Musculoskeletal physiotherapists have a therapeutic ‘bag of tricks’ that includes a range of interventions such as advice, pain science education, acupuncture, exercise and manual therapy to name a few. What turns a ‘trick’ into an effective ‘treatment’ is its application within a biopsychosocial framework, guided by clinical reasoning, informed by evidence within a person-centered, shared decision-making model of care.
Manual therapy as a “low-value” treatment
Manual therapy has been the subject of mounting criticism for being a passive, low value intervention that has potentially nocebic effects, that can create dependency, foster maladaptive beliefs and create unrealistic expectations of treatment. This assumes that manual therapy is applied indiscriminately, in isolation, without clinical reasoning or context. If that is the case, I would be the first to agree that manual therapy, and any other treatment applied in this way, literally becomes another ‘trick’ of the trade.
So what turns our manual therapy ‘tricks’ into an effective treatment for shoulder pain?
Like every other physical therapy intervention, manual therapy should be selected based on clinical reasoning throughout the assessment, diagnosis and treatment planning process to identify those people who are most likely to benefit from it. Deciding whether manual therapy may be an effective treatment tool starts during the assessment.
In my experience, the ability to modify a persons’ symptoms during the movement-based assessment suggests the person may benefit from the inclusion of manual therapy as an adjunct to their treatment programme. Indeed, evidence has shown that the ability to change shoulder symptoms and/or range of motion of shoulder elevation with manual facilitation of the scapula was associated with better functional outcomes of treatment for shoulder pain. 1
There are many forms of manual therapy ‘symptom modification’ techniques described for shoulder girdle pain 2-4 These are applied during the provocative movement (usually flexion or abduction) to the shoulder and surrounding areas (e.g cervicothoracic spine) and change in pain is measured. An improvement in pain with a manual therapy technique suggests a mechanical/nociceptive (vs nociplastic or neuropathic) flavour to the pain phenotype. Based on our understanding of nociplastic and neuropathic pain mechanisms, it is unlikely either of these would exhibit an immediate reduction in pain with a manual therapy intervention.
Mechanisms of symptom improvement
While our early assumptions were grounded in the biomechanical model, we now know that combinations of neurophysiologic changes, endogenous pain control mechanisms, placebo and contextual effects can all interact to result in improvements in pain with manual therapy. While we may never be certain which of the myriad mechanisms is responsible for the improvement for any given person, an improvement suggests the person may ‘respond’ to manual therapy.
Does the mechanism matter? No, but it matters how we explain the improvement to the patient to avoid maladaptive beliefs about the manual therapy “magic trick” that may create unrealistic expectations, lead to unnecessary health-seeking behaviour or foster dependency.
Manual therapy as a treatment for shoulder pain
The addition of manual therapy has been shown to improve treatment outcomes for pain and function for people with subacromial pain 5 and frozen shoulder.6 Scapula, humeral and cervicothoracic manual therapy techniques can be valuable adjuncts to treatment when they reduce pain and facilitate functional movement. Once functional movement is established, load can then be increased to build capacity within a multi-modal, movement and exercise-based programme.
There are other ‘non-specific’ benefits too. The application of manual therapy creates space within the clinical encounter to hear the patients’ story and develop the therapeutic alliance. The enhanced level of trust this affords often leads to the disclosure of other, more personal information, that may also influence treatment outcomes.
The ability to change symptoms gives the person hope that there may be a way to improve their symptoms, the level of trust in the practitioner increases and I find I get instant engagement with the treatment and exercise rehabilitation plan from that point on. The person is more confident to move, is less fearful that ‘something serious is wrong’ and when they can replicate this at home it gives them a self-management strategy for symptom improvement.
Here are two recent examples of patients I have seen who responded well to manual therapy:
Manual therapy can be an effective adjunct to treatment for people with shoulder pain when delivered within a multi-modal programme. When applied within a clinical reasoning model and aligned with the persons beliefs and realistic expectations it can be an effective treatment to help reduce symptoms and facilitate improvements in movement and function. Don’t treat manual therapy like a “trick” and you may start to see it as an effective treatment for the right person.
1. Chester R, Jerosch-Herold C, Lewis J, Shepstone L. Psychological factors are associated with the outcome of physiotherapy for people with shoulder pain: A multicentre longitudinal cohort study. British Journal of Sports Medicine. 2016.
2. Lewis JS. Rotator cuff tendinopathy/subacromial impingement syndrome: is it time for a new method of assessment? British Journal of Sports Medicine. 2009;43(4):259-64.
3. Satpute K, Reid S, Mitchell T, Mackay G, Hall T. Efficacy of mobilization with movement (MWM) for shoulder conditions: a systematic review and meta-analysis. J Man Manip Ther. 2022;30(1):13-32.
4. Aytona MC, Dudley K. Rapid resolution of chronic shoulder pain classified as derangement using the McKenzie method: a case series. J Man Manip Ther. 2013;21(4):207-12.
5. Pieters L, Lewis J, Kuppens K, Jochems J, Bruijstens T, Joossens L, et al. An update of systematic reviews examining the effectiveness of conservative physical therapy interventions for subacromial shoulder pain. J Orthop Sports Phys Ther. 2020;50(3):131-41.
6. Noten S, Meeus M, Stassijns G, Van Glabbeek F, Verborgt O, Struyf F. Efficacy of Different Types of Mobilization Techniques in Patients With Primary Adhesive Capsulitis of the Shoulder: A Systematic Review. Archives of Physical Medicine and Rehabilitation. 2016;97(5):815-25.
Dr Angela Cadogan
Passionate about learning and helping others to think critically about their practice. I hope these posts stimulate your thinking and help you in clinical practice.