Clinical Briefs

With Comments from Russell H. Greenfield, MD

Manipulative Therapy for Shoulder Pain

Source: Bergman GJD, et al. Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and pain. Ann Intern Med 2004;141:432-439.

Goal: To assess the effectiveness of manipulative therapy of the shoulder girdle plus usual care in the treatment of shoulder dysfunction and pain.

Design: Randomized, controlled clinical trial.

Subjects: 150 adults with shoulder dysfunction and associated symptoms unrelated to trauma recruited from 50 general practices in the Netherlands.

Methods: All subjects received usual care from their general practitioners; the intervention group (n = 79) also received up to six manipulative therapy sessions over a period of 12 weeks. Primary outcome measure was patient-perceived recovery, and determinations were made at baseline, six weeks, and 12 weeks. Secondary outcomes included severity of complaints, shoulder pain, functional disability, and general health.

Results: By study’s end, significantly more people who received manipulative therapy reported full recovery or major improvement than those in the control group. At 26 and 52 weeks follow-up, the main complaint was significantly less severe in the intervention group.

Conclusion: Manipulative therapy of the shoulder girdle accelerates recovery of shoulder symptoms when combined with usual medical care.

Study strengths: Standardized treatment protocol; excellent follow-up.

Study weaknesses: Complete blinding not possible with manipulative therapies; no sham manipulation group; more than 20% of subjects in each group were missing data for at least one outcome variable; no limit on duration of symptoms; no range of motion determinations; outcomes were practitioner-dependent.

Of note: Usual care comprised use of oral analgesics or anti-inflammatory agents, corticosteroid injections, and physiotherapy (including shoulder exercises and massage); manual therapies were applied based on the therapist’s preferred techniques (a total of eight therapists took part in the study); subjects in the intervention group received 3.8 ± 1.5 treatments lasting 23 ± 13 minutes; cost analysis is pending.

We knew that: The shoulder girdle is composed of the cervicothoracic spine and adjacent ribs; up to 20% of people with shoulder symptoms have no shoulder joint dysfunction and are ultimately found to have shoulder girdle dysfunction; European data suggest that at one year more than 40% of people with shoulder complaints remain somewhat disabled.

Clinical import: Shoulder injuries are becoming increasingly commonplace and a growing number of orthopedists now specialize in care of the shoulder joint. Concomitantly, there has been a rise in interest in manipulative therapies, both chiropractic and osteopathic. A significant amount of data has been amassed addressing the use of manipulative therapies for back and neck complaints, but very little on their use for shoulder disorders. While reinforcing the idea that manual therapists are seeing more patients with shoulder and other joint disorders, and that such therapy may benefit select patients, the article does not effectively counter arguments that outcome may depend more upon a therapist’s persona than upon the technique employed.

What to do with this article: Keep the abstract on your computer.

Dr. Greenfield, Medical Director, Carolinas Integrative Health Carolinas HealthCare System Charlotte, NC, is Editor of Alternative Medicine Alert.