression and functional brace. Further, Manual Therapy or exercise provided few or no additional benefits when combined with other physical Therapy interventions, and one type of Manual Therapy or exercise was rarely more effective than another. Authors' conclusions Despite identifying 60 eligible trials, only one trial compared a combination of Manual Therapy and exercise reflective of common current practice to placebo. We judged it to be of high quality and found no clinically important differences between groups in any outcome. Effects of Manual Therapy and exercise may be similar to those of glucocorticoid injection and arthroscopic subacromial decompression, but this is based on low quality evidence. Adverse events associated with Manual Therapy and exercise are relatively more frequent than placebo but mild in nature. Novel combinations of Manual Therapy and exercise should be compared with a realistic placebo in future trials. Further trials of Manual Therapy alone or exercise alone for rotator cuff disease should be based upon a strong rationale and consideration of whether or not they would alter the conclusions of this review.
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Manual Therapy and exercise for adhesive capsulitis frozen shoulder
Cochrane Database of Systematic Reviews, 2014Co-Authors: Matthew J Page, Sally Green, Brodwen Mcbain, Sharon Kramer, Renea V Johnston, Marisa Chau, Rachelle BuchbinderAbstract: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).
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The Cochrane Library - Manual Therapy and exercise for adhesive capsulitis (frozen shoulder)
Cochrane Database of Systematic Reviews, 2014Co-Authors: Matthew J Page, Sally Green, Brodwen Mcbain, Sharon Kramer, Renea V Johnston, Marisa Chau, Rachelle BuchbinderAbstract: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).
Francisco Alburquerquesendin - One of the best experts on this subject based on the ideXlab platform.
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effectiveness of Manual Therapy versus surgery in pain processing due to carpal tunnel syndrome a randomized clinical trial
European Journal of Pain, 2017Co-Authors: Cesar Fernandezdelaspenas, Joshua A Cleland, Maria Palacioscena, Stella Fuensalidanovo, Cristina Alonsoblanco, J A Pareja, Francisco AlburquerquesendinAbstract:Background People with carpal tunnel syndrome (CTS) exhibit widespread pressure pain and thermal pain hypersensitivity as a manifestation of central sensitization. The aim of our study was to compare the effectiveness of Manual Therapy versus surgery for improving pain and nociceptive gain processing in people with CTS. Methods The trial was conducted at a local regional Hospital in Madrid, Spain from August 2014 to February 2015. In this randomized parallel-group, blinded, clinical trial, 100 women with CTS were randomly allocated to either Manual Therapy (n = 50), who received three sessions (once/week) of Manual therapies including desensitization manoeuvres of the central nervous system, or surgical intervention (n = 50) group. Outcomes including pressure pain thresholds (PPT), thermal pain thresholds (HPT or CPT), and pain intensity which were assessed at baseline, and 3, 6, 9 and 12 months after the intervention by an assessor unaware of group assignment. Analysis was by intention to treat with mixed ANCOVAs adjusted for baseline scores. Results At 12 months, 95 women completed the follow-up. Patients receiving Manual Therapy exhibited higher increases in PPT over the carpal tunnel at 3, 6 and 9 months (all, p < 0.01) and higher decrease of pain intensity at 3 month follow-up (p < 0.001) than those receiving surgery. No significant differences were observed between groups for the remaining outcomes. Conclusions Manual Therapy and surgery have similar effects on decreasing widespread pressure pain sensitivity and pain intensity in women with CTS. Neither Manual Therapy nor surgery resulted in changes in thermal pain sensitivity. Significance The current study found that Manual Therapy and surgery exhibited similar effects on decreasing widespread pressure pain sensitivity and pain intensity in women with carpal tunnel syndrome at medium- and long-term follow-ups investigating changes in nociceptive gain processing after treatment in carpal tunnel syndrome.
Brodwen Mcbain - One of the best experts on this subject based on the ideXlab platform.
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SAT0508 Manual Therapy and Exercise for Rotator Cuff Disease: A Cochrane Review
Annals of the Rheumatic Diseases, 2016Co-Authors: Matthew J Page, Sally Green, Brodwen Mcbain, Stephen J Surace, Jessica Deitch, Nicolette Lyttle, Marshall A Mrocki, Rachelle BuchbinderAbstract:Background Initial management of rotator cuff disease often includes Manual Therapy and exercise, usually delivered together as components of a physical Therapy intervention. To best inform current practice, an up-to-date review which incorporates the most recently available evidence is needed. Objectives To systematically identify and synthesise the available evidence regarding the benefits and harms of Manual Therapy and exercise, alone or in combination, for the treatment of rotator cuff disease. Methods We included randomised controlled trials, including adults with rotator cuff disease, and comparing any Manual Therapy or exercise intervention with placebo, no intervention, a different type of Manual Therapy or exercise or any other intervention. Interventions included mobilisation, manipulation and supervised or home exercises, delivered alone or in combination. Trials investigating the primary or add-on effect of Manual Therapy plus exercise were the main comparisons of interest. Main outcomes of interest were overall pain, function, pain on motion, patient-reported global assessment of treatment success, quality of life and the number of participants experiencing adverse events. We searched CENTRAL, MEDLINE, EMBASE, CINAHL Plus, ClinicalTrials.gov and the WHO ICTRP clinical trials registries up to March 2015, unrestricted by language. Two review authors independently selected trials for inclusion, extracted data, performed risk of bias assessment and assessed the quality of the body of evidence for the main outcomes using the GRADE approach. Results We included 60 trials (3620 participants). Only one trial compared Manual Therapy plus exercise with placebo (inactive ultrasound Therapy) (120 participants; high quality evidence). At 22 weeks, there were no between-group differences in mean change in overall pain (placebo: 17.3 points on a 100-point scale; Manual Therapy plus exercise: 24.1 points; adjusted mean difference (MD) 6.8 points, 95% CI -0.7 to 14.3 points) and similar findings for function, pain on motion, treatment success and quality of life. More participants reported adverse events with Manual Therapy plus exercise (17/55, 31%) versus placebo (5/61, 8%): RR 3.77 (95% CI 1.49 to 9.54)) but these were mild and short-lived (short-term pain following treatment). Five trials (low quality evidence) found no important differences between Manual Therapy plus exercise compared with glucocorticoid injection and one trial (low quality evidence) showed no important differences between Manual Therapy plus exercise and arthroscopic subacromial decompression. Conclusions Despite identifying 60 eligible trials, only one trial has compared a combination of Manual Therapy and exercise reflective of common current practice to placebo. It was judged of high quality and found no clinically important differences between groups in any outcome. Effects of Manual Therapy plus exercise may be similar to those of other active interventions (e.g. glucocorticoid injecton, surgery), but this is based on low quality evidence. Disclosure of Interest None declared
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Manual Therapy and exercise for rotator cuff disease
Cochrane Database of Systematic Reviews, 2016Co-Authors: Matthew J Page, Sally Green, Brodwen Mcbain, Stephen J Surace, Jessica Deitch, Nicolette Lyttle, Marshall A Mrocki, Rachelle BuchbinderAbstract:Background Management of rotator cuff disease often includes 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 people with rotator cuff disease. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 3), Ovid MEDLINE (January 1966 to March 2015), Ovid EMBASE (January 1980 to March 2015), CINAHL Plus (EBSCO, January 1937 to March 2015), ClinicalTrials.gov and the WHO ICTRP clinical trials registries up to March 2015, unrestricted by language, and reviewed the reference lists of review articles and retrieved trials, to identify potentially relevant trials. Selection criteria We included randomised and quasi-randomised trials, including adults with rotator cuff disease, and comparing any Manual Therapy or exercise intervention with placebo, no intervention, a different type of Manual Therapy or exercise or any other intervention (e.g. glucocorticoid injection). Interventions included mobilisation, manipulation and supervised or home exercises. Trials investigating the primary or add-on effect of Manual Therapy and exercise were the main comparisons of interest. Main outcomes of interest were overall pain, function, pain on motion, patient-reported global assessment of treatment success, 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 60 trials (3620 participants), although only 10 addressed the main comparisons of interest. Overall risk of bias was low in three, unclear in 14 and high in 43 trials. We were unable to perform any meta-analyses because of clinical heterogeneity or incomplete outcome reporting. One trial compared Manual Therapy and exercise with placebo (inactive ultrasound Therapy) in 120 participants with chronic rotator cuff disease (high quality evidence). At 22 weeks, the mean change in overall pain with placebo was 17.3 points on a 100-point scale, and 24.8 points with Manual Therapy and exercise (adjusted mean difference (MD) 6.8 points, 95% confidence interval (CI) -0.70 to 14.30 points; absolute risk difference 7%, 1% fewer to 14% more). Mean change in function with placebo was 15.6 points on a 100-point scale, and 22.4 points with Manual Therapy and exercise (adjusted MD 7.1 points, 95% CI 0.30 to 13.90 points; absolute risk difference 7%, 1% to 14% more). Fifty-seven per cent (31/54) of participants reported treatment success with Manual Therapy and exercise compared with 41% (24/58) of participants receiving placebo (risk ratio (RR) 1.39, 95% CI 0.94 to 2.03; absolute risk difference 16% (2% fewer to 34% more). Thirty-one per cent (17/55) of participants reported adverse events with Manual Therapy and exercise compared with 8% (5/61) of participants receiving placebo (RR 3.77, 95% CI 1.49 to 9.54; absolute risk difference 23% (9% to 37% more). However adverse events were mild (short-term pain following treatment). Five trials (low quality evidence) found no important differences between Manual Therapy and exercise compared with glucocorticoid injection with respect to overall pain, function, active shoulder abduction and quality of life from four weeks up to 12 months. However, global treatment success was more common up to 11 weeks in people receiving glucocorticoid injection (low quality evidence). One trial (low quality evidence) showed no important differences between Manual Therapy and exercise and arthroscopic subacromial decompression with respect to overall pain, function, active range of motion and strength at six and 12 months, or global treatment success at four to eight years. One trial (low quality evidence) found that Manual Therapy and exercise may not be as effective as acupuncture plus dietary counselling and Phlogenzym supplement with respect to overall pain, function, active shoulder abduction and quality life at 12 weeks. We are uncertain whether Manual Therapy and exercise improves function more than oral non-steroidal anti-inflammatory drugs (NSAID), or whether combining Manual Therapy and exercise with glucocorticoid injection provides additional benefit in function over glucocorticoid injection alone, because of the very low quality evidence in these two trials. Fifty-two trials investigated effects of Manual Therapy alone or exercise alone, and the evidence was mostly very low quality. There was little or no difference in patient-important outcomes between Manual Therapy alone and placebo, no treatment, therapeutic ultrasound and kinesiotaping, although Manual Therapy alone was less effective than glucocorticoid injection. Exercise alone led to less improvement in overall pain, but not function, when compared with surgical repair for rotator cuff tear. There was little or no difference in patient-important outcomes between exercise alone and placebo, radial extracorporeal shockwave treatment, glucocorticoid injection, arthroscopic subacromial decompression and functional brace. Further, Manual Therapy or exercise provided few or no additional benefits when combined with other physical Therapy interventions, and one type of Manual Therapy or exercise was rarely more effective than another. Authors' conclusions Despite identifying 60 eligible trials, only one trial compared a combination of Manual Therapy and exercise reflective of common current practice to placebo. We judged it to be of high quality and found no clinically important differences between groups in any outcome. Effects of Manual Therapy and exercise may be similar to those of glucocorticoid injection and arthroscopic subacromial decompression, but this is based on low quality evidence. Adverse events associated with Manual Therapy and exercise are relatively more frequent than placebo but mild in nature. Novel combinations of Manual Therapy and exercise should be compared with a realistic placebo in future trials. Further trials of Manual Therapy alone or exercise alone for rotator cuff disease should be based upon a strong rationale and consideration of whether or not they would alter the conclusions of this review.
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The Cochrane Library - Manual Therapy and exercise for rotator cuff disease.
Cochrane Database of Systematic Reviews, 2016Co-Authors: Matthew J Page, Sally Green, Brodwen Mcbain, Stephen J Surace, Jessica Deitch, Nicolette Lyttle, Marshall A Mrocki, Rachelle BuchbinderAbstract:Background Management of rotator cuff disease often includes 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 people with rotator cuff disease. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 3), Ovid MEDLINE (January 1966 to March 2015), Ovid EMBASE (January 1980 to March 2015), CINAHL Plus (EBSCO, January 1937 to March 2015), ClinicalTrials.gov and the WHO ICTRP clinical trials registries up to March 2015, unrestricted by language, and reviewed the reference lists of review articles and retrieved trials, to identify potentially relevant trials. Selection criteria We included randomised and quasi-randomised trials, including adults with rotator cuff disease, and comparing any Manual Therapy or exercise intervention with placebo, no intervention, a different type of Manual Therapy or exercise or any other intervention (e.g. glucocorticoid injection). Interventions included mobilisation, manipulation and supervised or home exercises. Trials investigating the primary or add-on effect of Manual Therapy and exercise were the main comparisons of interest. Main outcomes of interest were overall pain, function, pain on motion, patient-reported global assessment of treatment success, 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 60 trials (3620 participants), although only 10 addressed the main comparisons of interest. Overall risk of bias was low in three, unclear in 14 and high in 43 trials. We were unable to perform any meta-analyses because of clinical heterogeneity or incomplete outcome reporting. One trial compared Manual Therapy and exercise with placebo (inactive ultrasound Therapy) in 120 participants with chronic rotator cuff disease (high quality evidence). At 22 weeks, the mean change in overall pain with placebo was 17.3 points on a 100-point scale, and 24.8 points with Manual Therapy and exercise (adjusted mean difference (MD) 6.8 points, 95% confidence interval (CI) -0.70 to 14.30 points; absolute risk difference 7%, 1% fewer to 14% more). Mean change in function with placebo was 15.6 points on a 100-point scale, and 22.4 points with Manual Therapy and exercise (adjusted MD 7.1 points, 95% CI 0.30 to 13.90 points; absolute risk difference 7%, 1% to 14% more). Fifty-seven per cent (31/54) of participants reported treatment success with Manual Therapy and exercise compared with 41% (24/58) of participants receiving placebo (risk ratio (RR) 1.39, 95% CI 0.94 to 2.03; absolute risk difference 16% (2% fewer to 34% more). Thirty-one per cent (17/55) of participants reported adverse events with Manual Therapy and exercise compared with 8% (5/61) of participants receiving placebo (RR 3.77, 95% CI 1.49 to 9.54; absolute risk difference 23% (9% to 37% more). However adverse events were mild (short-term pain following treatment). Five trials (low quality evidence) found no important differences between Manual Therapy and exercise compared with glucocorticoid injection with respect to overall pain, function, active shoulder abduction and quality of life from four weeks up to 12 months. However, global treatment success was more common up to 11 weeks in people receiving glucocorticoid injection (low quality evidence). One trial (low quality evidence) showed no important differences between Manual Therapy and exercise and arthroscopic subacromial decompression with respect to overall pain, function, active range of motion and strength at six and 12 months, or global treatment success at four to eight years. One trial (low quality evidence) found that Manual Therapy and exercise may not be as effective as acupuncture plus dietary counselling and Phlogenzym supplement with respect to overall pain, function, active shoulder abduction and quality life at 12 weeks. We are uncertain whether Manual Therapy and exercise improves function more than oral non-steroidal anti-inflammatory drugs (NSAID), or whether combining Manual Therapy and exercise with glucocorticoid injection provides additional benefit in function over glucocorticoid injection alone, because of the very low quality evidence in these two trials. Fifty-two trials investigated effects of Manual Therapy alone or exercise alone, and the evidence was mostly very low quality. There was little or no difference in patient-important outcomes between Manual Therapy alone and placebo, no treatment, therapeutic ultrasound and kinesiotaping, although Manual Therapy alone was less effective than glucocorticoid injection. Exercise alone led to less improvement in overall pain, but not function, when compared with surgical repair for rotator cuff tear. There was little or no difference in patient-important outcomes between exercise alone and placebo, radial extracorporeal shockwave treatment, glucocorticoid injection, arthroscopic subacromial decompression and functional brace. Further, Manual Therapy or exercise provided few or no additional benefits when combined with other physical Therapy interventions, and one type of Manual Therapy or exercise was rarely more effective than another. Authors' conclusions Despite identifying 60 eligible trials, only one trial compared a combination of Manual Therapy and exercise reflective of common current practice to placebo. We judged it to be of high quality and found no clinically important differences between groups in any outcome. Effects of Manual Therapy and exercise may be similar to those of glucocorticoid injection and arthroscopic subacromial decompression, but this is based on low quality evidence. Adverse events associated with Manual Therapy and exercise are relatively more frequent than placebo but mild in nature. Novel combinations of Manual Therapy and exercise should be compared with a realistic placebo in future trials. Further trials of Manual Therapy alone or exercise alone for rotator cuff disease should be based upon a strong rationale and consideration of whether or not they would alter the conclusions of this review.
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Manual Therapy and exercise for adhesive capsulitis frozen shoulder
Cochrane Database of Systematic Reviews, 2014Co-Authors: Matthew J Page, Sally Green, Brodwen Mcbain, Sharon Kramer, Renea V Johnston, Marisa Chau, Rachelle BuchbinderAbstract: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).
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The Cochrane Library - Manual Therapy and exercise for adhesive capsulitis (frozen shoulder)
Cochrane Database of Systematic Reviews, 2014Co-Authors: Matthew J Page, Sally Green, Brodwen Mcbain, Sharon Kramer, Renea V Johnston, Marisa Chau, Rachelle BuchbinderAbstract: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).