Monday 5th August, 2019
  Categories: Practitioners
  Topic(s): manual therapies

Adding manual therapies directed at improving function produces far superior results


A trial published in the Journal of Orthopaedic & Sports Physical Therapy compared the results of the treatment of shoulder impingement syndrome with exercises alone, versus treatment with exercises plus the addition of joint manipulation and other manual therapies. They found that when these were added the results were far superior.

What joint manipulation and manual therapies add

The basic principle of joint manipulation is to help restore normal articular function. This 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 that help normalise restricted sliding or spinning. An excellent summary was found at However, it is something that should definitely be left to those with the appropriate qualifications and training. In addition to joint manipulation soft tissue therapies were used. These would have the affect of relaxing hypertonic muscles and enabling them to function more optimally.

The trial


33 men and 22 women diagnosed with shoulder impingement syndrome were chosen.


Subjects were randomly assigned either exercise alone or exercise and manual therapy. Each group received six 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.

Manual therapy

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

As discussed in our articles on trigger points, pain syndromes such as impingement syndromes usually occur as a result of abnormal function (dysfunction). Normal function maintains the optimal relationship between joint surfaces and minimises the stress on tissues. However, when part of the system such as a muscle containing a trigger point or a joint not being able to move freely is not able to function normally, the central nervous system is forced to make adjustments to compensate. The result is extra stress being placed on tissues and the contact between joint surfaces no longer being optimal. It is important to note that this happens subconsiously and cannot consciously controlled. Also, as shown by research summarised elsewhere it cannot be corrected by exercises.

Given these facts the results of the trial can be clearly explained and the implications become obvious. Those suffering from shoulder impingement syndrome will usually have dysfunctional neuromuscular control and biomechanics creating extra stress on tissues and joints. Exercises alone were performed using the same dysfunctional biomechanics. When joint manipulation and soft tissue therapies were added this removed the impediment, allowing the central nervous system to perform the exercises with more normal movement.

If one googles “exercises for (any musculoskeletal pain syndrome)” one will find a huge number of listings of professionals, clinics and even professional bodies advising generic exercises alone. Clearly this approach is flawed. The correction of trigger points, articular dysfunction and any other sources of dysfunction needs to be done first.


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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Dr Graeme

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