Manual Therapy Combined with Therapeutic Exercise Vs Therapeutic Exercise Alone for Shoulder Impingement Syndrome: A Systematic Review and Meta-Analysis

Abstract

Introduction: Shoulder complaints are the third most common musculoskeletal presentation, after back and neck disorders, in primary care. Among people with shoulder pain, Shoulder Impingement Syndrome (SIS) has the highest prevalence and accounts for 27% of shoulder disorders. Various treatment options are available for SIS. However, literature suggests the need of a review regarding the addition of Manual Therapy (MT) to the Therapeutic Exercise (TE) program. Aim: To investigate the effectiveness of MT combined with TEs versus TEs alone for the management of SIS. Materials and Methods: The study examined published randomised controlled trials and quasi-experimental studies. A comprehensive search of two electronic databases (PubMed and PEDro) was performed from inception till the last week of August, 2020. The selected studies were assessed on methodological quality rating using the PEDro scale and the modified downs and black scale for experimental and quasi-experimental studies, respectively. The extracted outcomes were pain levels, strength, Range of Motion (ROM) and Shoulder Pain and Disability Index (SPADI) scale score. The meta-analysis was done on continuous data and the data were summarised qualitatively and quantitatively. Results: Seven trials were included (n=437) after evaluation. Standard Mean Difference (SMD) with 95% CI was used to denote summary effects of the outcome measures. Pain {SMD: -1.07; 95%CI: -1.85, -0.28; p<0.01} showed positive effect when managed with MT combined with TE while external rotation strength {SMD: 0.55; 95%CI 0.27, 0.84; p<0.01} improved with TE alone. The majority of the studies (six out of seven) had low risk of bias. Conclusion: The results indicate that evidence exists for improvement in pain level and muscle strength with MT combined with TE and TE alone respectively. The qualitative evidence suggests that glenohumeral mobilisation and exercises are associated with best outcomes for SIS management.