0

The full content of Annals is available to subscribers

Subscribe/Learn More  >
Articles |

Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder Dysfunction and Pain: A Randomized, Controlled Trial

Gert J.D. Bergman, MSc; Jan C. Winters, PhD, MD; Klaas H. Groenier, MSc; Jan J.M. Pool; Betty Meyboom-de Jong, PhD, MD; Klaas Postema, PhD, MD; and Geert J.M.G. van der Heijden, PhD
[+] Article and Author Information

From University of Groningen and University Hospital of Groningen, Groningen; Maastricht University, Maastricht; Vrije Universiteit Medical Center Amsterdam, Amsterdam; and University Medical Center Utrecht, Utrecht, the Netherlands.


Note: This trial is being registered in the International Standard Randomised Controlled Trial Number (ISRCTN) Register. The ISRCTN was not available before publication of this article.

Acknowledgments: The authors thank Jettie Nomden and Anton Slagers for assistance with data collection and Juliet Foster for editing the manuscript. They also thank the participating manual therapists, general practitioners, and patients.

Grant Support: By Netherlands Organization for Scientific Research (904-65-901) and Foundation De Drie Lichten.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Gert J.D. Bergman, MSc, Department of General Practice, University of Groningen, PO Box 196, 9700 AD Groningen, the Netherlands; e-mail, g.j.d.bergman@med.rug.nl.

Current Author Addresses: Mr. Bergman, Mr. Groenier, and Dr. Meyboom-de Jong: Department of General Practice, University of Groningen, PO Box 196, 9700 AD Groningen, the Netherlands.

Dr. Winters: Nieuwe Schoolweg 2a, 9756 BB Glimmen, the Netherlands.

Mr. Pool: Institute for Research in Extramural Medicine, Vrije Universiteit Medical Center Amsterdam, Van der Boechorststraat 5, 1081 BT Amsterdam, the Netherlands.

Dr. Postema: Center for Rehabilitation, University Hospital of Groningen, Hanzeplein 1, PO Box 30.001, 9700 RB Groningen, the Netherlands.

Dr. van der Heijden: Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht (Str. 6.131), PO Box 85500, 3508 GA Utrecht, the Netherlands.

Author Contributions: Conception and design: G.J.D. Bergman, J.C. Winters, B. Meyboom-de Jong, K. Postema, G.J.M.G. van der Heijden.

Analysis and interpretation of the data: G.J.D. Bergman, G.J.M.G. van der Heijden.

Drafting of the article: G.J.D. Bergman.

Critical revision of the article for important intellectual content: J.C. Winters, K.H. Groenier, J.J.M. Pool, B. Meyboom-de Jong, K. Postema, G.J.M.G. van der Heijden.

Final approval of the article: J.J.M. Pool, B. Meyboom-de Jong, K. Postema, G.J.M.G. van der Heijden.

Provision of study materials or patients: J.C. Winters.

Statistical expertise: K.H. Groenier, G.J.M.G. van der Heijden.

Obtaining of funding: J.C. Winters, G.J.M.G. van der Heijden.

Collection and assembly of data: G.J.D. Bergman.


Ann Intern Med. 2004;141(6):432-439. doi:10.7326/0003-4819-141-6-200409210-00008
Text Size: A A A

In our study, manipulative therapy for the cervicothoracic spine and the adjacent ribs in addition to usual medical care by a general practitioner accelerated recovery of shoulder symptoms. At 12 weeks after randomization, we found a statistically significant difference in recovery rate (43% vs. 21%; difference, 22 percentage points [CI, 6.9 to 35.4 percentage points]) in favor of additional manipulative therapy. Other outcome measures, such as shoulder pain and shoulder disability, consistently favored additional manipulative therapy, supporting our main finding.

First Page Preview

View Large
First page PDF preview

Figures

Grahic Jump Location
Figure 2.
Flow of patients through the study.

*Percentage of patients who received the intervention (wait-and-see policy along with injection therapy and physiotherapy). GP = general practitioner.

Grahic Jump Location

Tables

References

Letters

NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Comments

Submit a Comment
No Title
Posted on September 29, 2004
Richard C Galgano
No Affiliation
Conflict of Interest: None Declared

The use of manipulative therapy in shoulder dysfunction is analogous to using "medicine" to treat chest pain. Both the nature of condition and the specific treatment need to be identified. The authors described the type of treatments utilized in the study but did not classify the nature of the underlying cause For example, shoulder dysfunction can be caused by dysfunction of the spine, ribs, and shoulder articulations, etc. Have they performed an analysis of the efficacy of treatment with regard to specific conditions? If yes, what are the results of the subset analysis?

Conflict of Interest:

None declared

Author reply
Posted on November 10, 2004
Gert J Bergman
Department of General Practice, University of Groningen
Conflict of Interest: None Declared

The question regarding subgroup analysis is a logical one considering the positive message of our study (1). Our study was designed to examine the efficacy of additional manipulative treatment for shoulder complaints. At baseline all the included patients experienced manifest pain in or dysfunction of the shoulder, while at the same time the physical examination also demonstrated a concomitant dysfunction of the cervicothoracic spine and the adjacent ribs (shoulder girdle dysfunction). We did not perform subgroup analyses on the efficacy of manipulative treatment with regard to specific conditions for several reasons. Subgroup analysis should be based on theoretical considerations. We do not expect large differential effects of manipulative techniques in treatment of shoulder complaints for various postulated specific dysfunctions of the shoulder girdle. A firm theory regarding subgoup effects according to specific shoulder girdle dysfunction is lacking. Moreover, to our opinion there are more similarities than differences between available manipulative techniques for specific conditions of the cervicothoracic spine and adjacent ribs. In addition, physical examination has not shown to contribute to the accurate location of such specific conditions or differentiation between them (2). A recent study demonstrated that by physical examination a distinction between neck and shoulder complaints cannot be made accurately (3). Finally, with our sample size of 150 patients we were able to demonstrate significant results in our main analysis. Any subgroup analysis would require a larger sample size, because statistical power of such additional analyses is likely to be insufficient (4).

References

(1) Bergman GJD, Winters JC, Groenier KH, Pool JJM, Meyboom-de Jong B, Postema K et al. Manipulative therapy in addition to usual medical care for patients with shoulder pain and dysfunction. A randomized, controlled trial. Ann Intern Med. 2004;141:432-39.

(2) Pool JJ, Hoving JL, de Vet HC, van Mameren H, Bouter LM. The interexaminer reproducibility of physical examination of the cervical spine. J Manipulative Physiol Ther. 2004;27:84-90.

(3) Groenier KH, Winters JC, de Jong BM. Classification of shoulder complaints in general practice by means of nonmetric multidimensional scaling. Arch Phys Med Rehabil. 2003;84:812-17.

(4) Brookes ST, Whitely E, Egger M, Smith GD, Mulheran PA, Peters TJ. Subgroup analyses in randomized trials: risks of subgroup-specific analyses; power and sample size for the interaction test. J Clin Epidemiol. 2004;57:229-36.

Gert JD Bergman, MSc Department of General Practice, University of Groningen, Groningen, The Netherlands Center for Rehabilitation, University Hospital of Groningen, The Netherlands

Jan C Winters, MD, PhD, Department of General Practice, University of Groningen, Groningen, The Netherlands

Geert JMG van der Heijden, PT, PhD Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands

Conflict of Interest:

None declared

Submit a Comment

Summary for Patients

Manipulative Therapy for Patients with Shoulder Pain

The summary below is from the full report titled “Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder Dysfunction and Pain. A Randomized, Controlled Trial.” It is in the 21 September 2004 issue of Annals of Internal Medicine (volume 141, pages 432-439). The authors are G.J.D. Bergman, J.C. Winters, K.H. Groenier, J.J.M. Pool, B. Meyboom-de Jong, K. Postema, and G.J.M.G. van der Heijden.

Read More...

Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.

Toolkit

Buy Now

to gain full access to the content and tools.

Want to Subscribe?

Learn more about subscription options

Advertisement
Related Articles
Related Point of Care
Topic Collections
PubMed Articles
Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.
(Required)
(Required)