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 articular 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 https://www.physio-pedia.com/images/c/c0/Principles_of_Joint_Mobilization.pdf  However, it is something that should definitely be left to those with the appropriate qualifications and training.

The trial

33 men and 22 women diagnosed with shoulder impingement syndrome

Subjects were randomly assigned either exercise alone or exercise and manual therapy.  There were 6 sessions over three weeks. 
Exercises were conducted under the supervision of a physical therapist and were described as a standardised strength and flexibility program.  There were two passive stretches, plus six strengthening exercises described in the literature as being essential “core exercises” for shoulders.
In trial of medication and simple therapies the intervention is easy to describe and quantify.  However, for this trial experienced physiotherapists were basically told to assess the articular function and associated soft tissue issues of not only the glenohumeral joint but other related joints such as those of the cervical and thoracic spine.  They were instructed to use their skills in manipulation and soft tissue therapies to correct what they found.  This approach is not easy to quantify, but exactly what would happen if one consulted a quality clinician.

What was measured
Levels of pain were measured using visual analogue scales.  Functional assessment was done using questionnaires covering a variety of general and specific activities.

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.

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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