Shoulder Conditions (Hawk et al, 2017)

This study is a Systematic Review, which ranks very highly in the hierarchy of evidence. It investigated a number of conditions and their responses to various treatment modalities.

It was published in the International Journal of Manipulative and Physiological Therapeutics in June 2017. Funding was provided by The Council on Chiropractic Guidelines and Practice Parameters.

A full reference for the article is embedded at the end of this post.

Does osteopathy work for shoulder conditions?

Manual therapy is the hands-on treatment you expect to receive from your osteopath in the treatment room. This encompasses mobilisation and manipulation, which was sometimes differentiated between in the studies below.

Manual therapy was shown to be beneficial for non-calcific rotator cuff associated conditions, adhesive capsulitis, and shoulder impingement syndrome; less so for non-specific shoulder pain.

Your osteopath may employ other treatment modalities, such as electrotherapy. Shockwave therapy was proven to be effective for the treatment of rotator cuff calcific tendinitis. LLLT was effective to variable degrees for managing adhesive capsulitis.

It is important to remember that Osteopathy is a complementary therapy, not an alternative to medicine. We understand the limits of manual therapy, and there are patients who will benefit more from surgical intervention. However, we all see patients who have been told they need surgery, but would rather try a less invasive method first.

More detailed information of all findings is summarised below.

Non-calcific Rotator Cuff-Associated Conditions

• Three separate studies found that manual therapy was effective- two of these also found that manual therapy in addition to exercise was effective. A fourth study suggested that a combination of acupuncture and dietary advice was also effective.
• Extracorporeal Shock Wave Therapy was found to be ineffective for non-calcific rotator cuff tendinitis.
• There was insufficient evidence to conclude the level of effectiveness for TENS, or taping.
• Exercise therapy was found to be less effective than surgery in the mid- to long term.

Rotator Cuff Calcific Tendinitis

• High energy Extracorporeal Shock Wave Therapy was proven to be safe and effective in five reviews. A fourth study found improvements in function, pain levels, and reduction in calcifications with continued improvement over the following 6 months.
• Good outcomes were also found with ultrasound-guided needling, and arthroscopy.
• The study also noted that although there were some adverse effects, these only affected the minority and resolved within a few days.
• Manual and physical therapies were not investigated.

Adhesive Capsulitis (Frozen Shoulder)

• Two studies found mobilisation to be effective in reducing pain. The first also suggested spinal mobilisation as a beneficial technique, and the other found that exercise and mobilisation are most effective in the “frozen” and “thawing” stages. A third review found that manual therapy with or without exercise therapy did have some positive evidence, but that more research would be required to draw a strong conclusion.
• Low Level Laser Therapy (LLLT) gave very good results for pain relief, as shown in one study, but not for improving range of movement. A second study suggested that LLLT gave short term pain relief, and that steroid injections gave short to mid term benefits. In a third paper, LLLT showed improvement in pain levels for up to 4 weeks, and improvement in function for up to 4 months longer than combined placebo and exercise. Other electrotherapy modalities showed no benefit compared to placebos.
• Arthrographic distension was shown to be moderately effective in the short term.
• Glucocorticoid injections were indicated to be more effective than manual therapy and exercise in the short term.

Non-specific Shoulder Pain

• Suprascapular Nerve Blocks had similar results to intra-articular injection of the glenohumeral joints: these results were better pain relief and function than with placebo injections with physical therapy.
• A high quality systematic review found that thoracic manual therapy had an immediate effect in improving pain and function, and these benefits lasted for up to a year. The study also concluded that thoracic manual therapy helped to speed up recovery.
• Another high quality study found only minor benefits in multimodal physical therapy when compared to usual care performed by GPs, or no treatment
• Two more systematic reviews concluded that evidence is limited for mobilisation and/or manipulations with soft tissue release and exercise.
• Neither ultrasound nor interferential current therapy were found to be effective.
• A final systematic review reported that massage therapy gave significant immediate to short term effects. It also concluded that massage therapy was as effective as other therapies for improving shoulder function. However, pain was no better than when compared to other active therapies.

Shoulder Impingement Syndrome (SIS)

• A systematic review concluded that there is moderate evidence that conservative treatment is as effective as surgery for the reduction of pain from shoulder impingement syndrome
• Another paper found that taping and shockwave therapy are ineffective for SIS.
• A study of acceptable quality found little difference between multimodal care and placebo, but reported better improvement with multimodal care compared to corticosteroid injections at some stages of SIS.
• Isokinetic training had too little evidence for its effectiveness to be commented upon.

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Hawk, C., Minkalis, A., Khorsan, R., Daniels, C., Homack, D., Gliedt, J., Hartman, J. and Bhalerao, S. (2017). Systematic Review of Nondrug, Nonsurgical Treatment of Shoulder Conditions. Journal of Manipulative and Physiological Therapeutics, 40(5), pp.293-319.