Which Portion of Physiotherapy Treatments' Effect Is Not Attributable to the Specific Effects in People With Musculoskeletal Pain? A Meta-Analysis of Randomized Placebo-Controlled Trials.

OBJECTIVE: We aimed to quantify the proportion not attributable to the specific effects (PCE) of physical therapy interventions for musculoskeletal pain. DESIGN: Intervention systematic review with meta-analysis. LITERATURE SEARCH: We searched Ovid, MEDLINE, EMBASE, CINAHL, Scopus, PEDro, Cochrane Controlled Trials Registry, and SPORTDiscus databases from inception to April 2023. STUDY SELECTION CRITERIA: Randomized placebo-controlled trials evaluating the effect of physical therapy interventions on musculoskeletal pain. DATA SYNTHESIS: Risk of bias was evaluated using the Cochrane risk-of-bias tool for randomized trials (RoB 2). The proportion of physical therapy interventions effect that was not explained by the specific effect of the intervention was calculated, using the proportion not attributable to the specific effects (PCE) metric, and a quantitative summary of the data from the studies was conducted using the random-effects inverse-variance model (Hartung-Knapp-Sidik-Jonkman method). RESULTS: Sixty-eight studies were included in the systematic review (participants: n = 5238), and 54 placebo-controlled trials informed our meta-analysis (participants: n = 3793). Physical therapy interventions included soft tissue techniques, mobilization, manipulation, taping, exercise therapy, and dry needling. Placebo interventions included manual, nonmanual interventions, or both. The proportion not attributable to the specific effects of mobilization accounted for 88% of the immediate overall treatment effect for pain intensity (PCE = 0.88, 95% confidence interval [CI]: 0.57, 1.20). In exercise therapy, this proportion accounted for 46% of the overall treatment effect for pain intensity (PCE = 0.46, 95% CI: 0.41, 0.52). The PCE in manipulation excelled in short-term pain relief (PCE = 0.81, 95% CI: 0.62, 1.01) and in mobilization in long-term effects (PCE = 0.86, 95% CI: 0.76, 0.96). In taping, the PCE accounted for 64% of disability improvement (PCE = 0.64, 95% CI: 0.48, 0.80). CONCLUSION: The outcomes of physical therapy interventions for musculoskeletal pain were significantly influenced by factors not attributable to the specific effects of the interventions. Boosting these factors consciously to enhance therapeutic outcomes represents an ethical opportunity that could benefit patients. J Orthop Sports Phys Ther 2024;54(6):391-399. Epub 11 April 2024. doi:10.2519/jospt.2024.12126.

Is there any benefit of adding a central nervous system-focused intervention to a manual therapy and home stretching program for people with frozen shoulder? A randomized controlled trial.

BACKGROUND: Frozen shoulder (FS) is a highly disabling pathology of poorly understood etiology, which is characterized by the presence of intense pain and progressive loss of range of motion. The aim of this study was to evaluate the effect of adding a central nervous system (CNS)-focused approach to a manual therapy and home stretching program in people with FS. METHODS: A total of 34 patients with a diagnosis of primary FS were randomly allocated to receive a 12-week manual therapy and home stretching program or manual therapy and home stretching program plus a CNS-focused approach including graded motor imagery and sensory discrimination training. The Shoulder Pain and Disability Index score, self-perceived shoulder pain (visual analog scale score), shoulder range of motion, and the Patient-Specific Functional Scale score were measured at baseline, after a 2-week washout period just before starting treatment, after treatment, and at 3 months' follow-up. RESULTS: No significant between-group differences in any outcome were found either after treatment or at 3 months' follow-up. CONCLUSION: A CNS-focused approach provided no additional benefit to a manual therapy and home stretching program in terms of shoulder pain and function in people with FS.

Understanding the clinical profile of patients with frozen shoulder: a longitudinal multicentre observational study.

INTRODUCTION: There is a large diversity in the clinical presentation of frozen shoulder (FS) and the clinical outcome is not always satisfactory. The aim of the current study was to examine to what extent range of motion (ROM) limitation, metabolic factors (diabetes mellitus and thyroid disorders), autonomic symptoms and pain sensitivity may contribute to the prognosis in terms of shoulder pain and disability and quality of life in patients with FS. METHODS: Patients with stage 1 or 2 FS were longitudinally followed-up during 9 months after baseline assessment. They completed six questionnaires and underwent quantitative sensory testing (pressure pain thresholds, temporal summation and conditioned pain modulation) and ROM assessment. RESULTS: One hundred and forty-nine patients with FS were initially recruited and 121 completed at least one follow-up measurement. Shoulder pain and disability improved over time and diabetes mellitus was found to be a prognostic factor for final outcome. Several domains of quality of life also improved over time and external rotation ROM, diabetes mellitus, thyroid disorder and autonomic symptoms were found to be prognostic factors for final outcome. These prognostic factors explained 2.5%-6.3% of the final outcome of shoulder pain and disability and quality of life. DISCUSSION AND CONCLUSION: In patients with FS, prognostic variables were able to predict different outcomes, indicating that outcomes in this population can be variable-dependent. Other variables not explored in this study might contribute to the prognosis of patients with FS, which should be investigated in future research. In clinical practice, baseline assessment of prognostic factors and focusing on a more holistic approach might be useful to inform healthcare practitioners about progression of patients with FS during a 9-month period.

A Manual Therapy and Home Stretching Program in Patients With Primary Frozen Shoulder Contracture Syndrome: A Case Series.

BACKGROUND: Manual therapy has been demonstrated to reduce pain and improve function in patients with frozen shoulder contracture syndrome (FSCS), but no evidence exists to support one form of manual therapy over another. This case series describes both short- and long-term outcomes after a manual therapy program and home stretching exercises based on specific impairments in shoulder mobility and level of tissue irritability in patients with FSCS. CASE DESCRIPTION: Eleven patients with primary FSCS were treated with an individually tailored, multimodal manual therapy approach once weekly for 12 visits, coupled with home stretching exercises once a day, 5 days per week. Pain, disability, range of motion (ROM), and muscle strength of the affected shoulder were assessed at baseline, posttreatment, at 6 months, and at 9 months. OUTCOMES: Significant improvements in self-reported pain, disability, shoulder ROM, and strength were reported following treatment. Additionally, 4 of 11 patients showed pain improvements that exceeded the minimal clinically important difference (MCID) on the visual analog scale postintervention, and 8 of 11 showed pain improvements at 6 and 9 months. Moreover, 7 of 11 patients showed improvements in Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire scores exceeding the MCID postintervention and at 6 months, and 8 of 11 exceeded the MCID at 9 months. DISCUSSION: Clinically meaningful changes in shoulder pain and disability, ROM, or muscle strength were observed in 11 patients with primary FSCS treated with an individually tailored approach of both manual therapy techniques and stretching exercises, accounting for tissue irritability. LEVEL OF EVIDENCE: Therapy, level 5. J Orthop Sports Phys Ther 2019;49(3):192-201. Epub 18 Jan 2019. doi:10.2519/jospt.2019.8194.

The shoulder medial rotation test: an intertester and intratester reliability study in overhead athletes with chronic shoulder pain.

OBJECTIVE: The purpose of this study was to examine intertester and intratester reliability of the shoulder medial rotation test (MRT) and reliability differences depending on examiner expertise. METHODS: Seventeen athletes with chronic shoulder pain participated in the study. Four independent observers with different experience levels simultaneously rated MRT performance as "correct" or "incorrect," after a standardized assessment protocol, the same day (for intertester reliability) and in a 7-day interval (for intratester reliability). RESULTS: The intrarater reliability was admissible for 2 experts and one novice, with κ values ranging between 0.32 to 0.76 and poor for one novice (κ <0). Interrater agreement for all 4 assessors demonstrated slight agreement (κ = 0.06; 95% confidence interval: 0.06-0.47), increasing to fair agreement (κ = 0.33; 95% confidence interval: 0.21-0.69) when comparing the MRT findings between the 2 experienced assessors. Practice with the MRT in novices only marginally improved their level of agreement. CONCLUSIONS: Reliability of the MRT for detecting movement control of the shoulder girdle was fair at best for experienced examiners and poor overall. Dexterity and repetitive performance of the test is necessary for correct interpretation of the MRT.