The adjunctive benefit of manual therapy in addition to therapeutic exercise for subacromial pain syndrome


Subacromial Pain Syndrome (SAPS) constitutes the most common diagnostic subgroup of shoulder problems, for which therapeutic exercise (TE) is considered as an effective treatment intervention. Existing evidence suggests that its efficacy may be augmented when is combined with manual therapy (MT). However, the evidence regarding the effectiveness of this combined therapeutic approach is inconclusive. A limitation of the existing systematic reviews is the heterogeneity of the included treatment interventions for SAPS.

Evidence reports that the collective analysis of therapeutic interventions may lead to inaccurate estimation of treatment effect for particular treatments. Accordingly, it was considered appropriate to conduct a systematic review focusing on particular therapeutic methods for SAPS with the aim of establishing their effectiveness and thus informing clinical practice.

The purpose of this systematic review was to investigate whether TE combined with MT is superior to TE alone in improving patient reported outcomes of pain and shoulder function in SAPS


A systematic review was designed in accordance to published guidelines and reported in line with PRISMA. Key databases were searched until June 2018. Studies were included if they were RCT study designs, comparing TE with MT to TE alone and included measures of pain and disability. The Cochrane risk of bias tool was used to evaluate the quality of the included studies. Searching, data extraction and quality assessment was undertaken by 2 independent reviewers. Heterogeneity in key characteristics precluded meta-analysis.


From 1.469 articles 15 full text articles were evaluated, resulting in 7 included RCTs. Overall, in n=4 studies TE with MT was found superior to TE alone in improving pain and function in SAPS; in n=2 studies no between group differences were found in function.

Methodological deficits found in the majority of the studies, conduct of the studies; unclear randomisation methods; inadequate allocation concealment, raising doubts for the accuracy of the results. Thus 3 studies were classified as having high risk of bias while 3 had unclear risk of bias. Only one study (n=90) had low risk of bias, in which, the intervention group (TE with MT) reported a minor decrease of mean weekly pain at five weeks , measured by the visual numeric rating scale, (RR of 1.46; 95% CI 1.012.10), indicating a minor additional effect of MT in a TE programme.


Limited evidence suggests that MT may enhance the effectiveness of a TE programme in improving pain and shoulder function in SAPS in the short term. Poor quality coupled with heterogeneity of both interventions precludes strong conclusions to be drawn.

More methodologically high quality studies are required to evaluate further this combined therapeutic approach and establish the optimal TE programme and MT regimen, thus allowing clinicians to take an evidence based practice approach when treating patients with SAPS.

Funding acknowledgements


Additional notes

This work was presented at Physiotherapy UK 2019.