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No strong evidence that the addition of joint

mobilisation to an exercise programme
improves outcomes for shoulder
dysfunction
Brent D Leininger and Steven J Kamper

Br J Sports Med published online June 8, 2013

doi: 10.1136/bjsports-2013-092516

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Disease and health outcomes (20 articles)
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Physiotherapy (163 articles)
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 Downloaded from bjsm.bmj.com on October 22, 2013 - Published by group.bmj.com
BJSM Online First, published on June 8, 2013 as 10.1136/bjsports-2013-092516
PEDro systematic review update
This section features a recent systematic review that is indexed on
PEDro, the Physiotherapy Evidence Database (www.pedro.org.au).
PEDro is a free, web-based database of evidence relevant to
physiotherapy.
No strong evidence that the
addition of joint mobilisation
to an exercise programme
improves outcomes for
shoulder dysfunction
▸ Brudvig TJ, Kulkarni H, Shah S. The effect of therapeutic exercise and
mobilisation on patients with shoulder dysfunction: a systematic review with
meta-analysis. J Orthop Sports Phys Ther 2011;41:734–48.
BACKGROUND
Shoulder pain is a common musculoskeletal complaint affecting
approximately 18–31%1 of the population each month. Only
50–60% of those with shoulder pain completely recover in the
year after onset.2 3 Shoulder disorders are responsible for sub-
stantial disability, healthcare costs and work absenteeism.4 5
Societal costs due to shoulder pain are large with work loss
accounting for 50–80% of total costs.6 7 Thus, identifying effect-
ive interventions for shoulder pain is an important priority.
AIM
The authors’ primary aim was to determine the effectiveness of
the addition of joint mobilisation to a therapeutic exercise pro-
gramme in individuals with shoulder dysfunction.
SEARCHES AND INCLUSION CRITERIA
The authors included all randomised clinical trials evaluating
joint mobilisation and therapeutic exercise for adults with shoul-
der dysfunction. Trials including individuals with complete
rotator cuff tears, shoulder pain of cervical or neurological origin
or a history of shoulder surgery were excluded. Methodological
quality was assessed using a 24-item checklist covering seven
domains including study question, design, patient selection, out-
comes, analysis and recommendations.8 The authors searched
five databases including PubMed and Cochrane until October
2009. The search strategy was limited to studies published in
English. Bibliographies of retrieved articles were also hand
searched to identify potentially relevant trials.
INTERVENTIONS
The primary objective of the review was to compare the com-
bination of therapeutic exercise and joint mobilisation with
therapeutic exercise alone.
MAIN OUTCOME MEASURES
Pain, range of motion and function were listed as the main
outcome measures, but no specific time points for evaluation
were prespecified.
STATISTICAL METHODS
Meta analyses were conducted by pooling data from studies
reporting similar outcomes. The authors calculated standardised
mean differences with 95% CIs using post-treatment scores to
Copyright
Leininger BD, et al. Article
Br J Sports author
Med Month(or
2013their employer)
Vol 0 No 0
compare interventions. Dichotomous outcomes were compared
with Fisher’s exact test due to the small sample sizes. The
authors did not report on the type of meta-analysis performed
(fixed vs random effects model). Heterogeneity was assessed
using the Cochran Q test. Sensitivity analyses were performed
by inspecting the pooled effect estimates after removing studies
that contributed the most statistical heterogeneity.
RESULTS
Seven randomised clinical trials including 290 participants were
included in the meta-analyses. Average symptom duration for
the included trials ranged from 4 weeks to approximately
3 years. Four of the seven trials excluded participants with adhe-
sive capsulitis. Four of the trials were rated high in methodo-
logical quality and three were judged as moderate.
The combination of therapeutic exercise and joint mobilisation
was not more effective than therapeutic exercise alone for pain,
function or range of motion. Significant heterogeneity was noted
for the pooled analysis of pain and range of motion. The authors
concluded that the results are inconclusive due to the wide CIs.
LIMITATIONS/CONSIDERATIONS
The main pooled analyses appear to include multiple compari-
sons (eg, pain and pain on shoulder abduction) from the same
trial. This would inappropriately skew the pooled estimate
towards the results from the study with multiple comparisons
and represent a serious design flaw in a meta-analysis. Further,
the authors judged the methodology of included trials using a
quality-assessment checklist which contains many domains
related to generalisability and precision rather than internal val-
idity or risk of bias. For instance, the study by Winters et al9
was rated as being of high quality by the review authors, even
though 55% of participants were lost to follow-up. This degree
of attrition represents a high risk of bias.10 Third, the review
authors did not utilise a formal, prespecified evidence synthesis
system (eg, GRADE)11 to ensure that the scientific quality of
included studies was appropriately used in formulating conclu-
sions. A structured, transparent system highlighting how the
authors arrived at their conclusions, given the totality of evi-
dence, would strengthen the validity of the conclusions. Finally,
the authors did not detail which trials were excluded and why.
Transparency regarding trial eligibility decisions is vital for the
reader to assess if the inclusion/exclusion criteria were appropri-
ately followed and no selection bias occurred.
CLINICAL IMPLICATIONS
The review found that adding mobilisation to an exercise pro-
gramme does not confer additional benefit on patients with
shoulder pain. These findings suggest that performance of joint
mobilisation along with an exercise programme is unnecessary,
at least in the absence of specific clinical indications. It should
be noted that the strength of this recommendation is limited by
the poor quality of the review.
Brent D Leininger,1 Steven J Kamper2,3
1
Wolfe-Harris Center for Clinical Studies, Northwestern Health Sciences University,
Bloomington, Minnesota, USA
2
EMGO+ Institute, VU University, Amsterdam, The Netherlands
3
Musculoskeletal Division, The George Institute for Global Health, Sydney,
New South Wales, Australia
Correspondence to Brent D Leininger, Wolfe-Harris Center for Clinical Studies,
Northwestern Health Sciences University, Bloomington, MN 55431, USA;
bleininger@nwhealth.edu
2013. Produced by BMJ Publishing Group Ltd under licence. 1
 PEDro systematic review update
Contributors BDL and SJK contributed to the conception and interpretation of
data, drafting and critical revision for intellectual content and final approval of the
published version.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
To cite Leininger BD, Kamper SJ. Br J Sports Med Published Online First: [ please
include Day Month Year] doi:10.1136/bjsports-2013-092516
Accepted 12 May 2013
Br J Sports Med 2013;0:1–2. doi:10.1136/bjsports-2013-092516
REFERENCES
1 Luime JJ, Koes BW, Hendriksen IJ, et al. Prevalence and incidence of shoulder pain
in the general population; a systematic review. Scand J Rheumatol 2004;33:73–81.
2 Croft P, Pope D, Silman A. The clinical course of shoulder pain: prospective cohort
study in primary care. Primary Care Rheumatology Society Shoulder Study Group.
BMJ 1996;313:601–2.
3 Van der Windt DA, Koes BW, Boeke AJ, et al. Shoulder disorders in general
practice: prognostic indicators of outcome. Br J Gen Pract 1996;46:519–23.
2 Leininger BD, et al. Br J Sports Med Month 2013 Vol 0 No 0
4 Badcock LJ, Lewis M, Hay EM, et al. Chronic shoulder pain in the community:
a syndrome of disability or distress? Ann Rheum Dis 2002;61:128–31.
5 Macdermid JC, Ramos J, Drosdowech D, et al. The impact of rotator cuff pathology
on isometric and isokinetic strength, function, and quality of life. J Shoulder Elbow
Surg 2004;13:593–8.
6 Kuijpers T, Van Tulder MW, Van der Heijden GJ, et al. Costs of shoulder pain in
primary care consulters: a prospective cohort study in the Netherlands. BMC
Musculoskelet Disord 2006;7:83.
7 Virta L, Joranger P, Brox JI, et al. Costs of shoulder pain and resource use in
primary health care: a cost-of-illness study in Sweden. BMC Musculoskelet Disord
2012;13:17.
8 Macdermid JC. An introduction to evidence-based practice for hand therapists.
J Hand Ther 2004;17:105–17.
9 Winters JC, Sobel JS, Groenier KH, et al. Comparison of physiotherapy,
manipulation, and corticosteroid injection for treating shoulder complaints in general
practice: randomised, single blind study. BMJ 1997;314:1320–5.
10 Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0
[updated March 2011]. In Higgins JPT, Green S, eds. The Cochrane Collaboration.
http://www.cochrane-handbook.org c2011.
11 Guyatt GH, Oxman AD, Schunemann HJ, et al. GRADE guidelines: a new series of
articles. J Clin Epidemiol 2011;64:380–2.