Two new/additional medium[
37] to high quality[
38] RCTs relating to sciatica and back-related leg pain were identified, and a protocol of an on-going study[
39]. The medium quality RCT[
37] randomised 40 patients with sciatica to receive chiropractic spinal manipulation (high velocity, low-amplitude, short lever technique) or surgical microdiskectomy. At 12 weeks of follow-up there was significant improvement in quality of life, pain and disability in both intervention groups, with no significant difference between groups. The high quality RCT[
38] randomised 134 patients with non-specific low back pain (with or without sciatica) to orthopaedic manual therapy (mobilisation, high velocity low-force manipulation, translatoric thrust manipulation), the McKenzie method or advice only. At 12 months follow-up, all groups showed significant improvement in pain and disability, but there was no significant difference between groups.
Summary: Inconclusive (favourable) evidence for spinal manipulation/mobilisation in treating sciatica and back-related leg-pain (no change from the UK evidence report). The evidence suggests that chiropractic or orthopaedic manipulation may be effective in reducing symptoms of sciatica in adults, however, it is not clear due to the small sample size of the trials, if these manual treatment techniques are more beneficial compared to surgery, McKenzie method, or advice only.
Neck pain (cervical manipulation/mobilisation alone)
One low quality,[
40] four medium quality[
41‐
43] and two high quality RCTs[
44,
45] examined the effect of cervical spinal manipulation or mobilisation alone for neck pain of any duration[
40‐
46].
A medium quality RCT[
46] compared the effects of joint mobilisation applied to either symptomatic or asymptomatic cervical levels in 48 patients with chronic non-specific neck pain. Outcomes were only measured immediately following the treatment and while there were some within-group improvements in pain parameters, there were no significant differences between groups. In a medium quality RCT,[
42] 47 patients were randomised to receive a three-week treatment with cervical manipulation (cervical/upper thoracic segmental high velocity, low amplitude movements), mobilisation (cervical/upper thoracic segmental low velocity, low amplitude movements), or the activator instrument. At 12 months post-treatment, the proportion of patients who improved on the Patient Global Impression of Change scale was not significantly different across the three study groups, neither were any changes in disability, pain, or quality of life. However, there were significant within-group improvements from baseline in disability and pain intensity for the manipulation and activator instrument groups. Fifteen patients in the manipulation and four patients in each group of the mobilisation and activator experienced minor adverse events (e.g. mild headache, mild dizziness, mild arm weakness). Klein et al.[
45] compared a single strain-counter strain intervention with sham treatment in a high quality RCT including 61 patients with neck pain. After the treatment, there was no significant difference between groups in mobility restriction or pain. Leaver et al.[
44] conducted a high quality RCT comparing the effectiveness of cervical manipulation (high-velocity, low-amplitude thrust technique) versus mobilisation (low-velocity, oscillating passive movements) administered to 182 patients with non-specific neck pain (less than 3 months of duration) for two weeks. At three months of follow-up, the median number of days to recovery was not significantly different between the manipulation and mobilisation groups, and there was also no significant difference between the two groups in the mean post-treatment pain intensity, in disability, in function, and in global perceived effect. The most frequent adverse events were minor and included increased neck pain (22%) and headache (22%). Other less frequent events were dizziness (7%), nausea (6%), and paraesthesia (7%). The frequency of adverse events was not significantly different between the study groups. Martel et al.[
43] conducted a medium quality RCT of 98 patients with non-specific chronic neck pain, investigating the effectiveness of spinal manipulative therapy (standardised passive palpation on the cervical and thoracic spine) compared to spinal manipulative therapy plus home exercise, or no treatment for 10 months. After the treatment phase, all study groups experienced significant improvements in disability and lateral flexion. However, the between-group differences for all outcome measures were statistically non-significant. Puentedura et al.[
41] conducted a medium quality RCT comparing the effectiveness of 2-week thoracic thrust joint manipulation (TJM) plus cervical range of motion (ROM) exercises to that of cervical thoracic thrust joint manipulation plus cervical ROM exercises in 24 adults with acute neck pain. At six months of follow-up, the cervical TJM group compared to the thoracic TJM group experienced significantly improved scores for neck disability and overall success. Minor transient adverse events (increased neck pain, fatigue, headache, upper back pain) were reported by 70%-80% of the participants in the thoracic TJM group versus 7% in the cervical TJM group. In a low quality RCT, Schomacher et al.[
40] randomised 126 adult participants with chronic neck pain to receive a single 4-minute mobilisation technique (intermittent translatoric traction at the zygopophyseal joint between C2 and C7 with Kaltenborn’s grade II force) applied to symptomatic levels (concordant segment) versus asymptomatic levels (three levels below/above concordant segment) of the cervical spine. The immediate post-treatment between-group differences for the mean change in pain were not statistically significant.
Summary: Inconclusive (favourable) evidence for cervical spinal manipulation/mobilisation alone in treating neck pain (no change from the UK evidence report). Inconclusive (favourable) evidence for manipulation and mobilisation with/without soft tissue treatment (not evaluated in the UK evidence report). The evidence suggests there are similar improvements in the manipulation and/or mobilisation intervention groups compared to active treatment, however, some trials also found no improvement in comparison to a control group.
Three additional systematic reviews[
50‐
52] (2 high quality,[
50,
52] 1 medium quality[
51]) and six additional RCTs[
53‐
58] (1 high quality,[
58] 2 medium quality[
53,
56] and 3 low quality[
54,
55,
57]) and one ongoing RCT[
59] were identified on the treatment of ankle and foot conditions using manual therapy.
A high quality Cochrane review examined the effect of rehabilitation interventions for ankle fractures[
50]. With respect to manual therapy, one trial with a high risk of bias[
57] and one trial with a low risk of bias[
58] were identified. The trial by Wilson and colleagues included only 12 participants in total, who had an ankle fracture treated with or without surgery. The intervention group received physiotherapy including Kaltenborn-based manual therapy to the talocrural and talocalcaneal joints, both groups also received an exercise intervention. After five weeks of treatment, there was no statistically significant improvement in activity limitation or ankle plantarflexion range of motion, but the ankle dorsiflexion range of motion was statistically significant in favour of manual therapy. Lin et al. compared treatment with manual therapy (anterior-posterior joint mobilisation over the talus) plus a standard physiotherapy programme (experimental) with the standard physiotherapy programme only in 94 patients with ankle fracture within one week of cast removal. There was no significant difference between groups in functional, pain or quality of life parameters at 24 weeks’ follow-up. The review authors concluded that there is no evidence that manual therapy after a period of immobilisation may improve ankle range of motion in patients after ankle fracture. Another high quality systematic review[
52] examined the effects of manipulative therapy for lower extremity conditions. The authors identified one high, ten moderate and two low quality trials concerning manual therapy after ankle inversion sprain, one high and one moderate quality trial concerning plantar fasciitis, one moderate and one low quality trial concerning metatarsalgia, four moderate quality trials concerning decreased proprioception/balance/function secondary to foot and ankle injury/decreased range of motion/joint dysfunction, one moderate quality trial concerning hallux limitus and two moderate quality trials concerning hallus abducto valgus. They concluded that there was moderate evidence for manual therapy (mobilisation/manipulation) of the knee and/or full kinetic chain and of the ankle and/or foot, combined with multimodal or exercise therapy for ankle inversion sprain and limited evidence regarding long term effects. There was also moderate evidence for manual therapy (mobilisation/manipulation/stretching) of the ankle and/or foot combined with multimodal or exercise therapy for short-term treatment of plantar fasciitis. There was limited evidence for manual therapy (manipulation/mobilisation) of the ankle and/or foot combined with multimodal or exercise therapy for short-term treatment of metatarsalgia and hallux limitus/rigidus and for loss of foot and/or ankle proprioception and balance. There was insufficient evidence for manual therapy (mobilisation/manipulation) of the ankle and/or foot for hallux abducto valgus. The authors suggested that further high quality research is needed.
A low quality RCT[
54] examined the effects of a muscle energy technique versus manipulation in the treatment of 40 patients with chronic recurrent ankle sprain. After six chiropractic treatments over three weeks, there was significant improvement over time in the One Leg Standing Test (eyes open and closed), the McGill Pain Questionnaire, the Functional Evaluation Scale, and in dorsiflexion and plantarflexion; however, there was no significant difference between the two groups. Adverse events were reported but no serious adverse events were seen. Du Plessis et al.[
53] conducted a medium quality trial of chiropractic treatment in patients with hallux abducto valgus. Thirty patients were included and the intervention group was treated four times over two weeks with graded joint mobilisation of the first metatarsophalangeal joint plus joint manipulation, while the control group received a night splint. At the end of the intervention, there was no significant difference between the groups in terms of pain and foot function scores (with both groups showing improved values). However, these improvements were not maintained in the control group, while they were maintained in the intervention group (significant difference between groups in favour of the manual therapy group at the one month follow-up, p < 0.01). Hallux dorsiflexion was significantly greater in the manual therapy group both at the end of the intervention and at the end of the one month follow-up. Adverse events were reported but no serious adverse events were seen. Another medium quality RCT[
56] examined the effects of manual therapy in the treatment of plantar heel pain. The trial included 60 patients treated four times weekly for four weeks. Both groups received a self-stretching intervention (directed at the calf muscles and plantar fascia) and the intervention group also received myofascial trigger point manual therapy. After the intervention, results for pressure pain thresholds were significantly better for the manual therapy than for the stretching only group (p < 0.03) and results for the physical function and bodily pain subscales on the SF-36 quality of life questionnaire were also improved in favour of manual therapy. No significant differences were seen in any other subscales of the SF-36. Similarly, a low quality RCT[
55] examined the effects of myofascial therapy in 30 patients with plantar fasciitis and found significant pain and foot function values in the intervention group compared to the control.
Summary: Inconclusive (favourable) evidence that manipulation, mobilisation, and a muscle energy technique are of benefit in the treatment of ankle sprains (not evaluated in UK evidence report). Inconclusive (favourable) evidence for Kaltenborn-based manual therapy for rehabilitation following ankle fracture (not evaluated in the UK evidence report). Inconclusive (favourable) evidence for hallux abducto valgus that mobilisation/manipulation is more effective in leading to improvements in the intermediate term than night splints (no change from UK evidence report). Inconclusive (favourable) evidence for trigger point therapy in treating plantar fasciitis treatment (no change from the UK evidence report). Inconclusive (favourable) evidence for manual therapy (manipulation/mobilisation) of the ankle and/or foot combined with multimodal or exercise therapy (no change from the UK evidence report) in treating Morton’s neuroma, metatarsalgia, hallux limitus/rigidus.
Carpal tunnel syndrome
Three additional medium quality systematic reviews,[
60,
61] one high quality systematic review[
62] and three additional RCTs[
63‐
65] on the effectiveness of manual therapy in carpal tunnel syndrome were identified. The medium quality reviews[
60,
61] and a high quality review[
62] did not include any eligible trials not already considered by the UK evidence report and were therefore not considered here. Two medium quality RCTs[
63,
64] were included in one of the additional systematic reviews[
66]. Only one medium quality RCT[
65] was not included in any of the new reviews.
The medium quality systematic review[
66] summarised evidence on the effectiveness of non-surgical treatments for carpal tunnel syndrome. The authors concluded that there is limited evidence that carpal bone mobilisation is more effective with respect to symptom improvement than no treatment in the short term in the treatment of carpal tunnel syndrome. There was no evidence found for the effectiveness of neurodynamic treatment versus carpal bone mobilisation in the short term, for the effectiveness of a neurodynamic technique plus splinting compared with a sham therapy plus splinting group in the short term, or for the effectiveness of Graston instrument-assisted soft tissue mobilisation plus home exercises compared with soft tissue mobilisation plus home exercises in the midterm. There was no evidence for the effectiveness of chiropractic therapy compared with medical treatment for in the midterm.
A medium quality RCT[
65] was and compared 15 sessions of trigger point therapy over five weeks with sham treatment in 55 patients with carpal tunnel syndrome. After the end of the intervention, there was significant improvement in the severity of symptoms, functional status and perceived improvement in the intervention group compared to control (p < 0.05).
Summary: Inconclusive (favourable) evidence for carpal bone mobilisation and for trigger point therapy in the treatment of carpal tunnel syndrome (no change from the UK evidence report). Inconclusive (unclear) evidence for neurodynamic treatment, soft-tissue mobilisation (with or without Graston instrument), and diversified chiropractic care in the management of carpal tunnel syndrome (not evaluated in the UK evidence report).
Lateral epicondylitis (tennis elbow)
Eight additional low to moderate quality systematic reviews,[
60,
67‐
73] eight additional RCTs for low to moderate quality,[
74‐
81] one ongoing RCT,[
82] and three low quality non-randomised comparative studies were identified[
83‐
85]. Four of the additional RCTs[
75,
77‐
79] were included in the new additional reviews.
One systematic review of medium quality[
69] evaluated the effectiveness of manipulative therapy (MT) in treating adults with lateral epicondylitis. The review identified and included 13 randomised and non-randomised trials of fair quality overall. The review results indicated beneficial effects of Mulligan’s mobilisation with movement (versus no treatment, placebo, or corticosteroid injection) and manual therapy applied to the cervical spinal region (versus placebo). Cyriax physiotherapy was found to be more effective than conventional therapy (stretching, exercise, and modalities), but less effective than corticosteroid injection or supervised exercise. Kohia et al.[
70] systematically reviewed the effectiveness of various physical therapy treatments for lateral epicondylitis in adults (medium quality). In total, 16 RCTs of physical therapy were included in the review. The findings indicated that in the short-term (6 months or less), corticosteroid injections were more beneficial than physical therapy (elbow manipulation and exercise) or Cyriax physiotherapy. However, in the longer term (six months or longer), there was no difference between physical therapy (elbow manipulation and exercise) versus corticosteroid injections or no treatment. Moreover, radial head mobilisation was more effective compared to standard treatment (ultrasound, massage, stretching, exercise for wrist) at a follow-up of 15 weeks. The physical therapy protocol (pulsed ultrasound, friction massage, and stretching, exercise for wrist) was more effective than a brace with or without pulsed ultrasound. Cyriax physiotherapy was more beneficial than light therapy but less beneficial than supervised exercise of wrist extensors. And finally, the use of wrist manipulation led to greater improvements in lateral epicondylitis than a combination of ultrasound, friction massage, and muscle strengthening. According to the review authors, no single treatment technique was shown to be the most effective in treatment of lateral epicondylitis. In one systematic review of medium quality,[
71] the authors explored the effectiveness of physiotherapy, steroid injections, and relative rest for the treatment of adult lateral epicondylitis. The review identified and included 30 studies with quality scores ranging from 2 to 9 (out of 11). After 6 weeks of follow-up, steroid injections and multimodal physiotherapy (arm stretching, strengthening, ultrasound, and massage) were more effective than relative rest. However, after 3 months, multimodal physiotherapy was better than steroid injections but as effective as relative rest. The authors concluded that early active interventions such as steroid injections and multimodal physiotherapy may improve symptoms of lateral epicondylitis in adults. In a medium quality systematic review,[
73] evidence was summarised on the effectiveness of conservative treatments (e.g., ultrasound, acupuncture, rebox, exercise, wait and see, mobilisation/manipulation, laser) for lateral epicondylitis in adults. In total, 31 trials of conservative treatment were included, of which four trials reported on effectiveness of mobilisation/manipulation relative to placebo, standard physiotherapy, corticosteroid injections, or manipulation in combination with treatments. The results indicated that mobilisation/manipulation led to greater improvements in symptoms of lateral epicondylitis compared to placebo or standard physiotherapy. However, at one year of follow-up, there was no difference between corticosteroid injections and manipulation/mobilisation (Cyriax group). The authors concluded that level 2b (Sackett’s evidence rating) evidence indicated benefits of mobilisation/manipulation in treating lateral epicondylitis.
In one pilot study of low quality,[
74] the authors randomised 30 adults with lateral epicondylitis to receive either the chiropractic mobilisation (augmented soft tissue technique) or no treatment for five weeks. After three months of follow-up, the groups demonstrated significant improvements in the Patient-Rated Tennis Elbow Evaluation scale, in pain and in pain-free grip strength when compared to baseline. However, no between-group difference for these measures was statistically significant. In one trial of medium quality,[
76] 60 adult participants with lateral epicondylitis were randomised to 4-week Cyriax physiotherapy versus phonophoresis with diclofenac gel and supervised exercise. At 4 and 8 weeks, both groups demonstrated significant improvements in pain (VAS scale), pain-free grip strength (dynamometer), and functional status when compared to baseline. At both follow-ups, there were significantly greater mean improvements in pain, pain-free grip strength, and functional status with Cyriax physiotherapy compared to phonophoresis. In a non-randomised controlled experimental trial of low quality,[
83] the effect of the Mulligan technique (mobilisation, movement and taping) plus traditional treatment (thermal treatment, massage, ultrasound, exercise) was compared to that of traditional treatment alone given for 4 weeks to 34 participants with lateral epicondylitis. After 4 weeks, both groups demonstrated significant improvements in function, pain, and pain-free grip strength when compared to baseline with the mean improvements from baseline in pain and function being significantly greater in the Mulligan technique group compared to traditional treatment alone. A low quality RCT[
80] compared the effects of myofascial release with sham ultrasound in 68 computer professionals with lateral epicondylitis (12 sessions over 4 weeks). At 12 weeks follow-up, values on the Patient-rated Tennis Elbow Evaluation Scale were significantly more improved in the intervention group than in the control group. A low quality RCT[
81] compared the effectiveness of a supervised exercise programme with that of Cyriax physiotherapy (12 sessions over 4 weeks) in 20 patients with lateral epicondylitis. After the end of the treatment, pain and function (Tennis Elbow Function Scale) were significantly improved in both groups, but significantly more in the exercise group than in the Cyriax physiotherapy group.
In one observational cohort study of low quality,[
84] the authors retrospectively compared the effectiveness of adding cervical spine manual therapy (passive mobilisation, mobilisation with movement, muscle energy techniques) to local management directed at the elbow (pulsed ultrasound, iontophoresis, deep tissue massage, stretching, strengthening exercise for muscles of the upper extremity, cold packs, elbow joint mobilisation) administered to patients with lateral epicondylitis. The authors reviewed and divided charts of 112 participants into two groups of the cervical spine manual therapy plus local management (n = 51) versus local management alone (n = 61). The self-reported outcome of success (i.e., return to all functional activities without recurrence of elbow symptoms after discharge from physical therapy) was ascertained via telephone follow-up interviews (72–74 weeks after discharge) with a response rate of 85% (95 responders). Compared to the local management group, the cervical spine manual therapy group experienced a numerically higher rate of success in fewer visits. In a non-randomised controlled experimental trial of low quality[
85] manual therapy (soft mobilisation of the cervical spine/cervicothoracic junction and flexion mobilisation in the cervical joints) plus extracorporeal low-energy shockwave therapy (ESWT) was compared to that of ESWT alone given to 60 participants with chronic lateral epicondylitis. At 12 months of follow-up, both treatment groups experienced significant improvements in pain compared to baseline. However, there was no statistically significant difference between groups.
Summary: Inconclusive (non-favourable) evidence was found for the treatment of lateral epicondylitis (tennis elbow) with manipulation alone (no change from the UK evidence report). The reviewed evidence indicated some benefits of manual therapy in reducing symptoms in patients with lateral epicondylitis, when in combination with other treatments (exercise, traditional physiotherapy, local management, standard therapy), when compared to no treatment, or baseline values (within-group change), however, the evidence was still rated inconclusive (favourable) evidence (no change from the UK evidence report). When comparing manual therapy to other treatments (e.g., placebo, phonophoresis, low-energy shockwave therapy, relative rest), there was inconclusive or inconsistent (favourable) evidence (no change from the UK evidence report).
Shoulder conditions
Fifteen new or additional systematic reviews[
60,
86‐
99] were identified that included assessments of manual therapy for shoulder pain and disorders with inconclusive results in the UK evidence report, as well as twelve new or additional RCTs[
100‐
112]. However, eleven of the reviews were either included in other more comprehensive reviews or did not include any studies in addition to those in the UK evidence report or to those included in more specific reviews,[
60,
89‐
93,
95‐
99] and nine of the RCTs were included in relevant new reviews and will therefore not be described separately here[
100,
101,
104‐
110]. The remaining systematic reviews were rated medium quality[
86‐
88,
94]. The new RCTs not described in any of the reviews were of high[
103,
111] and medium[
112] quality.
In one of the new systematic reviews,[
86] the authors examined the effects of manipulative therapy with or without multimodal therapy for shoulder disorders. They identified 23 RCTs, five non-randomised trials, and seven non-controlled primary studies. The included studies used a variety of intervention techniques including mobilisation, manipulation with and without exercise, combination with soft tissue treatment in some studies, mobilisation with movement, myofascial treatments, and cervical lateral glide mobilisation. Each condition category examined (other than shoulder osteoarthritis) included at least one high quality study. The authors concluded that for rotator cuff disorders and for shoulder complaints, dysfunctions, disorders or pain, there was fair evidence for manual and manipulative therapy of the shoulder, shoulder girdle and/or full kinetic chain combined with multimodal or exercise therapy; similarly for frozen shoulder (adhesive capsulitis), there was fair evidence for manual and manipulative therapy of the shoulder, shoulder girdle and/or full kinetic chain combined with multimodal or exercise therapy (manual therapy included high velocity low amplitude manipulation, mid-or end-range mobilisation, mobilisation with movement). For shoulder soft tissue disorders there was fair evidence for using soft tissue or myofascial treatments (ischaemic compression, deep friction massage, therapeutic stretch). For minor neurogenic shoulder pain there was limited evidence for cervical lateral glide mobilisation and/or high velocity low amplitude manipulation with soft tissue release and exercise. There was insufficient evidence for the manual treatment of shoulder osteoarthritis (no trials in this patient group). Another medium quality systematic review[
87] examined the effectiveness of manual therapy for impingement-related shoulder pain. They considered systematic reviews, RCTs and quasi-RCTs of manual or exercise therapy in patients with pain arising locally in a shoulder with grossly abnormal mobility. The review included eight systematic reviews and six RCTs, of which three included exercise interventions only and three included both exercise and manual therapy (mobilisation). Of the included reviews, five reported evidence to favour manual therapy plus exercise over exercise alone. The evidence from the three additional RCTs was inconclusive, but with a tendency towards improved outcomes with interventions including both manual therapy and exercise. No evidence was found for the effectiveness of mobilisation alone. None of the systematic reviews and only one of the RCTs included a specific statement on adverse events; in the one RCT no adverse events were reported. The authors concluded that there is limited evidence to support the effectiveness of manual therapy and exercise interventions for impingement-related shoulder pain. This primarily related to sub-acute and chronic complaints and short and medium term effectiveness, with the conclusions being based on research of varying methodological quality, with varying risk of bias, and affected by weaknesses in the reporting quality. Cautious interpretation was also warranted due to the heterogeneity of populations, interventions and outcomes.
A medium quality systematic review[
88] examined the effectiveness of manual physical therapy for painful shoulder conditions. Treatment had to be by physical therapists and manual therapy interventions including low and high velocity mobilisations had to be directed at the glenohumeral joint only, without mobilisation of adjacent structures. Seven RCTs with a mean PEDro quality score of 7.86 of 10 (range 6 to 9) were included, and interventions included mobilisation with movement, the Cyriax approach, and static mobilisation performed at end-range or mid-ranges of motion. Of the included trials, three examined mobilisation with movement and two of these found a significant improvement in range of motion in the intervention group compared to the control, while the highest percentage change in range of motion was found in the intervention group in the third study. Significant improvement in pain compared to control was seen in one of two studies, and significant functional improvement in one study and highest percentage change in function in a second study. One study on Cyriax manual therapy found significant improvement in range of motion compared to the control, while three studies examining mobilisation at the end-range of motion all found a significant improvement in range of motion and end-range mobilisation compared to the control, while two studies reported no significant change in pain measures and two of three studies reported significantly improved function compared to the control. Mid-range mobilisation appeared to be less effective with no effect on range of motion or function and only one of four studies reporting a significant improvement in pain. The review authors concluded that the included studies demonstrated a benefit of manual therapy for improvements in mobility and a trend towards improving pain measures, while increases in function and quality of life were questionable. Similarly, Pribicevic et al.[
94] examined in their medium quality review the effectiveness of manipulative therapy for the treatment of shoulder pain (excluding adhesive capsulitis). Treatment had to include a manipulative thrust technique (chiropractic or physiotherapy). The authors included 22 case reports, four case series, and four RCTs. The RCTs had quality scores of 5 to 8 out of 10. One included chiropractic manipulations and three included physiotherapeutic manipulations. All trials provided some limited evidence that the groups receiving the manipulation intervention had better outcomes (in terms of pain, recovery, improvement) than the control groups. The authors concluded that the evidence was limited, as only two RCTs of reasonably sound methodology could be identified and that there is need for well-designed trials investigating multi-modal chiropractic treatment.
A low quality RCT examined the effects of manual therapy (mobilisation of the glenohumeral joint and soft tissues using Kaltenborn’s roll-glide techniques, Cyriax deep transverse massage, Mulligan’s mobilisation with movement and typical techniques of glenohumeral joint mobilisation in the anteroposterior direction) in 30 patients with chronic rotator cuff injury[
102]. The duration of the treatment was unclear (at least 15 treatments) and the intervention was combined with standard rehabilitation (TENS, ultrasound, exercise). A range of mobility parameters as well as pain were significantly more improved in the manual therapy group than in the control group after the intervention. The authors did not report on adverse effects. Another RCT[
103] was high quality and examined the effects of myofascial trigger point treatment in 72 patients with chronic unilateral non-traumatic shoulder pain (excluding adhesive capsulitis). The treatment involved inactivation of active myofascial trigger points by manual compression, which was combined with other manual techniques, namely deep stroking or strumming and intermittent cold application. Patients were also instructed to perform simple gentle static stretching and relaxation exercises at home several times a day to apply heat and received ergonomic advice. There was a ‘wait and see’ control group that received physiotherapy after the trial period. Treatment was given once a week for up to 12 weeks. After 12 weeks, the patients in the intervention group had significantly improved values for disability (DASH questionnaire), current pain, pain in the past seven days and most severe pain in the past seven days compared to the control. The Global Perceived Effect was also significantly better in the intervention than in the control group (55% versus 14% with improvement), as was the number of muscles with active trigger points. The authors did not report on adverse effects. A medium quality RCT[
112] compared therapy according to the fascial distortion model with classic manual therapy in 60 patients with frozen shoulder. Patients received four treatment sessions over four weeks. Six weeks after the end of treatment function and pain improved in both groups, but significantly more so in the fascial distortion model group than in the classic manual therapy group. Patients found the fascial distortion model treatment more uncomfortable than classic manual therapy, but no serious adverse effects were seen. A high quality RCT[
111] compared the effectiveness of end-range mobilisation/scapular mobilisation treatment in addition to standard physical therapy, compared to standard therapy alone in 34 patients with frozen shoulder syndrome. The main treatment groups included patients meeting criteria from a kinematics prediction, and an additional control group included patients not fulfilling the criteria. Treatment was provided twice weekly for eight weeks. At eight weeks, results for several range of motion parameters and function were significantly better for the intervention group fulfilling the criteria compared to the control group fulfilling the criteria. However, there was no difference between the intervention group and the control group not fulfilling the criteria. These results supported the use of a prediction method.
Summary: Moderate (positive) evidence for use of manual therapy combined with exercise in the treatment of rotator cuff disorders (change from inconclusive (favourable) evidence in UK evidence report). Inconclusive (favourable) evidence for the effectiveness of mobilisation with movement (not evaluated in UK evidence report) or osteopathy (Niel-Asher technique) (not evaluated in UK evidence report) or manual therapy with exercise in the treatment of adhesive capsulitis (not evaluated in UK evidence report). Inconclusive (favourable) evidence for the effectiveness of cervical lateral glide mobilisation and/or high velocity low amplitude manipulation with soft tissue release and exercise in minor neurogenic shoulder pain (not evaluated in the UK evidence report). Moderate (positive) evidence for using myofascial treatments (ischaemic compression, deep friction massage, therapeutic stretch) for soft tissue disorders of the shoulder (not evaluated in the UK evidence report).
Temporomandibular disorders
One systematic review protocol[
113] and five RCTs[
114‐
118] (3 low quality,[
115,
116,
118] 2 high quality[
114,
117]) were identified on manual therapy for temporomandibular disorders.
Craane et al.[
114] conducted a high quality RCT of 49 participants with temporomandibular closed lock who either received physical therapy (including joint mobilisation, exercises, and massage) or a control treatment. Over a year of follow-up, all pain variables decreased, and all function variables increased significantly over time for both groups, but there was no significant difference between the groups. In a low quality RCT,[
116] 50 adults with temporomandibular disorders were randomised to receive osteopathic manual therapy or conventional conservative therapy (oral appliance, physical therapy, hot/cold packs, transcutaneous electrical nerve stimulation) for 6 months. At 8 months of follow-up, the osteopathic group compared to the conventional conservative therapy group experienced significant improvement in maximal mouth opening and lateral movement of the head around its axis, but the mean jaw pain score between the two groups was not significantly different. In a high quality RCT,[
117] 30 participants with myogenous temporomandibular disorders were randomly assigned to receive one of the three treatments for 5 weeks: intra-oral myofascial therapy (IMT), IMT plus self-care (mandibular home exercises) and education (lecture on basic temporomandibular joint anatomy, biomechanics, disc displacement, dysfunction), or no treatment. At 6 months of post-treatment follow-up, both IMT groups compared to no treatment group experienced significant improvements in pain scores at rest, opening, and clenching (p < 0.01). Moreover, the IMT alone group had a significant improvement in pain at rest (p = 0.04), pain on opening (p < 0.01), and opening range (p < 0.01) compared to IMT combination with education and self-care. A low quality randomised trial[
118] compared the effectiveness of a single manipulation procedure plus non-steroidal anti-inflammatory drugs (NSAIDs) to that of NSAIDs alone in 305 adults with temporomandibular joint disc displacement (closed lock). The total success rate for the manual therapy group during the entire follow-up time was 172/204 (84.3%) while the success rates in the control group were 0%. No formal comparisons between intervention and control groups were presented. In a low quality RCT,[
115] 30 patients with myofascial pain lasting for at least six months were randomised to a single session of botulinum toxin injections or multiple session fascial manipulation (three 50 min sessions over two to four weeks). At three months follow-up, there were significant reductions in pain perception in both groups, but no significant difference between groups in most of the parameters measured. There was a tendency towards greater pain reduction in the manipulation group and greater increase in range of motion in the botulinum toxin group.
Summary: Results on the comparative effectiveness/safety of manual therapy for temporomandibular disorders remain inconclusive (favourable) evidence for mobilisation, massage, myofascial or osteopathic manipulation (no change from the UK evidence report).