J Manipulative Physiol Ther 2017 (Jun); 40 (5): 293319 ~ FULL TEXT
Cheryl Hawk, DC, PhD, Amy L. Minkalis, DC, MS, Raheleh Khorsan, MA,
Clinton J. Daniels, DC, MS, Dennis Homack, DC, MS, Jordan A. Gliedt, DC,
Julie A. Hartman, DC, MS, Shireesh Bhalerao, DC, MCR
Texas Chiropractic College,
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 shoulder impingement syndrome (SIS) and adhesive capsulitis (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.
KEYWORDS: Chiropractic; Conservative Treatment; Manual Therapy; Shoulder; Spinal Manipulation
From the FULL TEXT Article:
Painful conditions of the shoulder are the third leading musculoskeletal complaint in primary care, with a point prevalence as high as 26%.  Two-thirds (67%) of adults experience shoulder pain at some time in their life,  and prevalence is highest in middle age (4065 years).  Chronic shoulder pain characterizes a substantial subset of those with shoulder conditions because only 50% of patients recover within 6 months of onset. 
Disorders of the rotator cuff, including shoulder impingement syndrome (SIS), are among the most common causes of shoulder pain.  Other conditions include those that are unspecified and adhesive capsulitis (AC). [5, 6] 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. [7, 8] Compared with more conservative treatments, surgery is likely more costly and risky.  The utilization of arthroscopic interventions for the shoulder has quickly increased in recent decades, with an estimated complication rate of 4.8%10.6%.  Additionally, there are some negative effects of glucocorticoid injections on cellular characteristics and mechanical properties of tendons, especially when used for long-term treatment. 
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,  and in a survey of chiropractic practice in Australia, 12% of patients presented with shoulder pain. 
Reviews of MTs (eg, manipulation and mobilization) and multimodal treatments have found favorable effects supporting their use for the management of shoulder conditions.  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. [13, 14] 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.
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 24 weeks. Insufficient evidence exists to conclude on the effectiveness of KT or TENS for this type of shoulder pain.
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 (312 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 36 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.
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,  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.  For SIS, 2 reviews [95, 96] reported that MT combined with exercise was effective. Bronfort et al  concluded that combining MT with medical care was beneficial, and another 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. [14, 64, 95, 98] 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.  Another review reported MT was inconclusive but favorable for RCs.  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. [15, 16, 23] 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.
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.
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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with rotator cuff tendinopathy in comparison to subacromial corticosteroid injections:
A single-blind randomized trial.
J Orthop Sports Phys Ther. 2012; 42: 363370
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Clin Rehabil. 2011; 25: 731739
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Physiotherapy. 2012; 98: 143150
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Short-term effects of thoracic spinal manipulations and message conveyed
by clinicians to patients with musculoskeletal shoulder symptoms:
A randomized clinical trial.
J Man Manipulative Ther. 2015; 23: 311
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Man Ther. 2013; 18: 372377
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Relief of chronic shoulder pain: A comparative study of three approaches.
Middle East J Anaesthesiol. 2011; 21: 8392
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Ortop Traumatol Rehabil. 2011; 13: 920
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A comparative study between the efficacy of therapeutic utrasound and
soft tissue massage (deep friction massage) in supraspinatus tendinitis.
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The effectiveness of intensive mobilization techniques combined with
capsular distension for adhesive capsulitis of the shoulder.
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Treatment of impingement syndrome: A systematic review of the effects on
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J Hand Ther. 2004; 17: 152164
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Man Ther. 2009; 14: 463474
Chronic pediatric asthma and chiropractic spinal manipulation:
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J Manip Physiol Ther. 2002; 25: 540541
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