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Systematic Review of Nondrug, Nonsurgical Treatment of Shoulder Conditions

      Abstract

      Objective

      The purpose of this review was to evaluate the effectiveness of conservative nondrug, nonsurgical interventions, either alone or in combination, for conditions of the shoulder.

      Methods

      The review was conducted from March 2016 to November 2016 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), and was registered with PROSPERO. Eligibility criteria included randomized controlled trials (RCTs), systematic reviews, or meta-analyses studying adult patients with a shoulder diagnosis. Interventions qualified if they did not involve prescription medication or surgical procedures, although these could be used in the comparison group or groups. At least 2 independent reviewers assessed the quality of each study using the Scottish Intercollegiate Guidelines Network checklists. Shoulder conditions addressed were shoulder impingement syndrome (SIS), rotator cuff-associated disorders (RCs), adhesive capsulitis (AC), and nonspecific shoulder pain.

      Results

      Twenty-five systematic reviews and 44 RCTs met inclusion criteria. Low- to moderate-quality evidence supported the use of manual therapies for all 4 shoulder conditions. Exercise, particularly combined with physical therapy protocols, was beneficial for SIS and AC. For SIS, moderate evidence supported several passive modalities. For RC, physical therapy protocols were found beneficial but not superior to surgery in the long term. Moderate evidence supported extracorporeal shockwave therapy for calcific tendinitis RC. Low-level laser was the only modality for which there was moderate evidence supporting its use for all 4 conditions.

      Conclusion

      The findings of this literature review may help inform practitioners who use conservative methods (eg, doctors of chiropractic, physical therapists, and other manual therapists) regarding the levels of evidence for modalities used for common shoulder conditions.

      Key Indexing Terms

      Introduction

      Painful conditions of the shoulder are the third leading musculoskeletal complaint in primary care, with a point prevalence as high as 26%.
      • Linaker CH
      • Walker-Bone K
      Shoulder disorders and occupation.
      Two-thirds (67%) of adults experience shoulder pain at some time in their life,
      • Struyf F
      • Geraets J
      • Noten S
      • Meeus M
      • Nijs J
      A multivariable prediction model for the chronification of non-traumatic shoulder pain: A systematic review.
      and prevalence is highest in middle age (40-65 years).
      • Bussieres AE
      • Peterson C
      • Taylor JA
      Diagnostic imaging guideline for musculoskeletal complaints in adults—An evidence-based approach; Part 2. Upper extremity disorders.
      Chronic shoulder pain characterizes a substantial subset of those with shoulder conditions because only 50% of patients recover within 6 months of onset.
      • Struyf F
      • Geraets J
      • Noten S
      • Meeus M
      • Nijs J
      A multivariable prediction model for the chronification of non-traumatic shoulder pain: A systematic review.
      Disorders of the rotator cuff, including shoulder impingement syndrome (SIS), are among the most common causes of shoulder pain.
      • Saltychev M
      • Aarimaa V
      • Virolainen P
      • Laimi K
      Conservative treatment or surgery for shoulder impingement: Systematic review and meta-analysis (provisional abstract).
      Other conditions include those that are unspecified and adhesive capsulitis (AC).
      • Page MJ
      • Green S
      • Kramer S
      • Johnston RV
      • McBain B
      • Buchbinder R
      Electrotherapy modalities for adhesive capsulitis (frozen shoulder).
      • Page MJ
      • Green S
      • Kramer S
      • et al.
      Manual therapy and exercise for adhesive capsulitis (frozen shoulder).
      Primary treatment options considered in usual care typically consist of analgesics or exercises and progress to secondary and tertiary options of steroid injections or surgery if necessary.
      • House J
      • Mooradian A
      Evaluation and management of shoulder pain in primary care clinics.
      • Mitchell C
      • Adebajo A
      • Hay E
      • Carr A
      Shoulder pain: Diagnosis and management in primary care.
      Compared with more conservative treatments, surgery is likely more costly and risky.
      • Saltychev M
      • Aarimaa V
      • Virolainen P
      • Laimi K
      Conservative treatment or surgery for shoulder impingement: Systematic review and meta-analysis (provisional abstract).
      The utilization of arthroscopic interventions for the shoulder has quickly increased in recent decades, with an estimated complication rate of 4.8%-10.6%.
      • Pauzenberger L
      • Grieb A
      • Hexel M
      • Laky B
      • Anderl W
      • Heuberer P
      Infections following arthroscopic rotator cuff repair: incidence, risk factors, and prophylaxis.
      Additionally, there are some negative effects of glucocorticoid injections on cellular characteristics and mechanical properties of tendons, especially when used for long-term treatment.
      • Dean BJ
      • Lostis E
      • Oakley T
      • Rombach I
      • Morrey ME
      • Carr AJ
      The risks and benefits of glucocorticoid treatment for tendinopathy: A systematic review of the effects of local glucocorticoid on tendon.
      Patients pursuing treatment for shoulder pain seek care from manual therapy (MT) providers such as physical therapists, chiropractic practitioners, and others who use conservative interventions such as mobilization and manipulation. A study conducted in the Netherlands reported that shoulder complaints constituted 9.8% of physical therapy (PT) patients,
      • Kooijman MK
      • Barten DJ
      • Swinkels IC
      • et al.
      Pain intensity, neck pain and longer duration of complaints predict poorer outcome in patients with shoulder pain—A systematic review.
      and in a survey of chiropractic practice in Australia, 12% of patients presented with shoulder pain.
      • Pribicevic M
      • Pollard H
      • Bonello R
      An epidemiologic survey of shoulder pain in chiropractic practice in Australia.
      Reviews of MTs (eg, manipulation and mobilization) and multimodal treatments have found favorable effects supporting their use for the management of shoulder conditions.
      • Brantingham JW
      • Cassa TK
      • Bonnefin D
      • et al.
      Manipulative therapy for shoulder pain and disorders: Expansion of a systematic review.
      • Green S
      • Buchbinder R
      • Hetrick S
      Physiotherapy interventions for shoulder pain.
      • McHardy A
      • Hoskins W
      • Pollard H
      • Onley R
      • Windsham R
      Chiropractic treatment of upper extremity conditions: A systematic review.
      • Pribicevic M
      • Pollard H
      • Bonello R
      • de Luca K
      A systematic review of manipulative therapy for the treatment of shoulder pain.
      • Desjardins-Charbonneau A
      • Roy JS
      • Dionne CE
      • Fremont P
      • MacDermid JC
      • Desmeules F
      The efficacy of manual therapy for rotator cuff tendinopathy: A systematic review and meta-analysis.
      However, clinical trials studying these treatments are inconsistently conducted, tend to have low to moderate levels of scientific rigor, and infrequently collect long-term outcomes. Therefore, evidence is still inconclusive regarding the appropriate use of many MTs for shoulder conditions. Furthermore, evidence is inconclusive regarding other nondrug, nonsurgical interventions that are commonly combined and employed in multimodal management in clinical practice.
      • Brantingham JW
      • Cassa TK
      • Bonnefin D
      • et al.
      Manipulative therapy for shoulder pain and disorders: Expansion of a systematic review.
      • Green S
      • Buchbinder R
      • Hetrick S
      Physiotherapy interventions for shoulder pain.
      The purpose of this review was to evaluate the evidence for conservative nondrug, nonsurgical interventions, either alone or in combination, for conditions of the shoulder.

      Methods

      The systematic review was performed from March 2016 to November 2016. Its purpose was to answer the following question: What is the effectiveness of nondrug, nonsurgical interventions, either alone or in combination, for conditions of the shoulder? The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), and was registered with PROSPERO (No. 42016046341).

      Literature Search Parameters

      We developed a search strategy in collaboration with a health sciences librarian. The following items were considered in developing the strategy.

      Participants/Population and Setting

      We included adult (age ≥18 years) patients in ambulatory care settings who were eligible for the included trials and had diagnoses of conditions of the shoulder. Studies including only acute cases (<4 weeks’ duration) were excluded. No restrictions were placed on age, but mean ages were recorded.

      Interventions

      A nondrug, nonsurgical intervention had to be used in at least 1 of the study groups. This could be any combination of treatments, as long as no medications or surgical procedures were a formal part of the intervention.

      Comparators

      There were no restrictions on composition of the comparison group. Active treatments, placebos or shams, wait list, and no treatment were all included.

      Outcomes

      We included only pain and function/disability assessed by valid and reliable patient-based outcome measures. When other outcomes were reported, we excluded them from the data extraction tables. We included studies whether or not they reported on occurrence of adverse events, but noted adverse events in those that did.

      Eligibility Criteria

      The eligibility criteria for articles in the search are listed in Figure 1.

      Search Strategy

      The following databases were included in the search: PubMed, Index to Chiropractic Literature, Cochrane Database of Systematic Reviews, and Cumulative Index of Nursing and Allied Health Literature (CINAHL). A health sciences librarian worked with the investigators to develop the search strategies for each database; details of these are provided as appendices. Search terms related to a broad spectrum of shoulder diagnoses and any nondrug, nonsurgical interventions that serve as management strategies of these conditions were included. The terms were tailored for use in each database along with filters for systematic reviews and controlled trials. Titles and abstracts were screened independently by at least 2 reviewers for eligibility. Disagreements on eligibility were resolved by discussion. To attempt to address possible publication bias, we searched the US National Institutes of Health database (https://clinicaltrials.gov/) for trials that were conducted with no published results. This approach reflects methodology included in the updated guideline for systematic reviews published by the Cochrane Back and Neck Group.
      • Furlan AD
      • Malmivaara A
      • Chou R
      • et al.
      2015 Updated method guideline for systematic reviews in the Cochrane Back and Neck Group.
      An additional strategy was to use reference tracking on the systematic reviews identified in the search. We did not extract data from the systematic reviews themselves. The randomized controlled trials (RCTs) identified by this method were added to RCTs identified through the formal literature search. For the complete search strategies for all included databases, please see Appendix A (available online only).

      Evaluation of Risk of Bias

      We evaluated articles using modified versions of the Scottish Intercollegiate Guideline Network (SIGN) checklists (http://www.sign.ac.uk/methodology/checklists.html) for systematic reviews/meta-analyses (both of these are abbreviated as “SRs") and RCTs. In the SIGN checklists, each article is scored as “high quality, low risk of bias,” “acceptable quality, moderate risk of bias,” “low quality, high risk of bias,” or “unacceptable” quality, which resulted in rejection. We defined each level based on scoring the checklists by assigning a value of 1 for each “yes” response.
      • Harbour R
      • Miller J
      A new system for grading recommendations in evidence based guidelines.
      For SR checklists, which had 12 items, quality scores were assigned as follows: high quality, low risk of bias, >9; acceptable, moderate risk of bias, 6-9; low, high risk of bias <6; if items 1.1 and/or 1.2 were marked “no,” then the article was unacceptable and was rejected (Fig 2).
      For RCTs, checklists had 10 items and quality scores were assigned as follows: high quality, low risk of bias, 9-10; acceptable, moderate risk of bias, 6-8; low, high risk of bias, 3-5; unacceptable (reject), 0-2 (Fig 3).
      At least 2 investigators evaluated each article. If there was disagreement between reviewers, a third also reviewed the paper and the majority rating was used after discussion among reviewers. Studies of unacceptable quality were excluded from the evidence tables.

      Strength of Evidence

      Strength of evidence was based on the quality and quantity of evidence on a specific topic. We used criteria for determining strength of evidence modified from that described in the UK report
      • Bronfort G
      • Haas M
      • Evans R
      • Leiniger B
      • Triano J
      Effectiveness of manual therapies: The UK evidence report.
      • Clar C
      • Tsertsvadze A
      • Court R
      • Hundt GL
      • Clarke A
      • Sutcliffe P
      Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: Systematic review and update of UK evidence report.
      and detailed in Table 1: high quality, positive or negative; moderate quality, positive or negative; and inconclusive, favorable or unfavorable.
      Table 1Rating of Evidence
      Evidence from randomized controlled trials and systematic reviews.
      • Bronfort G
      • Haas M
      • Evans R
      • Leiniger B
      • Triano J
      Effectiveness of manual therapies: The UK evidence report.
      • Clar C
      • Tsertsvadze A
      • Court R
      • Hundt GL
      • Clarke A
      • Sutcliffe P
      Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: Systematic review and update of UK evidence report.
      Quality and Quantity of EvidenceRating
      Consistent results found in at least 2 low risk-of-bias studiesHigh
      Results of at least 1 low risk-of-bias study or at least 2 low risk-of-bias studies with some inconsistency in results, or at least 2 acceptable-quality studies with consistent resultsModerate
      Only acceptable-quality studies with inconsistent results or only high risk-of-bias studiesInconclusive
      a Evidence from randomized controlled trials and systematic reviews.

      Data Extraction

      Data were not extracted from SRs. Instead, we searched each included review for RCTs and added any eligible ones not identified in our literature search. We summarized the systematic review conclusions to compare to our findings with respect to the RCTs, as has been done elsewhere.
      • Bryans R
      • Decina P
      • Descarreaux M
      • et al.
      Evidence-based guidelines for the chiropractic treatment of adults with neck pain.
      Data were extracted from all included studies by at least 2 investigators, with 1 serving as primary extractor and the second verifying the data. Disagreements were resolved by discussion, including a third reviewer if necessary. Data extracted were entered into a Microsoft Word table grouped by the condition as outlined in the included studies. Items included on the data extraction form were as follows: study identification (first author and year of publication); quality score; population (age); duration of complaint; dosage (number of treatment sessions over period); pain and function outcome measures used; results in terms of pain and function outcomes; conclusions; and limitations.

      Results

      Figure 4 illustrates the results of the search. There were 77 full-text articles screened (26 SRs and 51 RCTs). Eight were excluded as follows: 1 systematic review was outside the scope of this review (it did not include RCTs of shoulder conditions),
      • Brantingham JW
      • Cassa TK
      • Bonnefin D
      • et al.
      Manipulative and multimodal therapy for upper extremity and temporomandibular disorders: A systematic review.
      leaving 25 SRs; 5 articles designated as RCTs did not actually meet the definition of an RCT (did not test efficacy or did not test between-group differences)
      • Al Dajah SB
      Soft tissue mobilization and PNF improve range of motion and minimize pain level in shoulder impingement.
      • Damian M
      • Zalpour C
      Trigger point treatment with radial shock waves in musicians with nonspecific shoulder-neck pain: Data from a special physio outpatient clinic for musicians.
      • Kumar N
      • Nehru A
      • Rajalakshmi D
      Effect of taping as a component of conservative treatment for subacromial impingement syndrome.
      • Muth S
      • Barbe MF
      • Lauer R
      • McClure PW
      The effects of thoracic spine manipulation in subjects with signs of rotator cuff tendinopathy.
      • Shrivastava A
      • Shyam AK
      • Sabnis S
      • Sancheti P
      Randomised controlled study of Mulligan's vs. Maitland's mobilization technique in adhesive capsulitis of shoulder joint.
      ; and 2 were outside the scope of our review (1 did not measure patient-based outcomes,
      • Djordjevic OC
      • Vukicevic D
      • Katunac L
      • Jovic S
      Mobilization with movement and kinesiotaping compared with a supervised exercise program for painful shoulder: Results of a clinical trial.
      and the other was a prognostic study
      • Yang JL
      • Chen SY
      • Hsieh CL
      • Lin JJ
      Effects and predictors of shoulder muscle massage for patients with posterior shoulder tightness.
      ), leaving 44 RCTs.

      Systematic Reviews of Effectiveness

      Table 2 lists the SRs of high, acceptable, or low quality (risk of bias) and condition addressed. One of the 25 was of unacceptable quality
      • Lee SY
      • Cheng BJ
      • Grimmer SK
      The midterm effectiveness of extracorporeal shockwave therapy in the management of chronic calcific shoulder tendinitis.
      and was not considered further, leaving 24 reviews. Twenty of the reviews addressed only 1 condition; 4 addressed multiple conditions.
      • Brantingham JW
      • Cassa TK
      • Bonnefin D
      • et al.
      Manipulative therapy for shoulder pain and disorders: Expansion of a systematic review.
      • Clar C
      • Tsertsvadze A
      • Court R
      • Hundt GL
      • Clarke A
      • Sutcliffe P
      Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: Systematic review and update of UK evidence report.
      • Goldgrub R
      • Cote P
      • Sutton D
      • et al.
      The effectiveness of multimodal care for the management of soft tissue injuries of the shoulder: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration.
      • Yu H
      • Cote P
      • Shearer HM
      • et al.
      Effectiveness of passive physical modalities for shoulder pain: Systematic review by the Ontario Protocol for Traffic Injury Management collaboration.
      In the sections below, the reviews covering multiple conditions are cited under each of the conditions they addressed.
      Table 2Systematic Reviews of Effectiveness by Condition and Quality (Risk of Bias) Rating
      ConditionQualityFirst Author, Year Published
      RCsHighDesmeules 2016
      • Desmeules F
      • Boudreault J
      • Roy JS
      • Dionne CE
      • Fremont P
      • MacDermid JC
      Efficacy of transcutaneous electrical nerve stimulation for rotator cuff tendinopathy: A systematic review.
      AcceptableDesjardins-Charbonneau 2015 (taping)
      • Desjardins-Charbonneau A
      • Roy JS
      • Dionne CE
      • Desmeules F
      The efficacy of taping for rotator cuff tendinopathy: A systematic review and meta-analysis.
      AcceptableDesjardins-Charbonneau 2015 (manual therapy)
      • Desjardins-Charbonneau A
      • Roy JS
      • Dionne CE
      • Fremont P
      • MacDermid JC
      • Desmeules F
      The efficacy of manual therapy for rotator cuff tendinopathy: A systematic review and meta-analysis.
      AcceptableHuisstede 2011
      • Huisstede BMA
      • Koes BW
      • Gebremariam L
      • Keijsers E
      • Verhaar JAN
      Current evidence for effectiveness of interventions to treat rotator cuff tears.
      RC-CTAcceptableHuisstede 2011
      • Huisstede BM
      • Gebremariam L
      • van der Sande R
      • Hay EM
      • Koes BW
      Evidence for effectiveness of extracorporal shock-wave therapy (ESWT) to treat calcific and non-calcific rotator cuff tendinosis—A systematic review.
      (ESWT) (noncalcific and RC-CT)
      HighLouwerens 2014
      • Louwerens JK
      • Sierevelt IN
      • van Noort A
      • van den Bekerom MP
      Evidence for minimally invasive therapies in the management of chronic calcific tendinopathy of the rotator cuff: A systematic review and meta-analysis.
      AcceptableLouwerens 2016
      • Louwerens JK
      • Veltman ES
      • van Noort A
      • van den Bekerom MP
      The effectiveness of high-energy extracorporeal shockwave therapy versus ultrasound-guided needling versus arthroscopic surgery in the management of chronic calcific rotator cuff tendinopathy: A systematic review.
      AcceptableSpeed 2014
      • Speed C
      A systematic review of shockwave therapies in soft tissue conditions: Focusing on the evidence.
      (noncalcific and RC-CT)
      AcceptableVerstraelen 2014
      • Verstraelen FU
      • In den Kleef NJ
      • Jansen L
      • Morrenhof JW
      High-energy versus low-energy extracorporeal shock wave therapy for calcifying tendinitis of the shoulder: Which is superior? A meta-analysis.
      ACAcceptableFavejee 2011
      • Favejee MM
      • Huisstede BM
      • Koes BW
      Frozen shoulder: The effectiveness of conservative and surgical interventions—Systematic review.
      HighPage 2014 (electrotherapy)
      • Page MJ
      • Green S
      • Kramer S
      • Johnston RV
      • McBain B
      • Buchbinder R
      Electrotherapy modalities for adhesive capsulitis (frozen shoulder).
      HighPage 2014 (manual therapy)
      • Page MJ
      • Green S
      • Kramer S
      • et al.
      Manual therapy and exercise for adhesive capsulitis (frozen shoulder).
      AcceptableJain 2014
      • Jain TK
      • Sharma NK
      The effectiveness of physiotherapeutic interventions in treatment of frozen shoulder/adhesive capsulitis: A systematic review (Provisional abstract).
      AcceptableNoten 2016
      • Noten S
      • Meeus M
      • Stassijns G
      • Van GF
      • Verborgt O
      • Struyf F
      Efficacy of different types of mobilization techniques in patients with primary adhesive capsulitis of the shoulder: A systematic review.
      SPHighChang 2016
      • Chang KV
      • Hung CY
      • Wu WT
      • Han DS
      • Yang RS
      • Lin CP
      Comparison of the effectiveness of suprascapular nerve block with physical therapy, placebo, and intra-articular injection in management of chronic shoulder pain: A meta-analysis of randomized controlled trials.
      HighPeek 2015
      • Peek AL
      • Miller C
      • Heneghan NR
      Thoracic manual therapy in the management of non-specific shoulder pain: A systematic review.
      AcceptableKong 2013
      • Kong LJ
      • Zhan HS
      • Cheng YW
      • Yuan WA
      • Chen B
      • Fang M
      Massage therapy for neck and shoulder pain: A systematic review and meta-analysis (provisional abstract).
      SISAcceptableSaltychev 2014
      • Saltychev M
      • Aarimaa V
      • Virolainen P
      • Laimi K
      Conservative treatment or surgery for shoulder impingement: Systematic review and meta-analysis (provisional abstract).
      LowWang 2014
      • Wang TL
      • Fu BM
      • Ngai G
      • Yung P
      Effect of isokinetic training on shoulder impingement.
      Multiple conditionsHighClar 2014
      • Clar C
      • Tsertsvadze A
      • Court R
      • Hundt GL
      • Clarke A
      • Sutcliffe P
      Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: Systematic review and update of UK evidence report.
      (RC, AC, SP)
      AcceptableBrantingham 2011
      • Brantingham JW
      • Cassa TK
      • Bonnefin D
      • et al.
      Manipulative therapy for shoulder pain and disorders: Expansion of a systematic review.
      (RC, SP)
      HighGoldgrub 2016
      • Goldgrub R
      • Cote P
      • Sutton D
      • et al.
      The effectiveness of multimodal care for the management of soft tissue injuries of the shoulder: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration.
      (RC, SIS, SP)
      AcceptableYu 2015
      • Yu H
      • Cote P
      • Shearer HM
      • et al.
      Effectiveness of passive physical modalities for shoulder pain: Systematic review by the Ontario Protocol for Traffic Injury Management collaboration.
      (RC-CT, SP, SIS)
      AC, adhesive capsulitis; SP, nonspecific shoulder pain; RC, rotator cuff-associated disorder; RC-TC, rotator cuff calcific tendinitis; SIS, shoulder impingement syndrome.

      Noncalcific Rotator Cuff-Associated Conditions

      Nine articles addressed various treatments for rotator cuff-associated disorders (RCs). Three focused on various types of MT
      • Brantingham JW
      • Cassa TK
      • Bonnefin D
      • et al.
      Manipulative therapy for shoulder pain and disorders: Expansion of a systematic review.
      • Desjardins-Charbonneau A
      • Roy JS
      • Dionne CE
      • Fremont P
      • MacDermid JC
      • Desmeules F
      The efficacy of manual therapy for rotator cuff tendinopathy: A systematic review and meta-analysis.
      • Clar C
      • Tsertsvadze A
      • Court R
      • Hundt GL
      • Clarke A
      • Sutcliffe P
      Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: Systematic review and update of UK evidence report.
      ; 2 on extracorporeal shockwave therapy (ESWT)
      • Huisstede BM
      • Gebremariam L
      • van der Sande R
      • Hay EM
      • Koes BW
      Evidence for effectiveness of extracorporal shock-wave therapy (ESWT) to treat calcific and non-calcific rotator cuff tendinosis—A systematic review.
      • Speed C
      A systematic review of shockwave therapies in soft tissue conditions: Focusing on the evidence.
      ; and 1 each on transcutaneous nerve stimulation (TENS),
      • Desmeules F
      • Boudreault J
      • Roy JS
      • Dionne CE
      • Fremont P
      • MacDermid JC
      Efficacy of transcutaneous electrical nerve stimulation for rotator cuff tendinopathy: A systematic review.
      taping,
      • Desjardins-Charbonneau A
      • Roy JS
      • Dionne CE
      • Desmeules F
      The efficacy of taping for rotator cuff tendinopathy: A systematic review and meta-analysis.
      multimodal therapies,
      • Goldgrub R
      • Cote P
      • Sutton D
      • et al.
      The effectiveness of multimodal care for the management of soft tissue injuries of the shoulder: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration.
      and exercise.
      • Huisstede BMA
      • Koes BW
      • Gebremariam L
      • Keijsers E
      • Verhaar JAN
      Current evidence for effectiveness of interventions to treat rotator cuff tears.
      For MT (skilled hand movements performed by a therapist
      • Desjardins-Charbonneau A
      • Roy JS
      • Dionne CE
      • Fremont P
      • MacDermid JC
      • Desmeules F
      The efficacy of manual therapy for rotator cuff tendinopathy: A systematic review and meta-analysis.
      ), manipulation and mobilization were included. One acceptable-quality study found low- to moderate-quality evidence that MT may have a beneficial effect on pain, but the evidence was unclear for function.
      • Desjardins-Charbonneau A
      • Roy JS
      • Dionne CE
      • Fremont P
      • MacDermid JC
      • Desmeules F
      The efficacy of manual therapy for rotator cuff tendinopathy: A systematic review and meta-analysis.
      Another acceptable-quality study found that the evidence was fair that MT including manipulation either alone or combined with exercise and modalities was effective.
      • Brantingham JW
      • Cassa TK
      • Bonnefin D
      • et al.
      Manipulative therapy for shoulder pain and disorders: Expansion of a systematic review.
      A high-quality review found that manipulation/mobilization combined with exercise had a moderate level of positive evidence for effectiveness.
      • Clar C
      • Tsertsvadze A
      • Court R
      • Hundt GL
      • Clarke A
      • Sutcliffe P
      Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: Systematic review and update of UK evidence report.
      The last study in this group
      • Goldgrub R
      • Cote P
      • Sutton D
      • et al.
      The effectiveness of multimodal care for the management of soft tissue injuries of the shoulder: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration.
      reported evidence from an RCT
      • Szczurko O
      • Cooley K
      • Mills EJ
      • Zhou Q
      • Perri D
      • Seely D
      Naturopathic treatment of rotator cuff tendinitis among Canadian postal workers: A randomized controlled trial.
      that found dietary advice combined with acupuncture was superior to supervised passive, active-assisted, and active range of motion (ROM) exercises combined with soft tissue and MT for rotator cuff tendinitis for ≥6 weeks. The study also reported statistically and clinically significant increases in patients’ perceived improvements. At follow-up, statistically and clinically significant differences favored the diet-based multimodal program of care in pain and disability. A detailed description of the soft tissue and MT was not provided by the single study.
      • Szczurko O
      • Cooley K
      • Mills EJ
      • Zhou Q
      • Perri D
      • Seely D
      Naturopathic treatment of rotator cuff tendinitis among Canadian postal workers: A randomized controlled trial.
      For ESWT, 2 acceptable-quality reviews both found that ESWT was not effective for noncalcific rotator cuff tendinitis.
      • Speed C
      A systematic review of shockwave therapies in soft tissue conditions: Focusing on the evidence.
      • Szczurko O
      • Cooley K
      • Mills EJ
      • Zhou Q
      • Perri D
      • Seely D
      Naturopathic treatment of rotator cuff tendinitis among Canadian postal workers: A randomized controlled trial.
      For TENS, a high-quality review found that because of the scarcity of evidence and high risk of bias of existing studies, no conclusions could be made about its effectiveness.
      • Desmeules F
      • Boudreault J
      • Roy JS
      • Dionne CE
      • Fremont P
      • MacDermid JC
      Efficacy of transcutaneous electrical nerve stimulation for rotator cuff tendinopathy: A systematic review.
      For taping, an acceptable-quality review found that the evidence for taping alone or with other therapies was insufficient to make a conclusion.
      • Desjardins-Charbonneau A
      • Roy JS
      • Dionne CE
      • Desmeules F
      The efficacy of taping for rotator cuff tendinopathy: A systematic review and meta-analysis.
      For exercise, 1 acceptable-quality review compared PT exercise therapy with surgery for patients with rotator cuff tears. It found moderate evidence that surgery was superior to exercise therapy in the mid- to long term.
      • Huisstede BMA
      • Koes BW
      • Gebremariam L
      • Keijsers E
      • Verhaar JAN
      Current evidence for effectiveness of interventions to treat rotator cuff tears.

      Rotator Cuff Calcific Tendinitis

      Five acceptable-quality reviews
      • Louwerens JK
      • Veltman ES
      • van Noort A
      • van den Bekerom MP
      The effectiveness of high-energy extracorporeal shockwave therapy versus ultrasound-guided needling versus arthroscopic surgery in the management of chronic calcific rotator cuff tendinopathy: A systematic review.
      • Verstraelen FU
      • In den Kleef NJ
      • Jansen L
      • Morrenhof JW
      High-energy versus low-energy extracorporeal shock wave therapy for calcifying tendinitis of the shoulder: Which is superior? A meta-analysis.
      • Yu H
      • Cote P
      • Shearer HM
      • et al.
      Effectiveness of passive physical modalities for shoulder pain: Systematic review by the Ontario Protocol for Traffic Injury Management collaboration.
      • Szczurko O
      • Cooley K
      • Mills EJ
      • Zhou Q
      • Perri D
      • Seely D
      Naturopathic treatment of rotator cuff tendinitis among Canadian postal workers: A randomized controlled trial.
      • Ioppolo F
      • Tattoli M
      • Di SL
      • et al.
      Clinical improvement and resorption of calcifications in calcific tendinitis of the shoulder after shock wave therapy at 6 months' follow-up: A systematic review and meta-analysis.
      and 1 high-quality review
      • Louwerens JK
      • Sierevelt IN
      • van Noort A
      • van den Bekerom MP
      Evidence for minimally invasive therapies in the management of chronic calcific tendinopathy of the rotator cuff: A systematic review and meta-analysis.
      addressed rotator cuff calcific tendinitis (RC-CT). The first SR included 20 individual studies (1544 participants). It found that high-energy ESWT is the most thoroughly investigated minimally invasive treatment option in the short term to midterm and has proven to be a safe and effective treatment.
      • Louwerens JK
      • Sierevelt IN
      • van Noort A
      • van den Bekerom MP
      Evidence for minimally invasive therapies in the management of chronic calcific tendinopathy of the rotator cuff: A systematic review and meta-analysis.
      The second review
      • Louwerens JK
      • Veltman ES
      • van Noort A
      • van den Bekerom MP
      The effectiveness of high-energy extracorporeal shockwave therapy versus ultrasound-guided needling versus arthroscopic surgery in the management of chronic calcific rotator cuff tendinopathy: A systematic review.
      by the same team found that with the 22 studies that were included (1258 shoulders), many patients can achieve good to excellent clinical outcomes after high-energy ESWT, US-guided needling, and arthroscopy for calcific tendinopathy of the shoulder. Two additional acceptable-quality reviews both found that ESWT was effective for RC-CT.
      • Speed C
      A systematic review of shockwave therapies in soft tissue conditions: Focusing on the evidence.
      • Szczurko O
      • Cooley K
      • Mills EJ
      • Zhou Q
      • Perri D
      • Seely D
      Naturopathic treatment of rotator cuff tendinitis among Canadian postal workers: A randomized controlled trial.
      The other reviews in this category analyzed similar treatments and outcomes. One review (6 studies included, 460 patients) evaluated the effectiveness of ESWT for functional improvement and reduction of pain in patients with calcific tendinitis of the shoulder.
      • Ioppolo F
      • Tattoli M
      • Di SL
      • et al.
      Clinical improvement and resorption of calcifications in calcific tendinitis of the shoulder after shock wave therapy at 6 months' follow-up: A systematic review and meta-analysis.
      Meta-analysis was performed in 4 of the 6 studies included for review because these had 2 treatment groups; the other 2 studies were analyzed descriptively because they had 3 treatment groups. This SR found that ESWT increases shoulder function, reduces pain, and is effective in dissolving calcifications. Improvements continued over the 6-month follow-up period. The last review found that all 5 RCTs included (359 patients) reported greater improvement in functional outcomes in patients treated with high-energy ESWT, compared with patients treated with low-energy ESWT, at 3 and 6 months.
      • Verstraelen FU
      • In den Kleef NJ
      • Jansen L
      • Morrenhof JW
      High-energy versus low-energy extracorporeal shock wave therapy for calcifying tendinitis of the shoulder: Which is superior? A meta-analysis.
      One acceptable-quality study
      • Yu H
      • Cote P
      • Shearer HM
      • et al.
      Effectiveness of passive physical modalities for shoulder pain: Systematic review by the Ontario Protocol for Traffic Injury Management collaboration.
      included patients diagnosed with RC-CT, nonspecific shoulder pain (SP), and SIS. The study reported that compared with control groups, shockwave therapy is effective for reducing shoulder pain and disability in adults with persistent calcific tendinitis.
      According to these SRs, ESWT has been proven to be an effective and safe treatment option after failed nonsurgical treatment of calcific tendinitis. Those studies that reported adverse events associated with the treatment found that only a small number of the treated participants were affected, and all of the adverse effects resolved within a few days.

      Adhesive Capsulitis

      Six studies analyzed a variety of therapeutic interventions for restoring motion and diminishing pain in patients with primary AC. Three studies
      • Page MJ
      • Green S
      • Kramer S
      • Johnston RV
      • McBain B
      • Buchbinder R
      Electrotherapy modalities for adhesive capsulitis (frozen shoulder).
      • Page MJ
      • Green S
      • Kramer S
      • et al.
      Manual therapy and exercise for adhesive capsulitis (frozen shoulder).
      • Clar C
      • Tsertsvadze A
      • Court R
      • Hundt GL
      • Clarke A
      • Sutcliffe P
      Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: Systematic review and update of UK evidence report.
      were scored as high quality, and 3 were scored as acceptable quality.
      • Favejee MM
      • Huisstede BM
      • Koes BW
      Frozen shoulder: The effectiveness of conservative and surgical interventions—Systematic review.
      • Jain TK
      • Sharma NK
      The effectiveness of physiotherapeutic interventions in treatment of frozen shoulder/adhesive capsulitis: A systematic review (Provisional abstract).
      • Noten S
      • Meeus M
      • Stassijns G
      • Van GF
      • Verborgt O
      • Struyf F
      Efficacy of different types of mobilization techniques in patients with primary adhesive capsulitis of the shoulder: A systematic review.
      Two of the high-quality studies were conducted by the same research team.
      • Page MJ
      • Green S
      • Kramer S
      • Johnston RV
      • McBain B
      • Buchbinder R
      Electrotherapy modalities for adhesive capsulitis (frozen shoulder).
      • Page MJ
      • Green S
      • Kramer S
      • et al.
      Manual therapy and exercise for adhesive capsulitis (frozen shoulder).
      The first meta-analysis reviewed the evidence of electrotherapy modalities, delivered alone or in combination with other interventions, for the treatment of AC.
      • Page MJ
      • Green S
      • Kramer S
      • Johnston RV
      • McBain B
      • Buchbinder R
      Electrotherapy modalities for adhesive capsulitis (frozen shoulder).
      Nineteen trials (RCTs and controlled clinical trials, 1249 participants) were included in the review. Two electrotherapy modalities studies compared low-level laser therapy (LLLT) and pulsed electromagnetic field therapy (PEMF) with placebo. No trial in this SR compared an electrotherapy modality plus MT and exercise with MT and exercise alone. The benefit and harm of electrotherapy modalities were investigated in 9 trials. Five of the 9 studies measured adverse events. They reported low-quality evidence that LLLT, over a 6-day period, may improve global assessment of treatment success more than placebo. No participant in either group reported any adverse events. It is unclear whether 2 weeks of PEMF improves pain or function any more than placebo because of the very low quality evidence from 1 trial. There was moderate-quality evidence that LLLT plus exercise for 8 weeks may improve pain for up to 4 weeks and function for up to 4 months longer than placebo plus exercise.
      • Page MJ
      • Green S
      • Kramer S
      • Johnston RV
      • McBain B
      • Buchbinder R
      Electrotherapy modalities for adhesive capsulitis (frozen shoulder).
      The overall conclusion of this SR is that only 1 electrotherapy modality, LLLT, has evidence of benefit when compared when placebo or when used as an adjunct to exercise.
      The second meta-analysis from the above team reviewed the benefit and harm of MT and exercise, alone or in combination, for the treatment of patients with AC.
      • Page MJ
      • Green S
      • Kramer S
      • et al.
      Manual therapy and exercise for adhesive capsulitis (frozen shoulder).
      They found 32 studies (1836 participants). No studies compared a combination of MT and exercise with placebo or no intervention. Meta-analysis was difficult because 7 trials compared a combination of MT and exercise with other interventions but were clinically heterogeneous in that a number of different interventions were used in the comparison groups. In the short term, the higher-quality studies in the Page et al meta-analysis
      • Page MJ
      • Green S
      • Kramer S
      • et al.
      Manual therapy and exercise for adhesive capsulitis (frozen shoulder).
      indicated that a combination of MT and exercise may not be as effective as glucocorticoid injection. They were unable to assess whether a combination of MT, exercise, and electrotherapy was an effective adjunct to glucocorticoid injection or oral nonsteroidal anti-inflammatory drugs. Following arthrographic joint distension with glucocorticoid and saline, MT 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 ROM.
      Three acceptable-quality SRs evaluated conservative treatments for AC. One reviewed 12 RCTs involving 810 patients.
      • Noten S
      • Meeus M
      • Stassijns G
      • Van GF
      • Verborgt O
      • Struyf F
      Efficacy of different types of mobilization techniques in patients with primary adhesive capsulitis of the shoulder: A systematic review.
      This SR found that mobilization techniques have beneficial effects in patients with primary AC of the shoulder. It reported that the Maitland technique and spine mobilization, combined with glenohumeral stretching and both angular and translational mobilization, seem to be most beneficial in reducing pain. Adverse events were not reviewed for each study included. The next study looked at the effectiveness of physiotherapeutic interventions in treatment of AC.
      • Jain TK
      • Sharma NK
      The effectiveness of physiotherapeutic interventions in treatment of frozen shoulder/adhesive capsulitis: A systematic review (Provisional abstract).
      This SR found that of the 39 studies (4350 patients) included, therapeutic exercises and mobilization therapy are the most effective for reducing pain and improving function in patients with stage 2 and 3 AC. Also, high-grade posterior mobilization along with self-exercise is also suggested for improving function. LLLT is strongly recommended for pain relief and moderate improvement of function, but not for improvement of ROM. Adverse events were not assessed in this SR.
      A high-quality review of treatments for RC, AC, and SP patients
      • Clar C
      • Tsertsvadze A
      • Court R
      • Hundt GL
      • Clarke A
      • Sutcliffe P
      Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: Systematic review and update of UK evidence report.
      found evidence for MT and manipulative therapy with multimodal or exercise therapy (MT included high-velocity low-amplitude manipulation, mid- or end-range mobilization, and mobilization with movement [MWM]) for the treatment of AC. However, because of a lack of research on MT and AC, the study concluded that further research is required to draw conclusions.
      • Clar C
      • Tsertsvadze A
      • Court R
      • Hundt GL
      • Clarke A
      • Sutcliffe P
      Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: Systematic review and update of UK evidence report.
      The last study reviewed 5 Cochrane reviews and 18 RCTs on the effectiveness of oral medication, injection therapy, physiotherapy, acupuncture, arthrographic distension, and suprascapular nerve block (SSNB).
      • Favejee MM
      • Huisstede BM
      • Koes BW
      Frozen shoulder: The effectiveness of conservative and surgical interventions—Systematic review.
      This SR found strong evidence for the effectiveness of LLLT and steroid injections on pain in the treatment of frozen shoulder in the short term. They reported moderate evidence in favor of mobilization techniques in the short and long term and for steroid injections in the midterm. And lastly, moderate evidence was found for the effectiveness of distension alone and as an addition to active PT in the short term.
      • Favejee MM
      • Huisstede BM
      • Koes BW
      Frozen shoulder: The effectiveness of conservative and surgical interventions—Systematic review.
      It is difficult to assess the safety of the interventions for AC because many of the included studies did not report on adverse events.

      Nonspecific SP

      Seven SRs assessed the effectiveness of nonconventional therapies for SP (3 studies on SP exclusively and 4 studies on multiple conditions including SP).
      Four of the 7 studies were rated as high quality
      • Clar C
      • Tsertsvadze A
      • Court R
      • Hundt GL
      • Clarke A
      • Sutcliffe P
      Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: Systematic review and update of UK evidence report.
      • Chang KV
      • Hung CY
      • Wu WT
      • Han DS
      • Yang RS
      • Lin CP
      Comparison of the effectiveness of suprascapular nerve block with physical therapy, placebo, and intra-articular injection in management of chronic shoulder pain: A meta-analysis of randomized controlled trials.
      • Peek AL
      • Miller C
      • Heneghan NR
      Thoracic manual therapy in the management of non-specific shoulder pain: A systematic review.
      • Goldgrub R
      • Cote P
      • Sutton D
      • et al.
      The effectiveness of multimodal care for the management of soft tissue injuries of the shoulder: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration.
      and 3 as acceptable quality.
      • Brantingham JW
      • Cassa TK
      • Bonnefin D
      • et al.
      Manipulative therapy for shoulder pain and disorders: Expansion of a systematic review.
      • Kong LJ
      • Zhan HS
      • Cheng YW
      • Yuan WA
      • Chen B
      • Fang M
      Massage therapy for neck and shoulder pain: A systematic review and meta-analysis (provisional abstract).
      • Yu H
      • Cote P
      • Shearer HM
      • et al.
      Effectiveness of passive physical modalities for shoulder pain: Systematic review by the Ontario Protocol for Traffic Injury Management collaboration.
      The first high-quality SR assessed the effectiveness of SSNB compared with PT, placebo, and intra-articular injections.
      • Chang KV
      • Hung CY
      • Wu WT
      • Han DS
      • Yang RS
      • Lin CP
      Comparison of the effectiveness of suprascapular nerve block with physical therapy, placebo, and intra-articular injection in management of chronic shoulder pain: A meta-analysis of randomized controlled trials.
      Eleven RCTs (591 patients) compared SSNB with PT, placebo, and intra-articular injections. This review found that SSNB provided better pain relief and improvement in function when compared with placebo injections and PT, but had results similar to those for intra-articular injection of the glenohumeral joints. Adverse events were reported, but none were severe, and no long-term complications were encountered.
      The second high-quality SR assessed thoracic MT (TMT).
      • Peek AL
      • Miller C
      • Heneghan NR
      Thoracic manual therapy in the management of non-specific shoulder pain: A systematic review.
      Three RCTs met the eligibility criteria of this SR. All 3 used usual care as a comparison (ie, general practitioner’s advice, steroid injections, or PT). This SR concluded that TMT helped accelerate recovery and reduced pain outcomes and disability measures immediately and for up to 52 weeks compared with usual care. Adverse events were not assessed.
      There were 4 reviews of multiple conditions that included SP; 2 of the 4 were high quality.
      • Brantingham JW
      • Cassa TK
      • Bonnefin D
      • et al.
      Manipulative therapy for shoulder pain and disorders: Expansion of a systematic review.
      • Clar C
      • Tsertsvadze A
      • Court R
      • Hundt GL
      • Clarke A
      • Sutcliffe P
      Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: Systematic review and update of UK evidence report.
      • Goldgrub R
      • Cote P
      • Sutton D
      • et al.
      The effectiveness of multimodal care for the management of soft tissue injuries of the shoulder: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration.
      • Yu H
      • Cote P
      • Shearer HM
      • et al.
      Effectiveness of passive physical modalities for shoulder pain: Systematic review by the Ontario Protocol for Traffic Injury Management collaboration.
      The third high-quality study
      • Goldgrub R
      • Cote P
      • Sutton D
      • et al.
      The effectiveness of multimodal care for the management of soft tissue injuries of the shoulder: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration.
      reported minor benefits with multimodal PT programs compared with wait list control or guideline-based usual care performed by general practitioners.
      Two SRs concluded that there is limited evidence for use of mobilization and/or high-velocity low-amplitude manipulation with soft tissue release and exercise for SP.
      • Brantingham JW
      • Cassa TK
      • Bonnefin D
      • et al.
      Manipulative therapy for shoulder pain and disorders: Expansion of a systematic review.
      • Clar C
      • Tsertsvadze A
      • Court R
      • Hundt GL
      • Clarke A
      • Sutcliffe P
      Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: Systematic review and update of UK evidence report.
      Mobilization alone was not an effective treatment for SP. These large SRs found that none of the SRs in their meta-analysis included a specific statement on adverse events. Therefore, the safety of manipulation and mobilization for SP is unknown.
      The Yu et al review reported that neither ultrasound nor interferential current therapy is more effective than placebo treatment for SP of variable duration.
      • Yu H
      • Cote P
      • Shearer HM
      • et al.
      Effectiveness of passive physical modalities for shoulder pain: Systematic review by the Ontario Protocol for Traffic Injury Management collaboration.
      The last SR evaluated the effectiveness of massage therapy for SP.
      • Kong LJ
      • Zhan HS
      • Cheng YW
      • Yuan WA
      • Chen B
      • Fang M
      Massage therapy for neck and shoulder pain: A systematic review and meta-analysis (provisional abstract).
      The meta-analysis reported significant immediate and short-term effects of massage for SP compared with inactive therapies (both p values < 0.01). However, these results were not significant for massage for pain when compared with other active therapies. Also, massage therapy did not significantly differ from other therapies with respect to functional status of the shoulder. Adverse events were not assessed.

      Shoulder Impingement Syndrome

      We found 4 SRs that evaluated the quality of RCTs for SIS (2 studies on SIS exclusively
      • Saltychev M
      • Aarimaa V
      • Virolainen P
      • Laimi K
      Conservative treatment or surgery for shoulder impingement: Systematic review and meta-analysis (provisional abstract).
      • Wang TL
      • Fu BM
      • Ngai G
      • Yung P
      Effect of isokinetic training on shoulder impingement.
      and 2 studies on SIS and other conditions
      • Goldgrub R
      • Cote P
      • Sutton D
      • et al.
      The effectiveness of multimodal care for the management of soft tissue injuries of the shoulder: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration.
      • Yu H
      • Cote P
      • Shearer HM
      • et al.
      Effectiveness of passive physical modalities for shoulder pain: Systematic review by the Ontario Protocol for Traffic Injury Management collaboration.
      ). Two were of high quality,
      • Saltychev M
      • Aarimaa V
      • Virolainen P
      • Laimi K
      Conservative treatment or surgery for shoulder impingement: Systematic review and meta-analysis (provisional abstract).
      • Goldgrub R
      • Cote P
      • Sutton D
      • et al.
      The effectiveness of multimodal care for the management of soft tissue injuries of the shoulder: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration.
      1 was of acceptable quality,
      • Yu H
      • Cote P
      • Shearer HM
      • et al.
      Effectiveness of passive physical modalities for shoulder pain: Systematic review by the Ontario Protocol for Traffic Injury Management collaboration.
      and the last was of low quality.
      • Wang TL
      • Fu BM
      • Ngai G
      • Yung P
      Effect of isokinetic training on shoulder impingement.
      The first SR
      • Saltychev M
      • Aarimaa V
      • Virolainen P
      • Laimi K
      Conservative treatment or surgery for shoulder impingement: Systematic review and meta-analysis (provisional abstract).
      reviewed trials that compared surgical techniques targeting release of shoulder impingement with any type of conservative treatment including physical training, education, and passive physiotherapy, or comparable treatment. Seven RCTs were considered to fulfill the inclusion criteria of the SR. The meta-analysis estimating the reduction of pain intensity contained moderate evidence that surgery and conservative methods have similar effects on the reduction of pain intensity.
      The second review
      • Yu H
      • Cote P
      • Shearer HM
      • et al.
      Effectiveness of passive physical modalities for shoulder pain: Systematic review by the Ontario Protocol for Traffic Injury Management collaboration.
      found that pretensioned tape and shockwave therapy are not more effective than placebo treatment for the management of SIS. The third study
      • Goldgrub R
      • Cote P
      • Sutton D
      • et al.
      The effectiveness of multimodal care for the management of soft tissue injuries of the shoulder: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration.
      reported multimodal care may not be superior to placebo interventions. However, they also reported that when comparing SIS of variable duration there are minor changes that may lead to improvements in recovery and pain when compared with corticosteroid injections (CSIs).
      The last SR evaluated the effect of isokinetic training in patients with SIS.
      • Wang TL
      • Fu BM
      • Ngai G
      • Yung P
      Effect of isokinetic training on shoulder impingement.
      Two RCTs met the inclusion criteria. Therefore, pooling of the data for a meta-analysis was not possible. Overall, the included studies found improvement in pain and disability after isokinetic training. However, both RCTs reported no statistically significant difference between isokinetic training and a comparison group. Therefore, they reported that there was not enough evidence to support or refute the effectiveness of isokinetic training for SIS because of the lack of evidence.
      • Wang TL
      • Fu BM
      • Ngai G
      • Yung P
      Effect of isokinetic training on shoulder impingement.
      Only 1 SR assessed safety and adverse events of the individual studies included.
      • Yu H
      • Cote P
      • Shearer HM
      • et al.
      Effectiveness of passive physical modalities for shoulder pain: Systematic review by the Ontario Protocol for Traffic Injury Management collaboration.
      They found that 8 of 11 RCTs reported on adverse events and that none of these observed any serious adverse events.

      Randomized Controlled Trials

      Table 3 lists the RCTs of high, acceptable, or low quality (risk of bias) with each item on the quality assessment instrument. Of the 44 RCTs, 5 were of unacceptable quality
      • Abdelshafi ME
      • Yosry M
      • Elmulla AF
      • Al-Shahawy EA
      • Adou Aly M
      • Eliewa EA
      Relief of chronic shoulder pain: A comparative study of three approaches.
      • Bialoszewski D
      • Zaborowski G
      Usefulness of manual therapy in the rehabilitation of patients with chronic rotator cuff injuries: Preliminary report.
      • Bansal K
      • Padamkumar S
      A comparative study between the efficacy of therapeutic utrasound and soft tissue massage (deep friction massage) in supraspinatus tendinitis.
      • Chauhan V
      • Saxena S
      • Grover S
      Effect of deep transverse friction massage and capsular stretching in idiopathic adhesive capsulitis.
      • Sun WP
      • Han SL
      • Jun HK
      The effectiveness of intensive mobilization techniques combined with capsular distension for adhesive capsulitis of the shoulder.
      and were not included in the table or considered further, leaving a total of 39 included RCTs.
      Table 3Risk-of-Bias Assessment of Included RCTs
      First Author and Year PublishedItems on SIGN Checklist
      Quality assessment items from modified SIGN checklist:1.Study addresses appropriate and clearly focused question.2.Assignment of patients to treatment groups is randomized.3.Sample size is justified by a power calculation.4.Investigators are adequately blinded to patients’ group assignment.5.Patients are blinded to group assignment.6.Treatment and control groups are similar at baseline.7.Only difference between groups is the treatment under investigation.8.All relevant outcomes are measured in a standard, valid and reliable way.9.Required sample size was reached; or, if no power calculation was made, attrition was <25%.10.Intention-to-treat analysis was used.
      12345678910TotalQuality
      Quality rating: 9-10 = high (H); 6-8 = acceptable (A); 3-5 = low (L); 0-2 = unacceptable (U, reject).
      Shoulder Impingement Syndrome
      Abrisham 2011
      • Abrisham SM
      • Kermani-Alghoraishi M
      • Ghahramani R
      • Jabbari L
      • Jomeh H
      • Zare M
      Additive effects of low-level laser therapy with exercise on subacromial syndrome: A randomised, double-blind, controlled trial.
      11011111119H
      Atya 2012
      • Atya AM
      Efficacy of microcurrent electrical stimulation on pain, proprioception accuracy and functional disability in subacromial impingement: Randomized controlled trial.
      11000111005L
      Cook 2014
      • Cook C
      • Learman K
      • Houghton S
      • Showalter C
      • O’Halloran B
      The addition of cervical unilateral posterior-anterior mobilisation in the treatment of patients with shoulder impingement syndrome: A randomised clinical trial.
      11100111107A
      Delgado-Gil 2015
      • Delgado-Gil JA
      • Prado RE
      • Rodrigues-de-Souza DP
      • Cleland JA
      • Fernandez-De-Las PC
      • Alburquerque SF
      Effects of mobilization with movement on pain and range of motion in patients with unilateral shoulder impingement syndrome: A randomized controlled trial.
      11101111119H
      Engebretsen 2011
      • Engebretsen K
      • Grotle M
      • Bautz-Holter E
      • Ekeberg OM
      • Juel NG
      • Brox JI
      Supervised exercises compared with radial extracorporeal shock-wave therapy for subacromial shoulder pain: 1-Year results of a single-blind randomized controlled trial.
      11110001117A
      Galace de Freitas 2014
      • Galace-de Frietas D
      • Lima MR
      • Beretta MF
      • et al.
      Pulsed electromagnetic field in patients with shoulder impingement syndrome.
      111111111110H
      Granviken 2015
      • Granviken F
      • Vasseljen O
      Home exercises and supervised exercises are similarly effective for people with subacromial impingement: A randomised trial.
      11110111119H
      Haik 2014
      • Haik MN
      • Alburquerque SF
      • Silva CZ
      • Siqueira-Junior AL
      • Ribeiro IL
      • Camargo PR
      Scapular kinematics pre- and post-thoracic thrust manipulation in individuals with and without shoulder impingement symptoms: a randomized controlled study.
      11011111119H
      Kardouni 2015
      • Kardouni JR
      • Pidcoe PE
      • Shaffer SW
      • et al.
      Thoracic spine manipulation in individuals with subacromial impingement syndrome does not immediately alter thoracic spine kinematics, thoracic excursion, or scapular kinematics: A randomized controlled trial.
      11101111119H
      Kardouni 2015
      • Kardouni JR
      • Shaffer SW
      • Pidcoe PE
      • Finucane SD
      • Cheatham SA
      • Michener LA
      Immediate changes in pressure pain sensitivity after thoracic spinal manipulative therapy in patients with subacromial impingement syndrome: A randomized controlled study.
      11101111119H
      Kaya 2014
      • Kaya DO
      • Baltaci G
      • Toprak U
      • Atay AO
      The clinical and sonographic effects of kinesiotaping and exercise in comparison with manual therapy and exercise for patients with subacromial impingement syndrome: a preliminary trial.
      11110111119H
      Kocyigit 2012
      • Kocyigit F
      • Akalin E
      • Gezer NS
      • Orbay O
      • Kocyigit A
      • Ada E
      Functional magnetic resonance imaging of the effects of low-frequency transcutaneous electrical nerve stimulation on central pain modulation: A double-blind, placebo-controlled trial.
      10011111107A
      Kromer 2013
      • Kromer TO
      • Bie RA
      • Bastiaenen CH
      Physiotherapy in patients with clinical signs of shoulder impingement syndrome: A randomized controlled trial.
      11111011119H
      Rhon 2014
      • Rhon DI
      • Boyles RB
      • Cleland JA
      One-year outcome of subacromial corticosteroid injection compared with manual physical therapy for the management of the unilateral shoulder impingement syndrome: A pragmatic randomized trial.
      11110001106A
      Senbursa 2011
      • Senbursa G
      • Baltaci G
      • Atay OA
      The effectiveness of manual therapy in supraspinatus tendinopathy.
      11000111005L
      Shakeri 2013
      • Shakeri H
      • Keshavarz R
      • Arab AM
      • Ebrahimi I
      Clinical effectiveness of kinesiological taping on pain and pain-free shoulder range of motion in patients with shoulder impingement syndrome: A randomized, double blinded, placebo-controlled trial.
      11111001107A
      Shakeri DASH 2013
      • Shakeri H
      • Keshavarz R
      • Arab AM
      • Ebrahimi I
      Therapeutic effect of kinesio-taping on disability of arm, shoulder, and hand in patients with subacromial impingement dyndrome: A randomized clinical trial.
      11100111107A
      Simsek 2013
      • Simsek HH
      • Balki S
      • Keklik SS
      • Ozturk H
      • Elden H
      Does kinesio-taping in addition to exercise therapy improve the outcomes in subacromial impingement syndrome? A randomized, double-blind, controlled clinical trial.
      111111111110H
      Yavuz 2014
      • Yavuz F
      • Duman I
      • Taskaynatan MA
      • Tan AK
      Low-level laser therapy versus ultrasound therapy in the treatment of subacromial impingement syndrome: A randomized clinical trial.
      11110111119H
      Adhesive Capsulitis
      Chen 2014
      • Chen CY
      • Hu CC
      • Weng PW
      • et al.
      Extracorporeal shockwave therapy improves short-term functional outcomes of shoulder adhesive capsulitis.
      11110111119H
      Doner 2013
      • Doner G
      • Guven Z
      • Atalay A
      • Celiker R
      Evaluation of Mulligan's technique for adhesive capsu76. litis of the shoulder.
      11000111005L
      Hsieh 2012
      • Hsieh LF
      • Hsu WC
      • Lin YJ
      • Chang HL
      • Chen CC
      • Huang V
      Addition of intra-articular hyaluronate injection to physical therapy program produces no extra benefits in patients with adhesive capsulitis of the shoulder: A randomized controlled trial.
      11010001105L
      Klc 2015
      • Klc Z
      • Filiz MB
      • Cakr T
      • Toraman NF
      Addition of suprascapular nerve block to a physical therapy program produces an extra benefit to adhesive capsulitis: A randomized controlled trial.
      11010111107A
      Ma 2013
      • Ma SY
      • Je HD
      • Jeong JH
      • Kim HY
      • Kim HD
      Effects of whole-body cryotherapy in the management of adhesive capsulitis of the shoulder.
      11110111119H
      Maryam 2012
      • Maryam M
      • Zahra K
      • Adeleh B
      • Morteza Y
      Comparison of corticosteroid injections, physiotherapy, and combination therapy in treatment of frozen shoulder.
      11000111016A
      Shi 2012
      • Shi H
      • Fang JQ
      • Li BW
      • Cong WJ
      • Zhang Y
      • Chen L
      Efficacy assessment for different acupuncture therapies in the treatment of frozen shoulder.
      11111010107A
      Smitherman 2015
      • Smitherman JA
      • Struk AM
      • Cricchio M
      • et al.
      Arthroscopy and manipulation versus home therapy program in treatment of adhesive capsulitis of the shoulder: a prospective randomized study.
      11000111016A
      Rotator Cuff-Associated Disorders
      Eslamian 2012
      • Eslamian F
      • Shakouri SK
      • Ghojazadeh M
      • Nobari OE
      • Eftekharsadat B
      Effects of low-level laser therapy in combination with physiotherapy in the management of rotator cuff tendinitis.
      10111111119H
      Kolk 2013
      • Kolk A
      • Auw-Yang KG
      • Tamminga R
      • Hoeven H
      Radial extracorporeal shock-wave therapy in patients with chronic rotator cuff tendinitis: A prospective randomised double-blind placebocontrolled multicentre trial.
      111111111110H
      Kukkonen 2014
      • Kukkonen J
      • Joukainen A
      • Lehtinen J
      • et al.
      Treatment of non-traumatic rotator cuff tears: A randomised controlled trial with one-year clinical results.
      11100001116A
      Kukkonen 2015
      • Kukkonen J
      • Joukainen A
      • Lehtinen J
      • et al.
      Treatment of nontraumatic rotator cuff tears: A randomized controlled trial with two years of clinical and imaging follow-up.
      11100001116A
      Liu 2012
      • Liu S
      • Zhai L
      • Shi Z
      • Jing R
      • Zhao B
      • Xing G
      Radial extracorporeal pressure pulse therapy for the primary long bicipital tenosynovitis: A prospective randomized controlled study.
      11001010005L
      Moosmayer 2014
      • Moosmayer S
      • Lund G
      • Seljom US
      • et al.
      Tendon repair compared with physiotherapy in the treatment of rotator cuff tears: A randomized controlled study in 103 cases with a five-year follow-up.
      11110111119H
      Rabini 2012
      • Rabini A
      • Piazzini DB
      • Bertolini C
      • et al.
      Effects of local microwave diathermy on shoulder pain and function in patients with rotator cuff tendinopathy in comparison to subacromial corticosteroid injections: A single-blind randomized trial.
      11110111119H
      Tornese 2011
      • Tornese D
      • Mattei E
      • Bandi M
      • Zerbi A
      • Quaglia A
      • Melegati G
      Arm position during extracorporeal shock wave therapy for calcifying tendinitis of the shoulder: A randomized study.
      11010011117A
      Nonspecific Shoulder Pain
      Bron 2011
      • Bron C
      • Gast A
      • Dommerholt J
      • Stegenga B
      • Wensing M
      • Oostendorp RA
      Treatment of myofascial trigger points in patients with chronic shoulder pain: A randomized, controlled trial.
      11110001016A
      Montes 2012
      • Montes-Molina R
      • Prieto-Baquero A
      • Martínez-Rodriguez ME
      • Romojaro-Rodriguez AB
      • Gallego-Méndez V
      • Martínez-Ruiz F
      Interferential laser therapy in the treatment of shoulder pain and disability from musculoskeletal pathologies: A randomised comparative study.
      111111111110H
      Riley 2015
      • Riley SP
      • Cote MP
      • Leger RR
      • et al.
      Short-term effects of thoracic spinal manipulations and message conveyed by clinicians to patients with musculoskeletal shoulder symptoms: A randomized clinical trial.
      11111001118A
      Teys 2013
      • Teys P
      • Bisset L
      • Collins N
      • Coombes B
      • Vicenzino B
      One-week time course of the effects of Mulligan's Mobilisation with Movement and taping in painful shoulders.
      11100111118A
      RCT, randomized controlled trial; SIGN, Scottish Intercollegiate Guideline Network.
      a Quality assessment items from modified SIGN checklist:
      • 1.
        Study addresses appropriate and clearly focused question.
      • 2.
        Assignment of patients to treatment groups is randomized.
      • 3.
        Sample size is justified by a power calculation.
      • 4.
        Investigators are adequately blinded to patients’ group assignment.
      • 5.
        Patients are blinded to group assignment.
      • 6.
        Treatment and control groups are similar at baseline.
      • 7.
        Only difference between groups is the treatment under investigation.
      • 8.
        All relevant outcomes are measured in a standard, valid and reliable way.
      • 9.
        Required sample size was reached; or, if no power calculation was made, attrition was <25%.
      • 10.
        Intention-to-treat analysis was used.
      b Quality rating: 9-10 = high (H); 6-8 = acceptable (A); 3-5 = low (L); 0-2 = unacceptable (U, reject).
      Table 4, Table 5, Table 6, Table 7 summarize the data extraction for all RCTs by condition addressed.
      Table 4Evidence Table for Included Randomized Controlled Trials of Nondrug, Nonsurgical Treatment of Shoulder Impingement Syndrome
      Citation and QualityPatient Population

      Mean Age, Mean Symptom Duration
      InterventionComparison Group(s)DosagePain and/or Disability Outcome MeasuresOutcomes (Mean Change Within and Between Groups)ConclusionsLimitations
      Spinal Manipulative Therapy
      Cook 2014
      • Cook C
      • Learman K
      • Houghton S
      • Showalter C
      • O’Halloran B
      The addition of cervical unilateral posterior-anterior mobilisation in the treatment of patients with shoulder impingement syndrome: A randomised clinical trial.


      High
      n = 68

      age: 53, both groups

      duration: >12 mo
      Cervical mobilization and shoulder MTShoulder MTIndividualized treatment d: TG = 60; CG = 52

      Total visits: TG = 10; CG = 9
      NPRS (0-10)

      QuickDASH
      Within group (% change): 60% NPRS; 54% QuickDASH

      Between groups: NS for NPRS or QuickDASH
      No additional benefit of cervical mobilizationSingle-blind

      Short-term
      Haik 2014
      • Haik MN
      • Alburquerque SF
      • Silva CZ
      • Siqueira-Junior AL
      • Ribeiro IL
      • Camargo PR
      Scapular kinematics pre- and post-thoracic thrust manipulation in individuals with and without shoulder impingement symptoms: a randomized controlled study.


      High
      n = 50

      age:

      TG = 34; CG = 30

      duration:

      TG = 49 mo

      CG = 43 mo
      Thoracic SMTSham thoracic SMT1 treatment visitNPRS (0-10)Within group (mean change): TG = –0.8; CG = –0.2

      p = 0.004

      Between groups: p = 0.11
      No significant difference between groupsSMT directed to T3-T7 only

      Potential floor effect on NPRS

      1 treatment
      Kardouni 2015
      • Kardouni JR
      • Shaffer SW
      • Pidcoe PE
      • Finucane SD
      • Cheatham SA
      • Michener LA
      Immediate changes in pressure pain sensitivity after thoracic spinal manipulative therapy in patients with subacromial impingement syndrome: A randomized controlled study.


      High
      n = 45

      age: 31, both groups

      duration: ≥6 wk
      Active thoracic SMTSham thoracic SMT with identical positioning1 treatment visitNPRS (0-10)





      PSS (0-100)
      Within group (mean change): TG = –0.9; CG = –1.5

      p ≤ 0.001

      Between groups: p = 0.28

      Within group:

      TG = 9.2; CG = 11.0

      p ≤ 0.001

      Between groups: p = 0.52
      Thoracic SMT no better than sham1 treatment

      Sample did not reach power calculation
      Kardouni 2015
      • Kardouni JR
      • Pidcoe PE
      • Shaffer SW
      • et al.
      Thoracic spine manipulation in individuals with subacromial impingement syndrome does not immediately alter thoracic spine kinematics, thoracic excursion, or scapular kinematics: A randomized controlled trial.


      High
      n = 52

      age:

      TG = 31

      CG = 33

      duration: ≥6 wk
      Active thoracic SMTSham thoracic SMT with identical positioning1 treatment visitNPRS (0-10)





      PSS (0-100)
      Within group (mean change): TG = –0.9; CG = –1.2

      p ≤ 0.001

      Between groups: p = 0.74

      Within group: TG = 8.6; CG = 9.3

      p < 0.001

      Between groups: p = 0.89
      Thoracic SMT no better than shamPotential floor effect on NPRS

      Only 1 treatment
      Manual Therapy
      Delgado-Gil 2015
      • Delgado-Gil JA
      • Prado RE
      • Rodrigues-de-Souza DP
      • Cleland JA
      • Fernandez-De-Las PC
      • Alburquerque SF
      Effects of mobilization with movement on pain and range of motion in patients with unilateral shoulder impingement syndrome: A randomized controlled trial.


      High
      n = 42

      age:

      TG = 55

      CG = 54

      duration: >3 mo
      MWMSham manual contact2 sessions/wk for 2 wk (total 4)VASWithin group: p ≤ 0.001

      Between groups: p = 0.011
      MWM superior to sham for painShort-term follow up

      MWM applied in isolation

      4 treatments
      Kaya 2014
      • Kaya DO
      • Baltaci G
      • Toprak U
      • Atay AO
      The clinical and sonographic effects of kinesiotaping and exercise in comparison with manual therapy and exercise for patients with subacromial impingement syndrome: a preliminary trial.


      High
      n = 54

      age:

      TG = 47

      CG = 51

      duration: 6-28 wk
      MT and exerciseKT and exercise1×/wk for 6 wkVAS (0-10 cm)





      VAS for night pain









      DASH (0-100)
      Within group (mean change): TG = 1.61 (p ≤ 0.001); CG = 1.07 (p = 0.04)

      Between groups: p = 0.58

      Within group:

      TG = 1.96 (p ≤ 0.001);

      CG = 3.64 (p ≤ 0.001)

      Between groups: p = 0.01

      Within group:

      TG = 29.36 (p ≤ 0.001);

      CG = 26.3 (p ≤ 0.001)

      Between groups: p = 0.46
      MT and KT with exercise similar short-term effects; KT had additional benefit for night painNo untreated comparison group

      Unbalanced attrition rate
      Kromer 2013
      • Kaya DO
      • Baltaci G
      • Toprak U
      • Atay AO
      The clinical and sonographic effects of kinesiotaping and exercise in comparison with manual therapy and exercise for patients with subacromial impingement syndrome: a preliminary trial.


      High
      n = 90

      mean age:

      TG = 50

      CG = 54

      duration: ≥4 wk
      IAEX plus MTIAEX only10 sessions within 5 wkNPRS (0-10)













      SPADI (0-100)
      Within group (mean change): TG = 2.3; CG= 1.6

      p = 0.001

      Between groups: p = 0.15

      Within group: TG = 16.2; CG = 14.4

      p = 0.001

      Between groups: p = 0.64
      IAEX effective; no additional benefit of MTNo sham or no-treatment comparison group
      Rhon 2014
      • Rhon DI
      • Boyles RB
      • Cleland JA
      One-year outcome of subacromial corticosteroid injection compared with manual physical therapy for the management of the unilateral shoulder impingement syndrome: A pragmatic randomized trial.


      Acceptable
      n = 104

      mean age:

      TG = 40

      CG = 42

      duration: >4 mo
      MPTCSITG: 2×/wk for 3 wk

      CG: ≤3 injections (>1 mo apart) in 1 y
      SPADI

      NPRS

      GRC

      1, 3, 6, and 12 mo
      Within group: Significant improvement for all measures at 12 mo, both groups

      Between groups: NS for all measures
      Both groups experienced significant improvementNo blinding; trial recruited only patients referred to MPT

      No standardized diagnostic criteria
      Senbursa 2011
      • Senbursa G
      • Baltaci G
      • Atay OA
      The effectiveness of manual therapy in supraspinatus tendinopathy.


      Low
      n = 77

      mean age:

      TG1 = 48

      TG2 = 51

      CG = 48

      duration not reported
      TG1: Supervised and home-based exercise

      TG2: MT, supervised and home-based exercise
      CG:

      Home-based exercise only
      TG1, TG2: Supervised exercise 3×/wk; TG2: MT 3×/wk

      All groups: Daily home-based exercise
      VAS (0-10 cm)

      MASES
      Within group: Significant improvement in pain and function in all groups at 4 and 12 wk

      Between groups: NS for all measures
      MT may relieve pain and/or shorten treatment periodsPower calculation not done

      Evaluators not blinded
      Kinesiotaping
      Shakeri 2013
      • Shakeri H
      • Keshavarz R
      • Arab AM
      • Ebrahimi I
      Therapeutic effect of kinesio-taping on disability of arm, shoulder, and hand in patients with subacromial impingement dyndrome: A randomized clinical trial.


      Acceptable
      n = 30

      age: 47, both groups

      duration:

      TG = 8 mo

      CG = 9 mo
      Standardized therapeutic KTStandardized sham KT72 h of initial application; reapplied for 48 hDASHWithin group: TG: p = 0.001; CG: p = 0.02

      Between groups: p = 0.01
      KT improved disability of shoulder, arm, and handConvenience sampling

      Small sample

      1-wk follow-up
      Shakeri 2013
      • Shakeri H
      • Keshavarz R
      • Arab AM
      • Ebrahimi I
      Clinical effectiveness of kinesiological taping on pain and pain-free shoulder range of motion in patients with shoulder impingement syndrome: A randomized, double blinded, placebo-controlled trial.


      Acceptable
      n = 30

      age: 46, both groups duration at least 1 wk within last 6 mo prior to study
      Standardized therapeutic KTStandardized sham KT72 h of initial application; reapplied for 48 hVASWithin group: Significant for TG for pain; significant for CG for night pain

      Between groups: NS for pain
      No significant difference between therapeutic KT and sham KTDid not measure functional ability

      Symptoms may have been acute
      Simsek 2013
      • Simsek HH
      • Balki S
      • Keklik SS
      • Ozturk H
      • Elden H
      Does kinesio-taping in addition to exercise therapy improve the outcomes in subacromial impingement syndrome? A randomized, double-blind, controlled clinical trial.


      High
      n = 38

      age:

      TG = 48

      CG = 53

      duration: ≥4 wk
      Standardized therapeutic KT and exerciseStandardized sham KT and exerciseTape was applied at baseline and every 3 d for a total of 12 dVAS (0-10 cm)

      At rest





      During activity





      During sleep











      DASH (0-100)







      CSSa
      Within group (mean change): TG = 1.31 (p ≤ 0.001); CG = 0.56 (p ≤ 0.05)

      Between groups: p = 0.116

      Within group:

      TG = 2.8 (p ≤ 0.001);

      CG = 1.68 (p ≤ 0.001)

      Between groups: p = 0.009

      Within group:

      TG = 3.86 (p ≤ 0.001);

      CG = 1.92 (p ≤ 0.001)

      Between groups:

      p = 0.018

      Within group:

      TG = 21.01 (p ≤ 0.001); CG = 5.59 (p ≤ 0.01)

      Between groups: p = 0.001

      Within group:

      TG = 20.42 (p ≤ 0.001);

      CG = 8.37 (p ≤ 0.001)

      Between groups: p = 0.146
      KT is effective in rehabilitation of SIS when combined with exerciseShort follow-up time
      Low-Level Laser Therapy
      Abrisham 2011
      • Abrisham SM
      • Kermani-Alghoraishi M
      • Ghahramani R
      • Jabbari L
      • Jomeh H
      • Zare M
      Additive effects of low-level laser therapy with exercise on subacromial syndrome: A randomised, double-blind, controlled trial.


      High
      n = 40

      age:

      TG = 52

      CG = 51

      duration not reported
      LLLT, exercise therapyPlacebo laser, exercise therapy6 min/session; 10 totalVAS (0-10 cm)Significant difference between groups in VAS (p = 0.00), with significant pain reduction TGLLLT combined with exercise therapy is more effective than exercise therapy alone in relieving painOutcome measures limited

      No long-term follow-up
      Yavuz 2014
      • Yavuz F
      • Duman I
      • Taskaynatan MA
      • Tan AK
      Low-level laser therapy versus ultrasound therapy in the treatment of subacromial impingement syndrome: A randomized clinical trial.


      High
      n = 31

      age:

      TG = 44

      CG = 45

      duration: >4 wk
      LLTL, hot packs, and exercise programCG: Ultrasound, hot packs and exercise program5×/wk for 2 wk (10 total)VAS (0-100 mm)

      –First month





      –Third month

















      SPADI (0-100)

      –First month

      –Third month
      Within group (mean change): TG = 17.0 (p = 0.026); CG = 14.9 (p = 0.034)

      Between groups: p > 0.05

      Within group:

      TG = 19.0 (p = 0.023);

      CG = 14.3 (p = 0.032)

      Between groups: p > 0.05

      Within group:

      TG = 20.0 (p = 0.004);

      CG = 19.8 (p = 0.025)

      Between groups: p > 0.05

      Within group:

      TG = 22.8 (p = 0.005);

      CG = 23.4 (p = 0.043)

      Between groups: p > 0.05
      Efficacy of LLLT and ultrasound seemed comparable regarding pain and disability reduction in patients with impingementNo nontreatment comparison group

      Small sample size

      Short-term follow-up
      Microcurrent
      Atya 2012
      • Atya AM
      Efficacy of microcurrent electrical stimulation on pain, proprioception accuracy and functional disability in subacromial impingement: Randomized controlled trial.


      Low
      n = 40

      age: 49, both groups

      duration:

      TG = 6 mo

      CG = 7 mo
      Microcurrent stimulationSham; identical procedure except electrodes not connectedDuration: 20 min 3×/wk for 6 wk (total of 18 treatments)VAS













      SDQ
      Within group (mean change): TG = –1.65 (p = 0.001); CG = –0.45 (p = 0.156)

      Between groups: p = 0.015

      Within group:

      TG = -5.35 (p = 0.003);

      CG = 0.55 (p = 0.52)

      Between groups: p = 0.007
      Microcurrent stimulation may be effective for improving pain and function in patients with SISNo power calculation and sample size was small

      Did not report attrition
      Extracorporeal Shockwave Therapy
      Engebretsen 2011
      • Engebretsen K
      • Grotle M
      • Bautz-Holter E
      • Ekeberg OM
      • Juel NG
      • Brox JI
      Supervised exercises compared with radial extracorporeal shock-wave therapy for subacromial shoulder pain: 1-Year results of a single-blind randomized controlled trial.


      Acceptable
      n = 94

      age:

      TG = 49

      CG = 47

      duration: >3 mo
      rESWTSupervised exercise and home exerciserESWT: 1×/wk for 4-6 wk

      SE: 2 45-min sessions/wk for maximum of 12 wk
      SPADIWithin group: Significant improvement (p = 0.001) in both groups

      Between groups: No significant difference at 1-y follow-up (p = 0.093).
      No significant differences between groups at 1-y follow-upNo placebo control

      Possible misclassification bias

      Possible attrition bias
      Pulsed Electromagnetic Field Therapy
      Galace de Frietas 2014
      • Galace-de Frietas D
      • Lima MR
      • Beretta MF
      • et al.
      Pulsed electromagnetic field in patients with shoulder impingement syndrome.


      High
      n = 56

      age:

      TG = 50

      CG = 51

      duration:

      TG = 22 mo

      CG = 21 mo
      PEMF and exercisesPlacebo PEMF and exercises30-min treatments. 9 sessions (3/wk for 3 wk)VAS

      UCLA shoulder rating scale

      Constant-Murley shoulder score
      Within group: Significant in both groups for improved function and decreased pain (p ≤ 0.05).

      Between groups: No significant difference for pain or function at 3 wk, 9 mo, and 3 mo
      Lack of Between-group differences indicate PEMF has no additional benefit to exerciseNo verification of patients performing their exercises
      Transcutaneous Nerve Stimulation
      Kocyigit 2012
      • Kocyigit F
      • Akalin E
      • Gezer NS
      • Orbay O
      • Kocyigit A
      • Ada E
      Functional magnetic resonance imaging of the effects of low-frequency transcutaneous electrical nerve stimulation on central pain modulation: A double-blind, placebo-controlled trial.


      Acceptable
      n = 20

      age:

      TG = 49

      CG = 45

      duration: ≥1 mo
      Low-frequency TENSSham TENS1 treatmentVAS (0-100 mm)Within group (mean change): TG = 18.0 (p = 0.015); CG = 0.8 (p = 0.624)

      Between groups: Significant difference VAS
      TENS showed significant reduction in painOnly 1 treatment and no follow-up
      Exercise
      Granviken 2015
      • Granviken F
      • Vasseljen O
      Home exercises and supervised exercises are similarly effective for people with subacromial impingement: A randomised trial.


      High
      n = 46

      age: 48, both groups

      duration: >12 wk
      SE and HEHE only6 wk

      TG: 10 SE sessions and HE

      CG: 1 training session for daily HE
      Pain scale (0-10)









      SPADI (0-100)
      Within group (mean change):

      6 wk: TG = –2.1; CG = –1.8

      Between groups: NS

      Within group:

      26 wk: TG = –27; CG = –26

      Between groups: NS
      Supervision of more than the first session of a 6-wk exercise regimen did not yield significant differences from HE aloneThere may be subgroups that benefit from supervision
      CG, comparison group; CSI, corticosteroid injection; DASH, Disabilities of the Arm, Shoulder and Hand Questionnaire; ECWT, extracorporeal shockwave therapy; GRC, Global Rating of Change; HE, home exercise; IAEX, individually adapted exercises; KT, kinesiotaping; LLLT, low-level laser therapy; MASES, Modified American Shoulder and Elbow Surgery questionnaire; MT, manual therapy, including any type of mobilization, stretching, or soft tissue technique applied to the shoulder and surrounding tissue, not the vertebral joints, unless otherwise specified; MPT, manual physical therapy; MWM, mobilization with movement; NPRS, Numeric Pain Rating Scale; NS, nonsignificant; PASS, Patient Acceptable Symptom State; PEMF, pulsed electromagnetic field therapy; PSS, Penn Shoulder Score; QuickDASH, Quick Disabilities of the Shoulder and Hand Questionnaire; SDQ, Shoulder Disability Questionnaire; SE, supervised exercise; SIS, shoulder impingement syndrome; SMT, spinal manipulative therapy, including manipulation and/or mobilization of vertebrae unless otherwise specified; SPADI, Shoulder Pain and Disability Index; TENS, transcutaneous nerve stimulation; TG, treatment group; VAS, visual analog scale for pain.
      Table 5Evidence Table for Included Randomized Controlled Trials of Nondrug, Nonsurgical Treatment of Adhesive Capsulitis
      Citation and QualityPatient Population, Mean Age, Mean Symptom DurationInterventionComparison Group(s)DosagePain and/or Disability Outcome MeasuresOutcomes (Mean Change Within and Between Groups)ConclusionsLimitations
      Doner 2013
      • Doner G
      • Guven Z
      • Atalay A
      • Celiker R
      Evaluation of Mulligan's technique for adhesive capsu76. litis of the shoulder.


      Low
      n = 40

      age: 59, both groups

      duration: >3 mo
      Mulligan’s shoulder mobilization, hot packs, TENSPassive shoulder stretching, hot packs, TENSBoth groups: 3 sets of 10 reps/d; 5 d/wk for 3 wkVAS at rest and during activity

      CSS

      SDQ

      Measured at 3 wk and 3 mo
      Within group: Both groups improved at 3 wk and 3 mo

      Between groups: VAS at rest at 3 mo (p = 0.02)

      VAS during activity at 3 wk and 3 mo (p = 0.005, 0.003)

      CSS and SDQ at 3 wk and 3 mo (p < 0.05)
      Mulligan’s mobilization is more effective than passive stretchingBlinding of therapists not possible

      Outside care difficult to control

      Compliance to study protocol in question
      Hsieh 2012
      • Hsieh LF
      • Hsu WC
      • Lin YJ
      • Chang HL
      • Chen CC
      • Huang V
      Addition of intra-articular hyaluronate injection to physical therapy program produces no extra benefits in patients with adhesive capsulitis of the shoulder: A randomized controlled trial.


      High
      n = 63

      age:

      TG = 56

      CG = 53

      duration: ≥3 mo
      Hyaluronic acid intra-articular injection + PTPT: therapeutic exercises, heat and electric therapyTG: 1 injection/wk for 3 wk, in addition to PT for 12 wk

      CG: 3 1-h sessions/wk for 12 wk
      SPADI

      SDQ

      SF-36 (QoL)
      Within group: Significant improvement in pain, disability and QoL (p < 0.05)

      Between groups: NS for any measure
      Addition of intra-articular hyaluronic acid injections to PT did not produce a significant added benefitNo untreated control group

      Injection using blind technique may have reduced procedure accuracy
      Klc 2015
      • Klc Z
      • Filiz MB
      • Cakr T
      • Toraman NF
      Addition of suprascapular nerve block to a physical therapy program produces an extra benefit to adhesive capsulitis: A randomized controlled trial.


      Acceptable
      n = 41

      age:

      TG = 55

      CG = 62

      duration: >1 mo
      Suprascapular nerve block injection before PTPT alone (hot pack, TENS, US, exercises, stretching)TG: 1 injection prior to PT

      CG: 5×/wk for 3 wk of PT
      CSS

      BPI-SF

      Measured immediately after course of PT and 1 mo later
      Within group: CSS and BPI-SF both significantly improved at both measurement intervals

      Between groups: Significantly greater improvement in TG immediately post-intervention in CSS and BPI-SF

      No difference in CSS at 1-mo follow-up; significantly greater improvement on BPI-SF
      PT and nerve block both effective for function and pain, with greater pain reduction with nerve blockYounger age of the TG

      Small sample size

      Short follow-up
      Ma 2013
      • Ma SY
      • Je HD
      • Jeong JH
      • Kim HY
      • Kim HD
      Effects of whole-body cryotherapy in the management of adhesive capsulitis of the shoulder.


      High
      n = 30

      age: 57, both groups

      duration: ≥3 mo
      WBC plus PTPT only3×/wk for 4 wk (12 sessions total)VAS

      ASES measured immediately post-intervention (at 4 wk)
      Within group: Both groups had significant improvement in VAS and ASES

      Between groups: Significant difference favoring WBC for VAS and ASES (p < 0.01)
      WBC exhibits additional benefit when combined with PTSmall sample size

      No group receiving no treatment

      Short follow-up
      Maryam 2012
      • Maryam M
      • Zahra K
      • Adeleh B
      • Morteza Y
      Comparison of corticosteroid injections, physiotherapy, and combination therapy in treatment of frozen shoulder.


      Acceptable
      n = 87

      age:

      TG1 & TG2 = 54

      CG = 53

      duration:

      TG1 = 4 mo

      TG2 = 6 mo

      CG = 7 mo
      TG1: CSI, home exercise

      TG: CSI, PT, home exercise
      CG: PT (TENS, ice, active ROM), home exerciseTG1: 1 CSI; TG2: 1 CSI prior to PT

      TG2 and CG: 10 sessions PT
      Pain score

      Disability score

      SPADI

      Measured 6 wk post-intervention
      Within group: Not analyzed

      Between groups: Significant improvement in disability and SPADI, but not pain, favoring combination of CSI and PT
      CSI + PT was more successful at 6 wk post-intervention than CSI or PT aloneSmall sample size

      High attrition rate
      Chen 2014
      • Chen CY
      • Hu CC
      • Weng PW
      • et al.
      Extracorporeal shockwave therapy improves short-term functional outcomes of shoulder adhesive capsulitis.


      High
      n = 40

      age:

      TG = 54

      CG = 52

      duration: ≥3 mo
      ESWTOral steroids (prednisone)ESWT: 3 treatments 2 wk apart

      Prednisone: 30 mg/d for 2 wk, 15 mg/d for 2 wk
      CSS

      OSS
      Within group: Both groups had significant improvement throughout study on both CSS and OSS

      Between groups: Significant difference favoring ESWT at 4 wk on CSS (p = 0.009) and on both CSS (p ≤ 0.001) and OSS (p = 0.020) at 6 wk and (p = 0.041) and 12 wk (p = 0.045)
      Both groups had improvement after receiving treatment, but those receiving ESWT had statistically significantly greater improvementSmall sample size

      Participants not blinded to treatment group
      Shi 2012
      • Shi H
      • Fang JQ
      • Li BW
      • Cong WJ
      • Zhang Y
      • Chen L
      Efficacy assessment for different acupuncture therapies in the treatment of frozen shoulder.


      Acceptable
      n = 174

      age:

      TG1 = 52

      TG2 = 55

      CG = 54

      duration: 2-24 wk
      TG: Electroacupuncture

      TG2: Warming needles
      CG:

      Filiform needle
      30 min each visit, with a total of 5 visits occurring every other dayVAS measured after 5-visit course of treatmentWithin group: Significant improvement in all groups (p ≤ 0.01)

      Between groups: TG1 and 2 significantly more effective than CG; TG1 significantly more effective than TG2 (p = 0.01)
      All 3 therapies effective but electroacupuncture and warming needles are superior to filiform needless, with electroacupuncture outperforming warming needlesShort-term follow- up
      Smitherman 2015
      • Smitherman JA
      • Struk AM
      • Cricchio M
      • et al.
      Arthroscopy and manipulation versus home therapy program in treatment of adhesive capsulitis of the shoulder: a prospective randomized study.


      Acceptable
      n = 26

      age: 52, both groups duration not stated, but all patients were treated at least 4 mo with PT before enrolling in study
      Arthroscopic capsular release, MUA, home stretching programHome stretching program onlyStretches were 2×/d for at least 15 min for at least 3 moSPADI at 12 wk and 1 yWithin group: Both groups improved significantly at 12 wk and 1 y

      Between groups:

      NS differences
      Both treatments provide significant improvement in functionSmall sample size

      Relatively large loss to follow-up
      ASES, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form; BPI-SF, Brief Pain Inventory—Short Form; CG, comparison group; CSI, corticosteroid injection; CSS, Constant Shoulder Score; DASH, Disabilities of the Arm, Shoulder and Hand Questionnaire; ESWT, extracorporeal shockwave therapy; MT, manual therapy, including any type of mobilization, stretching, or soft tissue technique applied to the shoulder and surrounding tissue, not the vertebral joints, unless otherwise specified; MUA, manipulation under anesthesia; NPRS, Numeric Pain Rating Scale; NS, nonsignificant; OSS, Oxford Shoulder Score; PT, physical therapy, including modalities such as heat, ultrasound, and electrotherapy, plus passive and/or active exercise, unless otherwise specified; QoL, quality of life; rESWT, radial ESWT; SDQ, Shoulder Disability Questionnaire; SPADI, Shoulder Pain and Disability Index; TENS, transcutaneous nerve stimulation; TG, treatment group; US, ultrasound; VAS, visual analog scale for pain; WBC, whole-body cryotherapy
      Table 6Evidence Table for Included Randomized Controlled Trials of Nondrug, Nonsurgical Treatment of Rotator Cuff-Associated Disorders
      Citation and QualityPatient Population, Mean Age, Mean Symptom DurationIntervention Group(s)Comparison Group(s)DosagePain and/or Disability Outcome MeasuresOutcomes (Mean Change Within and Between Groups)ConclusionsLimitations
      Physical Therapy
      Kukkonen 2014
      • Kukkonen J
      • Joukainen A
      • Lehtinen J
      • et al.
      Treatment of non-traumatic rotator cuff tears: A randomised controlled trial with one-year clinical results.


      Acceptable
      n = 167

      age: 65, all groups

      duration:

      TG = 26 mo

      CG1 = 28 mo

      CG2 = 28 mo
      PT only (consists of PT plus home exercises)CG1: PT plus acromioplasty

      CG2: PT plus acromioplasty and RC repair
      10 PT sessions (after surgery and home exercises for CG1 and CG2)CSS

      Measured at 1-y follow-up
      Within group: All groups improved significantly at 1 y

      Between groups: No significant difference (p = 0.34)

      Pain (p = 0.03) and ADL (p < 0.00001) subscales were significantly different, favoring CG1 and CG2 (strength and ROM did not differ)
      All 3 approaches effective in long term, although surgery superior to PT for pain and ADLOutcomes for ROM and strength were emphasized more than those for pain and ADL
      Kukkonen 2015
      • Kukkonen J
      • Joukainen A
      • Lehtinen J
      • et al.
      Treatment of nontraumatic rotator cuff tears: A randomized controlled trial with two years of clinical and imaging follow-up.


      Acceptable
      n = 167

      age:

      TG = 65

      CGI & CG2 = 66

      duration:

      TG = 26 mo

      CG1 = 26 mo

      CG2 = 28 mo
      PT only (consists of PT plus home exercises)CG1: PT plus acromioplasty

      CG2: PT plus acromioplasty and RC repair
      10 PT sessions

      (after surgery and home exercises for CG1 and CG2)
      CSS



























      VAS
      Within group: All groups improved significantly at 2 y

      Between groups: NS difference (p = 0.38)

      Pain (p = 0.01) and ADL (p < 0.01) subscales were significantly different, favoring CG1 and CG2 (strength and ROM did not differ)

      Pre-post mean change: TG, –1.3; CG1, –1.8; CG2, –2.0

      Between group (p = 0.45)
      Surgical treatment of nontraumatic rotator cuff tears had no benefit over conservative treatment7 patients with both shoulders enrolled in the study

      5 crossovers in group 1
      Moosmayer 2014
      • Moosmayer S
      • Lund G
      • Seljom US
      • et al.
      Tendon repair compared with physiotherapy in the treatment of rotator cuff tears: A randomized controlled study in 103 cases with a five-year follow-up.


      High
      n = 103

      age:

      TG = 59

      CG = 61

      duration: acute and chronic
      Tendon repair followed by sling and passive ROM for 6 wk, active assisted motions wk 6-12PT with individualized exercisesGroup 1: 12 wk

      Group 2: 40 min PT sessions 2×/wk for 12 wk
      CSS, ASES, SF-36 (Physical), VAS

      Measured at 5-y follow-up
      Within group: Both groups improved on all measurement scales

      Between groups: All measures significantly favored TG
      Small, but statistically significant difference in favor of primary tendon repair of small and medium-sized full-thickness tears of RC over PTPT and surgery were not completely standardized

      Traumatic and nontraumatic RC tears included

      Study group consisted exclusively of patients referred for secondary health care

      Biceps pathology treated with tenodesis in the surgical group, but not PT
      Extracorporeal Shockwave Therapy
      Kolk 2013
      • Kolk A
      • Auw-Yang KG
      • Tamminga R
      • Hoeven H
      Radial extracorporeal shock-wave therapy in patients with chronic rotator cuff tendinitis: A prospective randomised double-blind placebocontrolled multicentre trial.


      High
      n = 82 patients with RC tendinitis

      age:

      TG = 48

      CG = 46

      duration:

      TG = 24 mo

      CG = 29 mo
      rESWTSham rESWT3 sessions within 10- to 14-d periodVAS

      CMS

      SST

      Measured 3 and 6 mo post-intervention
      Within group: Significant for all measures (p < 0.001)

      Between group: No significant differences in any measure (p > 0.05)
      rESWT does not have benefit greater than shamPower calculation based on observations in a small sample

      No subgroup analysis for patients with and without calcific tendinitis
      Liu 2012
      • Liu S
      • Zhai L
      • Shi Z
      • Jing R
      • Zhao B
      • Xing G
      Radial extracorporeal pressure pulse therapy for the primary long bicipital tenosynovitis: A prospective randomized controlled study.


      High
      n = 79 patients with long bicipital tenosynovitis

      age:

      TG = 56

      CG = 55

      duration:

      TG = 22 mo

      CG = 18 mo
      Active rESWTSham/detuned rESWT4 treatments 1×/wk without anesthesiaVAS L’Insalata Shoulder Questionnaire

      Measured 1, 3, and 12 mo post-intervention
      Within group: VAS and L’Insalata significantly different in TG at all time points (p = 0.000), but not in CG



      Between-group

      Significant differences favoring ESWT (p = 0.000)
      Recommend rESWT in treatment of chronic, primary long-head bicipital tenosynovitisMay not have been a clinically meaningful effective dose

      Time of each treatment not clarified

      Unclear if disability questionnaire has been previously validated
      Tornese 2011
      • Tornese D
      • Mattei E
      • Bandi M
      • Zerbi A
      • Quaglia A
      • Melegati G
      Arm position during extracorporeal shock wave therapy for calcifying tendinitis of the shoulder: A randomized study.


      Acceptable
      n = 35 patients with calcific tendinitis

      age:

      TG = 52

      CG = 53

      duration not reported
      ESWT with internal rotation positioning of glenohumeral joint and exerciseESWT with neutral positioning and exercise3 treatments 1×/wkCSS

      Measured 3 mo post-intervention
      Between-group: NS (p > 0.05)

      Deposit resorption was statistically better in TG group (p < 0.05)
      GH internal rotation positioning for ESWT is beneficial when compared with neutral positioning for deposit resorptionSmall sample size

      Primary outcome (radiographic evidence of deposit resorption) may not correlate with functional and pain outcomes
      Low-Level Laser Therapy
      Eslamian 2012
      • Eslamian F
      • Shakouri SK
      • Ghojazadeh M
      • Nobari OE
      • Eftekharsadat B
      Effects of low-level laser therapy in combination with physiotherapy in the management of rotator cuff tendinitis.


      High
      n = 50

      age: 50, both groups

      duration not specifically reported
      LLLT and PTSham LLLT and PT (heat, ultrasound, TENS, exercise3×/wk for 10 sessionsVAS

      SDQ

      Measured 3 wk post-intervention
      Within group: VAS and SDQ significantly improved, both groups (p < 0.001)

      Between groups: Significant differences in favor of TG

      VAS (p = 0.031); SDQ (p = 0.029)
      LLLT provides added benefit to PTUnclear if CG and TG treated similarly during trial

      Short follow-up interval
      Diathermy
      Rabini 2012
      • Rabini A
      • Piazzini DB
      • Bertolini C
      • et al.
      Effects of local microwave diathermy on shoulder pain and function in patients with rotator cuff tendinopathy in comparison to subacromial corticosteroid injections: A single-blind randomized trial.




      High
      n = 82

      age:

      TG = 56

      CG = 59

      duration: >3 mo
      Subacromial corticosteroid injectionMicrowave DiathermyTG: 3 (1 injection every 2 wk)

      CG: 12 sessions (3/wk for 4 wk), 30 min each
      QuickDASH

      CSS

      VAS

      Measured 4, 12, and 24 wk post-intervention
      Within group: Significant effect in both groups on all measures

      Between groups: NS (p = 0.255)
      Both treatments were effectiveNo placebo group

      No exercise treatment group
      ADL, activities of daily living; ASES, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form; CG, comparison group; CMS, Constant-Murley Score; CSS, Constant Shoulder Score; ESWT, extracorporeal shockwave therapy; LLLT, low-level laser therapy; MT, manual therapy, including any type of mobilization, stretching or soft tissue technique applied to the shoulder and surrounding tissue, not the vertebral joints, unless otherwise specified; NS, nonsignificant; PT, physical therapy, including modalities such as heat, ultrasound, and electrotherapy, plus passive and/or active exercise, unless otherwise specified; QuickDASH, Quick Disabilities of the Shoulder and Hand Questionnaire; rESWT, radial ESWT; ROM, range of motion; SDQ, Shoulder Disability Questionnaire; SPADI, Shoulder Pain and Disability Index; SST, Simple Shoulder Test; TENS, transcutaneous nerve stimulation; TG, treatment group; VAS, visual analog scale
      Table 7Evidence Table for Included Randomized Controlled Trials of Nondrug, Nonsurgical Treatment of Nonspecific Shoulder Pain
      Citation and QualityPatient Population, Mean Age, Mean Symptom DurationIntervention Group(s)Comparison Group(s)DosagePain and Function/Disability Outcome MeasuresOutcomes (Mean Change Within and Between Groups)ConclusionsLimitations
      Bron 2011
      • Bron C
      • Gast A
      • Dommerholt J
      • Stegenga B
      • Wensing M
      • Oostendorp RA
      Treatment of myofascial trigger points in patients with chronic shoulder pain: A randomized, controlled trial.


      Acceptable
      n = 65

      age:

      TG = 43

      CG = 45

      duration: ≥6 mo
      PT including MT, cold and heat application, home exercises with portable myofeedback device, posture adviceWait list1 session/wk for maximum of 12 wkDASH (0-100)

      VAS (0-100)
      Within-group: Significantly greater improvement in DASH and VAS in TG, but not CG at 6 and 12 wk

      Between-group: NS on both measures at 6 wk, but significant at 12 wk (p < 0.05)
      PT superior to wait list control at 12-wk measurementSample size not met

      Possible misclassification if examiners gave CG patients advice

      TG had higher level of education than CG
      Riley 2015
      • Riley SP
      • Cote MP
      • Leger RR
      • et al.
      Short-term effects of thoracic spinal manipulations and message conveyed by clinicians to patients with musculoskeletal shoulder symptoms: A randomized clinical trial.


      Acceptable
      n = 88

      age: 49

      duration: 6 mo
      TG1: Thoracic SMT, home exercise and positive message

      TG2: Thoracic SMT, home exercise, neutral message
      CG1:

      Sham SMT, home exercise, positive message

      CG2: Sham SMT, home exercise, neutral message
      1 treatment visitSPADI

      NPRS measured immediately post-intervention and 1 wk later
      Within-group Statistically significant improvement in all groups except NPRS immediately post-intervention

      Between-group NS
      No significant differences in outcomes between type of message or type of SMT (active or sham)Statistically significant difference in symptom duration between the groups at baseline
      Montes 2012
      • Montes-Molina R
      • Prieto-Baquero A
      • Martínez-Rodriguez ME
      • Romojaro-Rodriguez AB
      • Gallego-Méndez V
      • Martínez-Ruiz F
      Interferential laser therapy in the treatment of shoulder pain and disability from musculoskeletal pathologies: A randomised comparative study.


      High
      n = 198

      age:

      TG = 57

      CG = 54

      duration varied from acute to chronic; most were chronic (>90 d)
      Interferential laserConventional laser3 sessions/wk, total of 10 treatmentsVAS

      SPADI

      Assessed immediately post-intervention
      Within-group: Significant improvement in VAS at night and SPADI (p < 0.001)

      Between-group: NS for VAS (p = 0.89) and SPADI (p = 0.80)
      Both types of laser were effective with no significant difference between groupsShort- term outcomes

      Some patients in each group performed exercises

      Heterogeneity of conditions
      Teys 2013
      • Teys P
      • Bisset L
      • Collins N
      • Coombes B
      • Vicenzino B
      One-week time course of the effects of Mulligan's Mobilisation with Movement and taping in painful shoulders.


      Acceptable
      n = 25

      age: 45

      duration: >4 wk
      3 sets of 10 repetitions of MWM3 sets of 10 repetitions of MWM with KT1 treatment session of each therapy (following 1-wk washout period and crossover)VAS

      (0-100 mm)

      Measured immediately post-intervention and 30 min, 24 h, and 1 wk later
      Within-group: Both groups significantly improved immediately and 30 min (p ≤ 0.001) only

      Between-group: NS at any time point (p = 0.7)
      Significant improvements in pain up to 30 min post-intervention but NS differences between groupsInclusion criteria of immediate positive response to screening procedure may limit generalizability

      Lack of blinding of outcome assessor and participants
      CG, comparison group; DASH, Disabilities of the Arm, Shoulder and Hand Questionnaire; GRC, Global Rating of Change; KT, kinesiotaping; MT, manual therapy, including any type of mobilization, stretching, or soft tissue technique applied to the shoulder and surrounding tissue, not the vertebral joints, unless otherwise specified; MWM, mobilization with movement; NPRS, Numeric Pain Rating Scale; NS, nonsignificant; PT, physical therapy; including modalities such as heat, ultrasound, and electrotherapy, plus passive and/or active exercise, unless otherwise specified; SMT, spinal manipulative therapy, including manipulation and/or mobilization of vertebrae unless otherwise specified; SPADI, Shoulder Pain and Disability Index; TG, treatment group; VAS, visual analog scale for pain.

      Shoulder Impingement Syndrome

      There were 19 RCTs focusing on SIS. Four compared spinal manipulative therapy (SMT) with another treatment or sham; 5 compared MT with another treatment or sham, and 10 compared various modalities with another treatment or sham (Table 4).

      SMT Trials

      For all 4 trials, both treatment and comparison groups improved. One high-quality trial (n = 68) with patients of mean age 53 with SIS symptom duration >12 months found no additional benefit from combining cervical SMT with MT, compared with MT alone.
      • Cook C
      • Learman K
      • Houghton S
      • Showalter C
      • O’Halloran B
      The addition of cervical unilateral posterior-anterior mobilisation in the treatment of patients with shoulder impingement syndrome: A randomised clinical trial.
      Three high-quality trials found no significant difference between thoracic SMT and sham thoracic SMT. However, in all 3 of these, only 1 SMT session was included and only short-term effects on pain were measured, with patients whose mean age was in the early 30s.
      • Haik MN
      • Alburquerque SF
      • Silva CZ
      • Siqueira-Junior AL
      • Ribeiro IL
      • Camargo PR
      Scapular kinematics pre- and post-thoracic thrust manipulation in individuals with and without shoulder impingement symptoms: a randomized controlled study.
      • Kardouni JR
      • Pidcoe PE
      • Shaffer SW
      • et al.
      Thoracic spine manipulation in individuals with subacromial impingement syndrome does not immediately alter thoracic spine kinematics, thoracic excursion, or scapular kinematics: A randomized controlled trial.
      • Kardouni JR
      • Shaffer SW
      • Pidcoe PE
      • Finucane SD
      • Cheatham SA
      • Michener LA
      Immediate changes in pressure pain sensitivity after thoracic spinal manipulative therapy in patients with subacromial impingement syndrome: A randomized controlled study.
      Only 1 of these trials
      • Delgado-Gil JA
      • Prado RE
      • Rodrigues-de-Souza DP
      • Cleland JA
      • Fernandez-De-Las PC
      • Alburquerque SF
      Effects of mobilization with movement on pain and range of motion in patients with unilateral shoulder impingement syndrome: A randomized controlled trial.
      reported on adverse events, and in that case, there were none.

      MT Trials

      For all 5 trials, both treatment and comparison groups improved significantly. One trial found a statistically significant difference between the treatment and comparison groups.
      • Delgado-Gil JA
      • Prado RE
      • Rodrigues-de-Souza DP
      • Cleland JA
      • Fernandez-De-Las PC
      • Alburquerque SF
      Effects of mobilization with movement on pain and range of motion in patients with unilateral shoulder impingement syndrome: A randomized controlled trial.
      In that study, the type of MT was MWM, and it was compared with a sham manual contact. Pain intensity was significantly improved in the MT group, compared with the sham, in a sample of 42 patients in their mid-50s with SIS of greater than 3 months’ duration.
      Two MT trials compared MT plus exercise with exercise alone; 1 was high quality
      • Kromer TO
      • Bie RA
      • Bastiaenen CH
      Physiotherapy in patients with clinical signs of shoulder impingement syndrome: A randomized controlled trial.
      and 1 low quality.
      • Senbursa G
      • Baltaci G
      • Atay OA
      The effectiveness of manual therapy in supraspinatus tendinopathy.
      Both found no added benefit from MT.
      One high-quality MT trial compared MT plus exercise with kinesiotaping (KT) plus exercise.
      • Kaya DO
      • Baltaci G
      • Toprak U
      • Atay AO
      The clinical and sonographic effects of kinesiotaping and exercise in comparison with manual therapy and exercise for patients with subacromial impingement syndrome: a preliminary trial.
      Both groups improved significantly in pain and function, but there was no significant between-group difference except for night pain, in which case KT was superior.
      One acceptable-quality trial compared MT (manual PT) with CSIs,
      • Rhon DI
      • Boyles RB
      • Cleland JA
      One-year outcome of subacromial corticosteroid injection compared with manual physical therapy for the management of the unilateral shoulder impingement syndrome: A pragmatic randomized trial.
      and both groups improved significantly, with no significant between-group difference. This was the only study reporting on adverse events, and these were transient pain from the injections.

      Modalities and Exercise Trials

      Ten trials investigated the following: KT (3); low-level laser treatment (2); microcurrent (1); ESWT (1); pulsed electromagnetic field therapy (1); transcutaneous electrical nerve stimulation (1); and exercise (1).

      Kinesiotaping

      One high-quality
      • Simsek HH
      • Balki S
      • Keklik SS
      • Ozturk H
      • Elden H
      Does kinesio-taping in addition to exercise therapy improve the outcomes in subacromial impingement syndrome? A randomized, double-blind, controlled clinical trial.
      and 2 acceptable-quality trials compared KT with sham KT.
      • Shakeri H
      • Keshavarz R
      • Arab AM
      • Ebrahimi I
      Clinical effectiveness of kinesiological taping on pain and pain-free shoulder range of motion in patients with shoulder impingement syndrome: A randomized, double blinded, placebo-controlled trial.
      • Shakeri H
      • Keshavarz R
      • Arab AM
      • Ebrahimi I
      Therapeutic effect of kinesio-taping on disability of arm, shoulder, and hand in patients with subacromial impingement dyndrome: A randomized clinical trial.
      The 2 acceptable-quality trials used standardized therapeutic KT and sham KT; the high-quality trial compared KT plus exercise with sham KT plus exercise. An acceptable-quality trial comparing KT and sham used the Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH) as the primary outcome and found significant between-group improvement.
      • Shakeri H
      • Keshavarz R
      • Arab AM
      • Ebrahimi I
      Therapeutic effect of kinesio-taping on disability of arm, shoulder, and hand in patients with subacromial impingement dyndrome: A randomized clinical trial.
      The other acceptable-quality trial comparing KT with sham KT used the visual analog scale for pain (VAS), and found no significant difference between groups, although both groups improved.
      • Shakeri H
      • Keshavarz R
      • Arab AM
      • Ebrahimi I
      Clinical effectiveness of kinesiological taping on pain and pain-free shoulder range of motion in patients with shoulder impingement syndrome: A randomized, double blinded, placebo-controlled trial.
      The third trial, which was high quality and included exercise in both groups, found significant improvement both within and between groups for both pain (VAS) and function (DASH), favoring the therapeutic KT group.
      • Simsek HH
      • Balki S
      • Keklik SS
      • Ozturk H
      • Elden H
      Does kinesio-taping in addition to exercise therapy improve the outcomes in subacromial impingement syndrome? A randomized, double-blind, controlled clinical trial.

      Low-Level Laser Therapy

      Two high-quality trials investigated LLLT. Both used LLLT combined with exercise. One used placebo laser with exercise as the comparison group,
      • Abrisham SM
      • Kermani-Alghoraishi M
      • Ghahramani R
      • Jabbari L
      • Jomeh H
      • Zare M
      Additive effects of low-level laser therapy with exercise on subacromial syndrome: A randomised, double-blind, controlled trial.
      and the other used ultrasound and hot packs with exercise.
      • Yavuz F
      • Duman I
      • Taskaynatan MA
      • Tan AK
      Low-level laser therapy versus ultrasound therapy in the treatment of subacromial impingement syndrome: A randomized clinical trial.
      One found significant improvement in pain (VAS) in the active LLLT group, but not in the placebo group.
      • Abrisham SM
      • Kermani-Alghoraishi M
      • Ghahramani R
      • Jabbari L
      • Jomeh H
      • Zare M
      Additive effects of low-level laser therapy with exercise on subacromial syndrome: A randomised, double-blind, controlled trial.
      The other trial found a within-group improvement in pain (VAS) and function (Shoulder Pain and Disability Index [SPADI]) for both LLLT plus exercise and ultrasound plus exercise, but no significant difference between groups.
      • Yavuz F
      • Duman I
      • Taskaynatan MA
      • Tan AK
      Low-level laser therapy versus ultrasound therapy in the treatment of subacromial impingement syndrome: A randomized clinical trial.

      Microcurrent

      One low-quality study comparing microcurrent with sham found significant improvement in pain (VAS) and disability (Shoulder Disability Questionnaire) both within and between the groups.
      • Ma SY
      • Je HD
      • Jeong JH
      • Kim HY
      • Kim HD
      Effects of whole-body cryotherapy in the management of adhesive capsulitis of the shoulder.

      Extracorporeal Shockwave Therapy

      One acceptable-quality trial compared radial ESWT with supervised and home exercise.
      • Engebretsen K
      • Grotle M
      • Bautz-Holter E
      • Ekeberg OM
      • Juel NG
      • Brox JI
      Supervised exercises compared with radial extracorporeal shock-wave therapy for subacromial shoulder pain: 1-Year results of a single-blind randomized controlled trial.
      Within-group improvements in the SPADI were significant at 1-year follow-up; however, the between-group difference was not significant.

      Pulsed Electromagnetic Field Therapy

      One high-quality trial compared PEMF and exercise with placebo PEMF and exercise.
      • Galace-de Frietas D
      • Lima MR
      • Beretta MF
      • et al.
      Pulsed electromagnetic field in patients with shoulder impingement syndrome.
      Although within-group improvements in both pain (VAS) and function (UCLA shoulder rating scale) were significant, there were no significant between-group differences at any follow-up interval.

      Transcutaneous Electrical Nerve Stimulation

      One acceptable-quality trial compared TENS with sham TENS with 1 treatment.
      • Kocyigit F
      • Akalin E
      • Gezer NS
      • Orbay O
      • Kocyigit A
      • Ada E
      Functional magnetic resonance imaging of the effects of low-frequency transcutaneous electrical nerve stimulation on central pain modulation: A double-blind, placebo-controlled trial.
      The active TENS group had a significant improvement in pain (VAS) and the sham group did not; there was a significant between-group difference.

      Supervised Exercise

      A high-quality trial compared supervised exercise (SE) and home exercise with home exercise only.
      • Granviken F
      • Vasseljen O
      Home exercises and supervised exercises are similarly effective for people with subacromial impingement: A randomised trial.
      Both groups exhibited a significant improvement in pain (VAS) and function (SPADI) at 6 and 26 weeks, but no significant between-group differences at either time point.

      Adhesive Capsulitis

      There were 8 RCTs focusing on AC. Five studies compared a treatment combined with standardized PT with standardized PT alone.
      • Hsieh LF
      • Hsu WC
      • Lin YJ
      • Chang HL
      • Chen CC
      • Huang V
      Addition of intra-articular hyaluronate injection to physical therapy program produces no extra benefits in patients with adhesive capsulitis of the shoulder: A randomized controlled trial.
      • Klc Z
      • Filiz MB
      • Cakr T
      • Toraman NF
      Addition of suprascapular nerve block to a physical therapy program produces an extra benefit to adhesive capsulitis: A randomized controlled trial.
      • Ma SY
      • Je HD
      • Jeong JH
      • Kim HY
      • Kim HD
      Effects of whole-body cryotherapy in the management of adhesive capsulitis of the shoulder.
      • Maryam M
      • Zahra K
      • Adeleh B
      • Morteza Y
      Comparison of corticosteroid injections, physiotherapy, and combination therapy in treatment of frozen shoulder.
      • Smitherman JA
      • Struk AM
      • Cricchio M
      • et al.
      Arthroscopy and manipulation versus home therapy program in treatment of adhesive capsulitis of the shoulder: a prospective randomized study.
      In 4 of 5, both groups improved significantly; in the fifth trial; within-group changes were not reported.
      • Maryam M
      • Zahra K
      • Adeleh B
      • Morteza Y
      Comparison of corticosteroid injections, physiotherapy, and combination therapy in treatment of frozen shoulder.
      In the low-quality trial comparing a specific PT technique with standardized PT alone, the specific technique (Mulligan’s mobilization) was superior to passive stretching at 3 weeks and 3 months post-intervention.
      • Doner G
      • Guven Z
      • Atalay A
      • Celiker R
      Evaluation of Mulligan's technique for adhesive capsu76. litis of the shoulder.
      In a high-quality trial comparing standardized PT with standardized PT plus intra-articular hyaluronic acid injection, both groups improved significantly but there was no added benefit to the injection.
      • Hsieh LF
      • Hsu WC
      • Lin YJ
      • Chang HL
      • Chen CC
      • Huang V
      Addition of intra-articular hyaluronate injection to physical therapy program produces no extra benefits in patients with adhesive capsulitis of the shoulder: A randomized controlled trial.
      In an acceptable-quality trial comparing SSNB injection before a course of PT with PT alone, both groups improved significantly immediately and 1 month post-intervention. However, the nerve block group had significantly greater improvement in pain and function at both intervals.
      • Klc Z
      • Filiz MB
      • Cakr T
      • Toraman NF
      Addition of suprascapular nerve block to a physical therapy program produces an extra benefit to adhesive capsulitis: A randomized controlled trial.
      In a high-quality trial of whole-body cryotherapy added to PT compared with PT alone, both groups improved significantly in pain and function immediately post-intervention, but the whole-body cryotherapy group improved significantly more.
      • Ma SY
      • Je HD
      • Jeong JH
      • Kim HY
      • Kim HD
      Effects of whole-body cryotherapy in the management of adhesive capsulitis of the shoulder.
      A high-quality, 3-arm trial of CSI compared CSI alone, CSI plus PT, and PT alone.
      • Maryam M
      • Zahra K
      • Adeleh B
      • Morteza Y
      Comparison of corticosteroid injections, physiotherapy, and combination therapy in treatment of frozen shoulder.
      Although within-group changes were not reported, the combination of CSI plus PT resulted in significantly greater improvement in disability, but not in pain, at 6 weeks post-intervention.
      • Maryam M
      • Zahra K
      • Adeleh B
      • Morteza Y
      Comparison of corticosteroid injections, physiotherapy, and combination therapy in treatment of frozen shoulder.
      Three trials compared various modalities and treatments. A high-quality trial compared ESWT with oral prednisone and found that although both groups improved significantly, ESWT was significantly superior at 4, 6, and 12 weeks post-intervention.
      • Chen CY
      • Hu CC
      • Weng PW
      • et al.
      Extracorporeal shockwave therapy improves short-term functional outcomes of shoulder adhesive capsulitis.
      An acceptable-quality trial compared 3 types of acupuncture approaches: electroacupuncture, warming needles, and filiform needles. Pain was the only measurement, assessed immediately post-treatment, and was improved in all 3 groups. However, in the between-group comparison, electroacupuncture and warming needles were both superior to filiform needles, and electroacupuncture was superior to warming needles.
      • Shi H
      • Fang JQ
      • Li BW
      • Cong WJ
      • Zhang Y
      • Chen L
      Efficacy assessment for different acupuncture therapies in the treatment of frozen shoulder.
      Another acceptable-quality trial compared arthroscopic capsular release combined with both manipulation under anesthesia and a home stretching program to a home stretching program alone. Both groups improved in function significantly at 12 weeks and 1 year post-intervention, but there were no significant between-group differences at any time point.
      • Smitherman JA
      • Struk AM
      • Cricchio M
      • et al.
      Arthroscopy and manipulation versus home therapy program in treatment of adhesive capsulitis of the shoulder: a prospective randomized study.

      Rotator Cuff-Associated Disorders

      There were 8 RCTs addressing RC. Three investigated PT,
      • Kukkonen J
      • Joukainen A
      • Lehtinen J
      • et al.
      Treatment of non-traumatic rotator cuff tears: A randomised controlled trial with one-year clinical results.
      • Kukkonen J
      • Joukainen A
      • Lehtinen J
      • et al.
      Treatment of nontraumatic rotator cuff tears: A randomized controlled trial with two years of clinical and imaging follow-up.
      • Moosmayer S
      • Lund G
      • Seljom US
      • et al.
      Tendon repair compared with physiotherapy in the treatment of rotator cuff tears: A randomized controlled study in 103 cases with a five-year follow-up.
      3 ESWT,
      • Kolk A
      • Auw-Yang KG
      • Tamminga R
      • Hoeven H
      Radial extracorporeal shock-wave therapy in patients with chronic rotator cuff tendinitis: A prospective randomised double-blind placebocontrolled multicentre trial.
      • Liu S
      • Zhai L
      • Shi Z
      • Jing R
      • Zhao B
      • Xing G
      Radial extracorporeal pressure pulse therapy for the primary long bicipital tenosynovitis: A prospective randomized controlled study.
      • Tornese D
      • Mattei E
      • Bandi M
      • Zerbi A
      • Quaglia A
      • Melegati G
      Arm position during extracorporeal shock wave therapy for calcifying tendinitis of the shoulder: A randomized study.
      1 LLLT,
      • Eslamian F
      • Shakouri SK
      • Ghojazadeh M
      • Nobari OE
      • Eftekharsadat B
      Effects of low-level laser therapy in combination with physiotherapy in the management of rotator cuff tendinitis.
      and 1 diathermy.
      • Rabini A
      • Piazzini DB
      • Bertolini C
      • et al.
      Effects of local microwave diathermy on shoulder pain and function in patients with rotator cuff tendinopathy in comparison to subacromial corticosteroid injections: A single-blind randomized trial.

      Physical Therapy

      Two acceptable-quality trials compared PT (including home exercises, but not MT) with PT combined with acromioplasty or PT combined with acromioplasty and RC repair. Outcomes were measured at 1
      • Kukkonen J
      • Joukainen A
      • Lehtinen J
      • et al.
      Treatment of non-traumatic rotator cuff tears: A randomised controlled trial with one-year clinical results.
      and 2
      • Kukkonen J
      • Joukainen A
      • Lehtinen J
      • et al.
      Treatment of nontraumatic rotator cuff tears: A randomized controlled trial with two years of clinical and imaging follow-up.
      years. At both 1 and 2 years, all 3 groups improved significantly in function and pain. There were no significant differences between groups with respect to function, but pain and activities of daily living were significantly better in the surgical groups compared with the PT-only group. A high-quality study
      • Moosmayer S
      • Lund G
      • Seljom US
      • et al.
      Tendon repair compared with physiotherapy in the treatment of rotator cuff tears: A randomized controlled study in 103 cases with a five-year follow-up.
      compared PT with individualized exercises to tendon repair with a sling followed by 6 weeks of passive ROM and 6 additional weeks of active assisted motions. Both groups exhibited significant improvement in pain and function at 5-year follow-up, but between-group measures significantly favored the tendon repair group at 5 years.

      Extracorporeal Shockwave Therapy

      Two high-quality studies compared ESWT with sham ESWT.
      • Kolk A
      • Auw-Yang KG
      • Tamminga R
      • Hoeven H
      Radial extracorporeal shock-wave therapy in patients with chronic rotator cuff tendinitis: A prospective randomised double-blind placebocontrolled multicentre trial.
      • Liu S
      • Zhai L
      • Shi Z
      • Jing R
      • Zhao B
      • Xing G
      Radial extracorporeal pressure pulse therapy for the primary long bicipital tenosynovitis: A prospective randomized controlled study.
      One found that both groups improved significantly in pain and function at 3 and 6 months post-intervention, with no significant between-group differences.
      • Kolk A
      • Auw-Yang KG
      • Tamminga R
      • Hoeven H
      Radial extracorporeal shock-wave therapy in patients with chronic rotator cuff tendinitis: A prospective randomised double-blind placebocontrolled multicentre trial.
      The other found significant within-group improvement on all measures at 1, 3, and 12 months post-intervention, but a significantly greater improvement at all time points favoring ESWT over sham.
      • Liu S
      • Zhai L
      • Shi Z
      • Jing R
      • Zhao B
      • Xing G
      Radial extracorporeal pressure pulse therapy for the primary long bicipital tenosynovitis: A prospective randomized controlled study.
      One acceptable-quality trial compared ESWT with internal rotation positioning of the glenohumeral joint plus exercise with neutral positioning of the joint plus exercise.
      • Tornese D
      • Mattei E
      • Bandi M
      • Zerbi A
      • Quaglia A
      • Melegati G
      Arm position during extracorporeal shock wave therapy for calcifying tendinitis of the shoulder: A randomized study.
      Both groups improved, but the group with internal rotation had greater resorption of calcium deposits.

      Low-Level Laser Therapy

      One high-quality study compared LLLT plus PT with sham LLLT plus PT. PT, in this study, consisted of heat, ultrasound, TENS, and exercise.
      • Eslamian F
      • Shakouri SK
      • Ghojazadeh M
      • Nobari OE
      • Eftekharsadat B
      Effects of low-level laser therapy in combination with physiotherapy in the management of rotator cuff tendinitis.
      Both groups improved significantly at 3 weeks post-intervention in both pain and function, but there were significantly greater improvements in pain and function in the active LLLT group compared with the sham.

      Diathermy

      One high-quality trial compared subacromial CSI with microwave diathermy.
      • Rabini A
      • Piazzini DB
      • Bertolini C
      • et al.
      Effects of local microwave diathermy on shoulder pain and function in patients with rotator cuff tendinopathy in comparison to subacromial corticosteroid injections: A single-blind randomized trial.
      They found significant improvements in pain and function at 4, 12, and 24 weeks post-intervention in both groups and no significant between-group differences at any time point on any measure.

      Nonspecific SP

      Four RCTs addressed SP.
      • Bron C
      • Gast A
      • Dommerholt J
      • Stegenga B
      • Wensing M
      • Oostendorp RA
      Treatment of myofascial trigger points in patients with chronic shoulder pain: A randomized, controlled trial.
      • Montes-Molina R
      • Prieto-Baquero A
      • Martínez-Rodriguez ME
      • Romojaro-Rodriguez AB
      • Gallego-Méndez V
      • Martínez-Ruiz F
      Interferential laser therapy in the treatment of shoulder pain and disability from musculoskeletal pathologies: A randomised comparative study.
      • Riley SP
      • Cote MP
      • Leger RR
      • et al.
      Short-term effects of thoracic spinal manipulations and message conveyed by clinicians to patients with musculoskeletal shoulder symptoms: A randomized clinical trial.
      • Teys P
      • Bisset L
      • Collins N
      • Coombes B
      • Vicenzino B
      One-week time course of the effects of Mulligan's Mobilisation with Movement and taping in painful shoulders.
      One investigated thoracic SMT, 2 investigated different PT protocols, and 1 investigated 2 types of LLLT.

      Thoracic SMT

      An acceptable-quality trial compared thoracic SMT with sham SMT, with outcomes measured after a single treatment and 1 week later.
      • Riley SP
      • Cote MP
      • Leger RR
      • et al.
      Short-term effects of thoracic spinal manipulations and message conveyed by clinicians to patients with musculoskeletal shoulder symptoms: A randomized clinical trial.
      Both groups were also instructed to do home exercises. At 1 week post-intervention, both groups had statistically significantly improved in pain and function, but there were no significant differences between groups.

      PT Protocols

      One acceptable-quality trial compared a PT protocol including MT, application of heat and cold, posture advice, and home exercises done using a portable myofeedback device with a wait list control.
      • Bron C
      • Gast A
      • Dommerholt J
      • Stegenga B
      • Wensing M
      • Oostendorp RA
      Treatment of myofascial trigger points in patients with chronic shoulder pain: A randomized, controlled trial.
      There were weekly PT sessions for a maximum of 12 weeks. At 6 and 12 weeks, the PT group improved significantly in pain and function, but the wait list control did not. Between-group differences in pain and function were not statistically significant at 6 weeks but were at 12 weeks.
      Another acceptable-quality trial compared a PT protocol, MWM, with MWM plus KT.
      • Teys P
      • Bisset L
      • Collins N
      • Coombes B
      • Vicenzino B
      One-week time course of the effects of Mulligan's Mobilisation with Movement and taping in painful shoulders.
      Three sets of 10 repetitions of MWM were done in each group for a total of 1 treatment session, followed by a 1-week washout and crossover. Pain was assessed immediately post-intervention and 30 minutes, 24 hours, and 1 week later. Both groups significantly improved immediately and at 30 minutes only, and there were no significant between-group differences at any time point.

      Low-Level Laser Therapy

      One high-quality trial compared inferential LLLT with conventional LLLT, with 3 sessions per week for a total of 10 treatments.
      • Montes-Molina R
      • Prieto-Baquero A
      • Martínez-Rodriguez ME
      • Romojaro-Rodriguez AB
      • Gallego-Méndez V
      • Martínez-Ruiz F
      Interferential laser therapy in the treatment of shoulder pain and disability from musculoskeletal pathologies: A randomised comparative study.
      Pain and function were assessed immediately post-intervention. There was significant improvement in both groups in night pain and in function, with no significant between-group differences.

      Adverse Events Reported in RCTs

      RCTs of Treatments for SIS

      Of 19 trials, 5 included a report of adverse events. Three of the 5 reported that there were no adverse events in any group. One of these was on LLLT
      • Abrisham SM
      • Kermani-Alghoraishi M
      • Ghahramani R
      • Jabbari L
      • Jomeh H
      • Zare M
      Additive effects of low-level laser therapy with exercise on subacromial syndrome: A randomised, double-blind, controlled trial.
      ; 1 on MT, specifically cervical mobilization
      • Cook C
      • Learman K
      • Houghton S
      • Showalter C
      • O’Halloran B
      The addition of cervical unilateral posterior-anterior mobilisation in the treatment of patients with shoulder impingement syndrome: A randomised clinical trial.
      ; and 1 on spinal manipulation.
      • Haik MN
      • Alburquerque SF
      • Silva CZ
      • Siqueira-Junior AL
      • Ribeiro IL
      • Camargo PR
      Scapular kinematics pre- and post-thoracic thrust manipulation in individuals with and without shoulder impingement symptoms: a randomized controlled study.
      Engebretsen et al
      • Engebretsen K
      • Grotle M
      • Bautz-Holter E
      • Ekeberg OM
      • Juel NG
      • Brox JI
      Supervised exercises compared with radial extracorporeal shock-wave therapy for subacromial shoulder pain: 1-Year results of a single-blind randomized controlled trial.
      reported that 2 patients in the ESWT group dropped out because of pain, with 1 crossing over to the supervised exercise group, and that 1 patient in the supervised exercise group reported increased pain.
      • Engebretsen K
      • Grotle M
      • Bautz-Holter E
      • Ekeberg OM
      • Juel NG
      • Brox JI
      Supervised exercises compared with radial extracorporeal shock-wave therapy for subacromial shoulder pain: 1-Year results of a single-blind randomized controlled trial.
      Rhon et al
      • Rhon DI
      • Boyles RB
      • Cleland JA
      One-year outcome of subacromial corticosteroid injection compared with manual physical therapy for the management of the unilateral shoulder impingement syndrome: A pragmatic randomized trial.
      reported that in their trial of MT PT compared with CSIs, transient pain from the injection was the only adverse event reported.

      RCTs of Treatments for AC

      Four of 9 studies included a report on adverse events. Three of the 4 reported that there were no side effects or complications in any treatment group, which included nerve block injections and PT,
      • Klc Z
      • Filiz MB
      • Cakr T
      • Toraman NF
      Addition of suprascapular nerve block to a physical therapy program produces an extra benefit to adhesive capsulitis: A randomized controlled trial.
      PT and whole-body cryotherapy,
      • Ma SY
      • Je HD
      • Jeong JH
      • Kim HY
      • Kim HD
      Effects of whole-body cryotherapy in the management of adhesive capsulitis of the shoulder.
      and PT and arthroscopic capsular release.
      • Smitherman JA
      • Struk AM
      • Cricchio M
      • et al.
      Arthroscopy and manipulation versus home therapy program in treatment of adhesive capsulitis of the shoulder: a prospective randomized study.
      Chen et al
      • Chen CY
      • Hu CC
      • Weng PW
      • et al.
      Extracorporeal shockwave therapy improves short-term functional outcomes of shoulder adhesive capsulitis.
      reported that 9 patients in the ESWT group had transient swelling and redness after treatment, and 2 had petechial bleeding at the treatment site.

      RCTs of Treatments for RCs

      Five of 8 trials included a report on adverse events. Four of the 5 reported that there were no adverse events in any of the groups, which included PT, acromioplasty, and rotator cuff repair
      • Kukkonen J
      • Joukainen A
      • Lehtinen J
      • et al.
      Treatment of nontraumatic rotator cuff tears: A randomized controlled trial with two years of clinical and imaging follow-up.
      ; PT and tendon repair
      • Moosmayer S
      • Lund G
      • Seljom US
      • et al.
      Tendon repair compared with physiotherapy in the treatment of rotator cuff tears: A randomized controlled study in 103 cases with a five-year follow-up.
      ; diathermy and CSIs
      • Rabini A
      • Piazzini DB
      • Bertolini C
      • et al.
      Effects of local microwave diathermy on shoulder pain and function in patients with rotator cuff tendinopathy in comparison to subacromial corticosteroid injections: A single-blind randomized trial.
      ; and ESWT and sham ESWT.
      • Kolk A
      • Auw-Yang KG
      • Tamminga R
      • Hoeven H
      Radial extracorporeal shock-wave therapy in patients with chronic rotator cuff tendinitis: A prospective randomised double-blind placebocontrolled multicentre trial.
      Liu et al
      • Liu S
      • Zhai L
      • Shi Z
      • Jing R
      • Zhao B
      • Xing G
      Radial extracorporeal pressure pulse therapy for the primary long bicipital tenosynovitis: A prospective randomized controlled study.
      reported that 4 patients had transient post-intervention pain from ESWT and 2 reported local hyperemia.

      RCTs of Treatments for SP

      Two of 4 trials included a report on adverse events. Both reported that no adverse effects were observed in patients in any of the treatment groups, which included inferential light therapy
      • Montes-Molina R
      • Prieto-Baquero A
      • Martínez-Rodriguez ME
      • Romojaro-Rodriguez AB
      • Gallego-Méndez V
      • Martínez-Ruiz F
      Interferential laser therapy in the treatment of shoulder pain and disability from musculoskeletal pathologies: A randomised comparative study.
      and PT MWM and taping.
      • Teys P
      • Bisset L
      • Collins N
      • Coombes B
      • Vicenzino B
      One-week time course of the effects of Mulligan's Mobilisation with Movement and taping in painful shoulders.

      Strength of Evidence

      Strength of evidence, based on criteria in Table 1, is summarized by condition and treatment.

      Shoulder Impingement Syndrome

      Spinal Manipulative Therapy

      Strong evidence indicates that a single application of thoracic SMT is no better than placebo for pain and function related to SIS.

      Manual Therapy

      Moderate evidence indicates that MWM is better than sham MT for pain related to SIS. Evidence was inconclusive but favorable for MT compared with other treatments, in that both MT and the comparison treatment appeared to be beneficial.

      Kinesiotaping

      Moderate evidence supports the use of KT for SIS.

      Low-Level Laser Therapy

      Moderate evidence supports the use of LLLT for SIS.

      Microcurrent

      Evidence was inconclusive because of the scarcity of studies.

      Extracorporeal Shockwave Therapy

      The evidence was inconclusive but favorable for ESWT for SIS pain and function, in that it appeared to be as effective as exercise.

      Pulsed Electromagnetic Field Therapy

      Moderate evidence indicates that both PEMF and exercise are effective for pain and function for SIS at any interval.

      Transcutaneous Electrical Nerve Stimulation

      Evidence was inconclusive because of the scarcity of studies.

      Supervised Exercise

      Moderate evidence indicates that both supervised and home exercises are effective for pain and function for SIS in both the short and long term.

      Adhesive Capsulitis

      Manual Therapy

      Low to moderate evidence supports mobilization in the short and long term.

      Low-Level Laser Therapy

      Low to moderate evidence supports LLLT either alone or combined with exercise in the short and long term.

      Modalities Other Than LLLT Added to Standardized PT for AC

      Because of the heterogeneity of the treatments, evidence is inconclusive.

      Modalities Alone

      Because of the scarcity of trials for any 1 modality except LLLT, evidence is inconclusive.

      Rotator Cuff-Associated Disorders

      Manual Therapy

      Low to moderate evidence indicates that MT, including manipulation and mobilization, is effective, either alone or combined with other therapies.

      PT Compared With Surgical Interventions

      Moderate evidence indicates that although PT alone is effective for RCs, various surgical approaches combined with PT appear to be superior in the long term.

      Extracorporeal Shockwave Therapy

      For noncalcific tendinitis, evidence is inconclusive, but unfavorable because of inconsistencies in results. For calcific tendinitis, moderate evidence indicates that ESWT is effective.

      Low-Level Laser Therapy

      Moderate evidence indicates that, although PT with sham LLLT was effective, PT with LLLT resulted in greater improvements in pain and function in the short term.

      Diathermy

      Moderate evidence indicates that both microwave diathermy and CSI improved pain and function in both the short and long term.

      Taping and TENS

      Evidence is inconclusive.

      Shoulder Pain

      Spinal Manipulative Therapy

      Evidence is conclusive, but unfavorable for the effect of a single application of thoracic SMT on pain and function in SP. The evidence is inconclusive, but favorable that thoracic SMT provided in multiple sessions may help reduce pain and accelerate recovery in the short and long term.

      PT Protocols

      The evidence was inconclusive but favorable because of the heterogeneity of protocols.

      Low-Level Laser Therapy

      Moderate evidence indicates that both inferential LLLT and conventional LLLT are beneficial for pain and function in SP in the short term.

      Discussion

      This review evaluated the evidence for a variety of nondrug, nonsurgical interventions for the treatment of shoulder disorders commonly seen in practice. The disorders focused on in our overall findings were categorized as rotator cuff conditions (calcific or noncalcific), AC, SIS, and SP.

      Rotator Cuff-Associated Disorders

      We found variable-quality (low to high) evidence that MT, including manipulation and mobilization, may be effective either alone or when combined with exercise or passive modalities. A moderate level of evidence was reported in doses ranging from 10 to 24 sessions for the effectiveness of PT alone or when combined with active LLLT; however, surgery may be of more benefit in the mid- to long term. Also, there is moderate evidence to suggest diathermy 3 times per week for 4 weeks is effective in the short and long term. Studies consistently reported the effectiveness of high-energy ESWT for calcific but not noncalcific tendinitis. Treatment for calcific tendinitis was reported at approximately once per week for 2-4 weeks. Insufficient evidence exists to conclude on the effectiveness of KT or TENS for this type of shoulder pain.

      Adhesive Capsulitis

      Mostly moderate-quality evidence suggests that manual mobilization techniques are beneficial when used alone or in combination with exercise for primary AC in the short and long term. In general, PT (3-12 weeks) was an effective treatment, but studies indicated enhanced improvement when combined with injections and whole-body cryotherapy. Low to moderate evidence indicated the effectiveness of LLLT alone over a period of 6 days or paired with an injection or exercise in the short and long term.

      Shoulder Impingement Syndrome

      We found moderate evidence that MWM twice per week for 2 weeks provided more relief than a sham treatment. In general, studies reported improved outcomes with MT interventions; however, the benefits seemed to be as effective when combining MT with other treatments such as SMT, exercise, and KT. Moderate-quality studies also reported similar effectiveness for MT compared with injections and surgery for shoulder impingement. MT doses varied from 1 to 3 times per week for 3-6 weeks. Inconsistencies were found for KT and ESWT treatments, but LLLT (10 sessions) and PEMF with exercise (3 times per week for 3 weeks) and supervised or home exercises (6 weeks) were effective. There was inconclusive evidence for microcurrent and TENS.

      Nonspecific SP

      The evidence for SMT was inconclusive and unfavorable for 1 treatment, but favorable for multiple treatment sessions in the short and long term. A high-quality review indicated that when compared with usual care, TMT accelerated recovery and improved pain and function immediately and for up to 1 year. Limited evidence exists for the effectiveness of mobilization or manipulation techniques combined with soft tissue release and exercise; additionally, mobilization was not found effective when administered alone. Massage therapy was reported to have significant immediate and short-term effects over inactive treatment for pain, but not compared with active therapies for pain or function. We found inconclusive but favorable evidence for PT combined with MT at 1 treatment per week for 12 weeks and a single treatment of both MWM and MWM with KT. There was moderate evidence of the effectiveness of interferential and conventional LLLT at 3 treatments per week for a total of 10.
      All nondrug, nonsurgical treatments included in this review are within the scope of chiropractic practice. Our findings on the effectiveness of these treatments have similarities and distinctions from previously published systematic reviews. Comparison results include those from Green et al,
      • Green S
      • Buchbinder R
      • Hetrick S
      Physiotherapy interventions for shoulder pain.
      who concluded that exercise was beneficial for short-term recovery and long-term functional improvement for RC, as well as an additional benefit when adding mobilization to exercise. Their results regarding laser therapy also paralleled ours in that it was more effective than placebo for AC.
      • Green S
      • Buchbinder R
      • Hetrick S
      Physiotherapy interventions for shoulder pain.
      For SIS, 2 reviews
      • Faber E
      • Kuiper JI
      • Burdorf A
      • Miedema HS
      • Verhaar JA
      Treatment of impingement syndrome: A systematic review of the effects on functional limitations and return to work.
      • Michener LA
      • Walsworth MK
      • Burnet EN
      Effectiveness of rehabilitation for patients with subacromial impingement syndrome: A systematic review.
      reported that MT combined with exercise was effective. Bronfort et al
      • Bronfort G
      • Haas M
      • Evans R
      • Leiniger B
      • Triano J
      Effectiveness of manual therapies: The UK evidence report.
      concluded that combining MT with medical care was beneficial, and another review
      • Ho CY
      • Sole G
      • Munn J
      The effectiveness of manual therapy in the management of musculoskeletal disorders of the shoulder: A systematic review.
      found evidence to suggest massage was superior to no treatment. Our results contrasted with several reviews that reported that passive therapies such as LLLT and PEMF were not effective or that results were inconclusive for the treatment of RCs, AC, and SIS.
      • Green S
      • Buchbinder R
      • Hetrick S
      Physiotherapy interventions for shoulder pain.
      • Rhon DI
      • Boyles RB
      • Cleland JA
      One-year outcome of subacromial corticosteroid injection compared with manual physical therapy for the management of the unilateral shoulder impingement syndrome: A pragmatic randomized trial.
      • Faber E
      • Kuiper JI
      • Burdorf A
      • Miedema HS
      • Verhaar JA
      Treatment of impingement syndrome: A systematic review of the effects on functional limitations and return to work.
      • Kukurin GW
      Chronic pediatric asthma and chiropractic spinal manipulation: A prospective clinical series and randomized clinical pilot study.
      Additionally, 1 review determined that the evidence for MT was conflicting for the treatment of SIS and SP and that it was not more effective when compared with other interventions for AC.
      • Ho CY
      • Sole G
      • Munn J
      The effectiveness of manual therapy in the management of musculoskeletal disorders of the shoulder: A systematic review.
      Another review reported MT was inconclusive but favorable for RCs.
      • Bronfort G
      • Haas M
      • Evans R
      • Leiniger B
      • Triano J
      Effectiveness of manual therapies: The UK evidence report.
      The differences noted in our systematic review are likely due to the inclusion of more recent studies, as all of the mentioned reviews included studies that are about 10 years or older.
      Other systematic reviews have also been conducted evaluating manipulation, mobilization, and multimodal (nondrug, nonsurgical) treatments for shoulder conditions.
      • McHardy A
      • Hoskins W
      • Pollard H
      • Onley R
      • Windsham R
      Chiropractic treatment of upper extremity conditions: A systematic review.
      • Pribicevic M
      • Pollard H
      • Bonello R
      • de Luca K
      A systematic review of manipulative therapy for the treatment of shoulder pain.
      • Brantingham JW
      • Cassa TK
      • Bonnefin D
      • et al.
      Manipulative and multimodal therapy for upper extremity and temporomandibular disorders: A systematic review.
      These reviews found favorable results suggesting these interventions, mostly highlighting multimodal care, are beneficial for pain and function; however, the results are based on mostly low-level evidence from case reports and series. Although reviews report clinical use of multimodal treatments, a description is still lacking regarding what multi-modal components of chiropractic care are appropriate for specific shoulder conditions. Even when a specific diagnosis is made, there are typically other regions and structures involved either contributing to or exacerbating the condition. Therefore, checking adjacent areas for concomitant disorders such as joint dysfunction, myofascial adhesions, or scapular dyskinesis may be justification for the use of multimodal treatments to address all issues involved.

      Limitations and Future Study Recommendations

      Although we identified 44 relevant RCTs and 25 SRs, they covered such a wide variety of interventions and several different conditions that still the overall quantity and quality of evidence was at best moderate for any 1 intervention. Furthermore, the heterogeneity of protocols and procedures used makes generalizations difficult and did not allow for pooling of results. In particular, wide ranges of dosages were found for most treatments (number of treatments and interval of care), also making it difficult to draw conclusions about optimal dosage, in most cases. It is also possible that some studies were missed, despite the reference tracking and hand searching in addition to the formal literature search.
      Additional research is needed concerning the use of various combinations of interventions, as well as the value of single modalities. Studies should clearly describe treatment protocols, including frequency, intensity, and duration.

      Conclusion

      The findings of this literature review may help inform practitioners who use conservative methods (eg, doctors of chiropractic, physical therapists, and other manual therapists) regarding the levels of evidence for nondrug, nonsurgical interventions used for common shoulder conditions. The evidence found ranged from low to moderate supporting the use of MTs and/or modalities for the conditions SIS, RC, AC, and SP. Exercise, particularly provided as part of PT protocols, was found to be beneficial for SIS and AC. For SIS, moderate evidence was found supporting the use of KT, LLLT, ESWT, and PEMF. For RCs, PT protocols were found to be helpful, although they may not be superior to surgery in the long term. ESWT was supported by moderate evidence only for calcific tendinitis RCs. Of all the modalities studied, LLLT appears to be the only 1 with moderate evidence supporting its use for all the conditions studied.
      The following is the supplementary data related to this article.

      Funding Sources and Conflicts of Interest

      The Council on Chiropractic Guidelines and Practice Parameters provided funding for this study and the authors received financial compensation from the Council on Chiropractic Guidelines and Practice Parameters. No conflicts of interest were reported for this study.

      Contributorship Information

      • Concept development (provided idea for the research): C.H., A.M.
      • Design (planned the methods to generate the results): C.H., A.M., R.K.
      • Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): C.H., A.L.M.
      • Data collection/processing (responsible for experiments, patient management, organization, or reporting data): C.H., A.L.M., R.K., C.D., D.H., J.A.G., J.A.H., S.B.
      • Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): C.H., A.L.M., R.K., C.D., D.H., J.A.G., J.A.H., S.B.
      • Literature search (performed the literature search): C.H., A.L.M.
      • Writing (responsible for writing a substantive part of the manuscript): C.H., A.L.M., R.K.
      • Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): C.H., A.L.M., R.K., C.D., D.H., J.A.G., J.A.H., S.B.

      Practical Applications

      • Manual therapy is beneficial for common shoulder conditions.
      • Low-level laser therapy is beneficial for common shoulder conditions.
      • Exercise protocols are beneficial for SIS and AC.

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