Manipulative Therapy for Patients with Shoulder Pain

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The summary below is from the full report titled "Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder Dysfunction and Pain. A Randomized, Controlled Trial." It is in the 21 September 2004 issue of Annals of Internal Medicine (volume 141, pages 432-439). The authors are G.J.D. Bergman, J.C. Winters, K.H. Groenier, J.J.M. Pool, B. Meyboom-de Jong, K. Postema, and G.J.M.G. van der Heijden.

What is the problem and what is known about it so far?

Shoulder pain is a common reason for seeking medical care. The best treatment for shoulder pain is unclear unless the pain is due to a bone fracture or other specific injury that requires surgical therapy. Care for shoulder pain often includes medications to treat pain and inflammation, physical therapy to improve range of motion and strength, and therapies such as massage or heat to relieve symptoms. Manipulative therapy is an alternative therapy that some believe can be helpful in shoulder pain that is accompanied by neck symptoms. During manipulative therapy, a specially trained therapist or chiropractor applies movements to the spine with the aim of realigning or mobilizing specific segments. Manipulative therapy is different from physical therapy. Physical therapy involves range-of-motion and strengthening exercises that do not aim to realign or mobilize the spine.

Why did the researchers do this particular study?

To see whether the addition of manipulative therapy to usual care improves outcomes for patients with shoulder pain.

Who was studied?

150 Dutch patients 18 years of age or older who presented to their primary care physicians with shoulder pain, defined as pain that occurs at rest or during movement of the upper arm in the area between the neck and the elbow and that is accompanied by neck symptoms. Patients who had signs of compression of the nerves in the neck or whose shoulder pain was due to severe trauma, fracture, rupture, dislocation, specific joint disease such as rheumatoid arthritis, or disease of the chest or abdomen were not eligible for the study.

How was the study done?

The researchers assigned patients to receive usual care from their primary care physicians (usual care could include physical therapy) or usual care plus manipulative therapy. Manipulative therapy included up to 6 sessions over 12 weeks. One of 8 specially trained therapists provided the manipulative therapy. The researchers compared patients' reports of recovery, severity of pain, shoulder disability, and general health at 6, 12, 26, and 52 weeks after assignment to a treatment group.

What did the researchers find?

At 6 weeks, there were no differences between the study groups. At 12 weeks, 43% of the patients who received manipulative therapy plus usual care reported recovery compared with only 21% in the usual care group. At 52 weeks, 52% of the patients who received manipulative therapy plus usual care reported recovery compared with 35% of the usual care group.

What were the limitations of the study?

The patients knew which treatment they were receiving, and this knowledge alone may have influenced their reports of improvement. It is also uncertain whether different therapists would achieve similar results.

What are the implications of the study?

In patients with shoulder pain accompanied by neck symptoms, manipulative therapy added to usual care may increase patient-reported recovery from shoulder pain.