Thursday 13th April 2018

Adding manual therapies directed at improving function produces far superior results


The control and co-ordination of joint movement is largely determined by factors that are not under conscious control. This research deals with some of these issues: articular function (discussed below) and to a lesser extent some soft tissue issues.  The researchers compared the results obtained for exercise therapy alone for shoulder pain with exercise combined with physical therapy directed at normalising function.  The results obtained when joint function was addressed in this manner were far superior.

Articular function

Articular function is a complex issue.  However, for simplification normal joint function needs the joint surfaces to be able to slide or spin freely upon one another through their normal ranges of movement.  When this sliding and spinning is restricted joint movement becomes restricted or abnormal.  The analysis of this function requires specialised training and an excellent knowledge of biomechanics.  Correction is often achieved using specialised correctional techniques.  An excellent summary was found at  However, it is something that should definitely be left to those with the appropriate qualifications and training.

For further information on this research please see our practitioner version.

The results

The results as measured by pain and function were clearly much superior for the group that received the manual therapy in addition to the exercises. It is best described by the following conclusion given by the authors.

Manual therapy combined with supervised shoulder exercise is superior to supervised shoulder exercise alone for enhancing strength and function and reducing pain in patients with shoulder impingement syndrome.  Our study also provides evidence that effective outcomes are obtainable after a relatively few physical therapy visits.  It is important to recognise the functional interdependence of joints and soft tissues in the upper quarter when treating dysfunction of the shoulder.

Clinical comments

We googled “exercises for shoulder pain” and found a huge number of listings of professionals, clinics and even a national professional body advising generic exercises for shoulder pain.  The following findings from this research and others previously summarised raise questions about this approach and point to a different approach.

  1. The common diagnosis of shoulder pain is “impingement syndromes”.  However, a very high prevalence of trigger points was found in those suffering shoulder pain.  Treatment of trigger points produced a corresponding reduction in pain.  The treatment of trigger points requires a lage number of applications of therapy over time. See summary
  2. Trigger points that are highly prevalent even in the shoulders of asymptomatic people alter muscle activation patterns causing dysfunction.  The treatment of trigger points remedies this. See Summary
  3. Abnormal muscle activation patterns that cause dysfunction are not corrected by exercises See summary
  4. Far superior results were obtained when addressing articular function and soft tissue issues with manual therapy in addition to a course of exercises.  This summary

As the author states, it is important to consider the function.  Far better results were obtained combining their manual therapy.  Most likely results would be better still if trigger points were specifically addressed as well.


Bang M Deyle G Comparison of supervised exercise with and without manual physical therapy  for patients with shoulder impingement syndrome  J Orthop Sports Phys Ther. 2000 Mar;30(3):126-37.

Professional consultation

Despite the issues raised here the use of exercises alone without correcting function is common practice. We encourage you to share this information with your health care professional. Download the .pdf of the practitioner version of this summary: Download

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About Dr Graeme

Several years ago Dr Graeme, a Chiropractor practicing in Victoria, Australia was looking for a serious hand held massager his patients could use at home to get the extra quality massage they needed. The ones he found in the shops and on-line for home use looked nice but were not serious, and ... read more