From: J Manipulative Physiol Ther. 2010 Feb;33(2):96-101
The purpose of this study was to examine the effect of manipulative therapy on the shoulder girdle, in addition to usual care provided by the general practitioner, on the outcomes of physical examination tests for the treatment of shoulder complaints.
In clinical practice, a dysfunction of the shoulder girdle can be treated by manipulative therapy, which aim is to restore normal functioning of the shoulder girdle. To date, with only 1 randomized trial favoring manipulative therapy for the shoulder girdle, the evidence for the effectiveness of manipulative treatment in the treatment of shoulder complaints is scarce. Therefore, the authors conducted a randomized trial to study the effect of manipulative therapy for the shoulder girdle in addition to usual care by the general practitioner in the treatment of shoulder complaints. The design of this study and the main patient-experienced results are already published. The results indicate that additional manual therapy for the structures of the shoulder girdle accelerates recovery of patient-experienced shoulder symptoms and reduces their severity. In the present article, the results for the physical examination outcome measures are presented.
In the clinical research of musculoskeletal complaints, physical testing of pain and mobility by the physician are important outcomes. However, this concerns mostly multiple physical examination tests and multiple outcome measures. This requires multiple statistical testing. Together with small study sizes (more outcomes than patients), this may lead to spurious significant results from randomized trials affecting the interpretability of the outcome of the trial.
The challenge is to reduce the number of variables in such a way that they are clinically sensible and statistically manageable. To overcome the aforementioned problems with pain and mobility as outcome measures of our randomized trial, we tried to reduce the individual physical examination tests for pain and mobility to relevant components. In this study, we used a physical assessment of pain and mobility of the shoulder and shoulder girdle as outcome measures. They consist primarily of the assessment of active and passive limitations in shoulder movement and pain experienced during these movements and a physical examination of the cervicothoracic spine, consisting of passive movements of the neck and pain experienced in these movements. The authors used factor analysis to identify relevant components from these variables thereby reducing the number of outcome measures in a clinically meaningful sense and to increase statistical power. The purpose of this study was to examine the effect of manipulative therapy on the shoulder girdle, in addition to usual care provided by the general practitioner, on the outcomes of physical examination tests for the treatment of shoulder complaints.
This was a randomized controlled trial in a primary care setting in the Netherlands. A total of 150 participants were recruited from December 2000 until December 2002. All patients received usual care by the general practitioner. Usual care included one or more of the following depending on the needs of the patient: information/advice, oral analgesics or nonsteroidal antiinflammatory drugs, corticosteroid injections, exercises, and massage. In addition to usual care, the intervention group received manipulative therapy, up to 6 treatment sessions in a 12-week period. Twenty-four physical examination tests were done at baseline and after 6, 12, and 26 weeks. Factor analysis was done to reduce the number of outcome measures.
The factor analysis resulted in 4 factors: “shoulder pain,” “neck pain,” “shoulder mobility,” and “neck mobility.” At 6 weeks, no significant differences between groups were found. At 12 weeks, the mean changes of all 4 factors favored the intervention group; the factors “shoulder pain” and “neck pain” reached statistical significance. At 26 weeks, differences in the factors “shoulder pain”, “shoulder mobility”, and “mobility neck” statistically favored the intervention group.
In clinical trials concerning treatment of shoulder complaints, factor analysis is useful for the reduction of multiple outcomes of physical examination data and therefore increases statistical power. On the basis of the factors derived from physical examination tests of the shoulder and the cervicothoracic spine, the authors conclude that manipulative therapy, in addition to usual care by the general practitioner, diminishes the severity of the pain in the shoulder and neck and improves the mobility of the shoulder and the cervicothoracic spine. Results were most prominent at 26 weeks after initiation of treatment.