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Effectiveness of soft tissue massage and exercise
for the treatment of non-specific shoulder pain:
a systematic review with meta-analysis
Paul Andrew van den Dolder,
1,2
Paulo H Ferreira,
1
Kathryn M Refshauge
1
▸Additional data are published
online only. To view this file
please visit the journal online
(http://bjsm.bmj.com).
1
Discipline of Physiotherapy,
University of Sydney, Sydney,
New South Wales, Australia
2
Department of Ambulatory and
Primary Health Care, Illawarra
Shoalhaven Local Health
District, Wollongong, New
South Wales, Australia
Correspondence to
Paul Andrew van den Dolder,
Faculty of Health Sciences, The
University of Sydney, 75 East
Street, Lidcombe, NSW 2141,
Australia;
pvan0651@uni.sydney.edu.au
Received 1 October 2011
Accepted 26 June 2012
ABSTRACT
Objective To determine the effectiveness of exercise
and soft tissue massage either in isolation or in
combination for the treatment of non-specific shoulder
problems.
Methods Database searches for articles from 1966 to
December 2011 were performed. Studies were eligible if
they investigated ‘hands on’soft tissue massage
performed locally to the shoulder or exercises aimed at
improving strength, range of motion or coordination; non-
surgical painful shoulder disorders; included participants
aged 18–80 years and outcomes measured included
pain, disability, range of motion, quality of life, work
status, global perceived effect, adverse events or
recurrence.
Results Twenty-three papers met the selection criteria
representing 20 individual trials. We found low-quality
evidence that soft tissue massage was effective for
producing moderate improvements in active flexion and
abduction range of motion, pain and functional scores
compared with no treatment, immediately after the
cessation of treatment. Exercise was shown by meta-
analysis to produce greater improvements than placebo,
minimal or no treatment in reported pain (weighted
mean=9.8 of 100, 95% CI 0.6 to 19.0) but these
changes were of a magnitude that was less than that
considered clinically worthwhile. Exercise did not produce
greater improvements in shoulder function than placebo,
minimal or no treatment (weighted mean=5.7 of 100,
95% CI −3.3 to 14.7).
Conclusion There is low-quality evidence that soft
tissue massage is effective for improving pain, function
and range of motion in patients with shoulder pain in the
short term. Exercise therapy is effective for producing
small improvements in pain but not in function or range
of motion.
INTRODUCTION
Shoulder pain is an important medical and socio-
economic problem in the western world, with
between 7% and 26% of the population reporting
shoulder problems at any one time.
1
The presence
of pain and stiffness in the shoulder can lead to an
inability to work and/or to carry out domestic and
recreational activities, thus creating a high burden
of disease for both the individual and society.
Information on the costs associated with health-
care use and loss of productivity in patients with
shoulder pain is scarce but thought to be consider-
able.
2
For many people, shoulder complaints are
not self-limiting: almost 40% of patients who
visited a general practitioner for shoulder pain
reported complaints that had persisted for more
than 12 months.
3
Most shoulder pain experienced
has no clearly defined pathology or physical signs
and as such has been termed as ‘non-specific shoul-
der pain’.
4
Up to 50% of patients with shoulder pain are
referred to a physiotherapist for treatment.
5
with
soft tissue massage and exercise being the most
common treatments. A recent study in the
Netherlands found that therapists used soft tissue
massage techniques to treat 91.6% of 119 patients
with shoulder complaints, and exercise for 96.6%
of patients. In 85% of cases, these treatments were
used in combination.
6
Similarly, a recent survey of
experienced shoulder physiotherapists in Australia
found that exercise was considered an essential
component of effective treatment by 100% of
respondents and soft tissue massage by 66%.
7
Despite this, there has been no previous systematic
review specifically investigating the effectiveness
of soft tissue massage for the treatment of non-
specific shoulder pain. A number of systematic
reviews have evaluated the effectiveness of exercise
for shoulder disorders
38–19
with conflicting conclu-
sions. None conducted a meta-analysis, which
would provide an indication of the magnitude of
the overall effect of exercise through statistically
combining the effects of all studies.
The aim of this study, therefore, was to conduct
a systematic review of the effectiveness of soft
tissue massage and of exercise for non-specific
shoulder pain when these interventions were com-
pared with placebo, no treatment, another active
treatment or when soft tissue massage or exercise
were added as a supplement to other interven-
tions. Meta-analysis was conducted where
possible.
METHODS
Criteria for inclusion of trials
To be included in the review, studies had to be ran-
domised controlled trials reported in any language.
Participants were adults with symptoms in the
shoulder region that were labelled with the follow-
ing diagnoses: rotator cuff tendonitis, rotator cuff
tendinopathy, rotator cuff tear, impingement syn-
drome, bursitis, adhesive capsulitis, periarthritis
and ‘frozen shoulder’. In addition, studies in
which participants were not given a specific diag-
nosis but rather classified as having non-specific
shoulder pain were included. Trials that included
participants with the following diagnoses were
excluded: infection, neoplasm, fracture, instability,
dislocation, hemiplegia, postoperative or periopera-
tive shoulder pain or inflammatory disease.
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Treatments included were soft tissue massage or exercise,
administered in isolation or in conjunction with other therap-
ies. To be included in this review, trials of massage had to
implement techniques aimed at the muscular structure and
soft tissues local to the shoulder including applying fixed or
movable pressure. Similarly, trials of exercise therapy had to
include the performance of physical activity in order to
improve health. This included therapeutic exercises that aimed
to improve muscle strength, power, endurance, control, range of
motion or flexibility, proprioception, cardiorespiratory fitness
and tolerance to activity.
Measures of at least one of the following outcomes had to be
reported: disability, pain, return to work, number of episodes,
global perceived effect or health-related quality of life. To be
included in the review, trials had to present sufficient data to
be able to estimate effect sizes.
Identification and selection of trials
Searches were conducted of the electronic databases of
MEDLINE (1966 to December 2011), EMBASE (1974 to
December 2011), CINAHL (1982 to December 2011),
SPORTDiscus (1800 to December 2011), Web of Science (to
December 2011), EBM reviews (to December 2011) and PEDro
(to December 2011). Terms for searches included a combination
of subject headings and text words related to the domains of
randomised controlled trials and shoulder pain as described by
Green et al
3
and Furlan et al
20
Specific search terms based on
Medical Subject Headings (MeSH) for this review are presented
in Appendix 1. The protocol for this review was assessed exter-
nally and independently by a researcher not involved in this
study.
Two reviewers independently screened search results for
potentially eligible studies. Any disagreement on the inclusion
of trials was resolved through consensus discussion. Researchers
currently involved in the area were identified from bibiolo-
graphic searches as well as through the knowledge of the
authors and were contacted to ensure that no trial had been
missed by our searches. In addition, trial registers were checked
to ascertain whether there were new trials currently being con-
ducted or unpublished data. Citation tracking was performed
by manually screening reference lists of eligible trials as well as
reviewing reference lists from other systematic reviews evaluat-
ing the effectiveness of massage and exercise for the treatment
of relevant shoulder pain.
Assessment of quality of the evidence
The GRADE (Grades of Recommendation, Assessment,
Development and Evaluation) system for grading evidence for
systematic reviews was used to evaluate the overall quality of
the evidence and the strength of the recommendations.
21
This
system evaluates the quality of the evidence for a specific
outcome based on five principal measures: (1) limitations (eg,
study design), (2) consistency of results, (3) directness (eg, gen-
eralisability of the findings), (4) precision (eg, sufficient data)
and (5) other considerations, such as reporting bias.
The overall quality of the evidence was considered to be high
when randomised controlled trials with a low risk of bias dem-
onstrate consistent, generalisable and precise results for a par-
ticular outcome.
22
Single studies were considered to provide
‘low-quality evidence’if associated with a low risk of bias or
‘very low-quality evidence’if associated with a high risk of bias
(table 1).
Assessment of risk of bias of included studies
Two reviewers working independently (PV and either KMR or
PHF) assessed the risk of bias and performed data extraction.
Risk of bias was assessed using the criteria list advised by the
Cochrane Back Review Group, which consists of 12 items
evaluating internal validity. Items were scored as positive if
they fulfilled the criterion, negative when bias was likely or
marked as inconclusive if there was insufficient information.
Differences in the scoring and data extraction were discussed
during a consensus meeting. A study with a low risk of bias
was defined as fulfilling six or more of the validity items.
22
Analysis of effect size of treatment for individual trials
For continuous outcomes we extracted the mean and SD for
the between-group difference of the end points.
23
When dichot-
omous data were provided, relative risk was calculated.
24
We
used the formulae for binary and continuous data calculations
described by Fleiss.
25
Effect size for pooled estimates from multiple trials
When trials were considered sufficiently clinically and statistic-
ally homogeneous they were grouped according to treatment
comparisons and outcomes (disability, pain, number of epi-
sodes, global perceived effect and return to work). Pooled esti-
mates were obtained using a random effects model using
RevMan 5 software.
26
Pain, disability and quality-of-life scales
were converted to 0–100 scales. Individual data were presented
following the definition of short (≤3 months), intermediate
(>3 and <12 months) and long-term (≥12 months) follow-up
based on the proposal by the Cochrane Back Review Group.
22
For shoulder pain, previous studies have demonstrated that
the minimal clinically important difference in pain is around
14% improvement
27
and at least 12% improvement for func-
tion.
28
These figures were used in this review to determine
whether any changes were of a magnitude considered to be
clinically worthwhile for patients.
RESULTS
Included trials
Database searches identified 3096 studies; abstracts of 260
studies suggested that 95 articles were potentially eligible for
inclusion but only 23 met the inclusion criteria. Of the 23
Table 1 Levels of evidence
21
Level of
evidence Description
High quality Recommendations based on consistent findings from at least two
RCTs with low risk of bias. Results are generalisable to the
population in question. There are sufficient data with narrowCI.
There are no known or suspected reporting biases. Further
research is very unlikely to change the level of evidence
Moderate
quality
Further research is likely to have an important impact on
confidence in the estimate of effect and may change the estimate;
one of the factors is not met
Low quality Further research is very likely to have an important impact on
confidence in the estimate of effect and is likely to change it; two
of the factors are not met
Very low quality Great uncertainty about the estimate; three of the factors are not
met
No evidence No evidence from RCTs
RCT, randomised controlled trial.
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included articles three sets of two articles shared data from the
same trials giving a total of 20 discrete trials with sufficient
data to estimate effect sizes (table 1). The most commonly
assessed outcomes were pain (19 trials) and function (19 trials)
although in three articles these outcomes could not be
extracted from the global shoulder outcome measures used that
combined pain, disability and range of motion scores. The
process for inclusion into this study is summarised in the flow
chart of the study selection according to the recommendations
of the PRISMA statement
29
in figure 1.
Risk-of-bias assessment
Risk-of-bias scores (table 2) ranged from 6 to 11 points out of a
maximum of 12 points (mean±SD, 8.8±1.5; table 2). The
most common risks of bias were failure to blind therapists (all
22 trials) which is expected in trials examining the effectiveness
of hands-on therapy, failure to blind participants (18 trials) and
failure to conceal allocation (11 trials). All trials scored more
than 6, indicating low risk of bias.
22
A summary of the trials
investigating the use of soft tissue massage for the treatment of
shoulder pain can be found in table 3, for exercise in
Figure 1 PRISMA statement of study selection process.
Br J Sports Med 2012;0:1–12. doi:10.1136/bjsports-2011-090553 3
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supplementary table S1 and for soft tissue massage combined
with exercise in table 4.
Effectiveness of soft tissue massage
Soft tissue massage versus no treatment
One study was located that compared massage with no treat-
ment. This study, conducted by one of the authors (PV) of this
paper (risk-of-bias score=9),
30
delivered six treatments of soft
tissue massage over 2 weeks to the lateral border of the scapula
in end-of-range flexion, posterior deltoid in end-of-range hori-
zontal flexion, anterior deltoid in end-of-range hand behind
back and pectoralis major in the stretch position. This study
found that soft tissue massage was more effective for improv-
ing active flexion (mean improvement 26.1°, 95% CI 10.8 to
41.4), pain (mean improvement 22.0 out of 100, 95% CI 2.8 to
41.2) and functional scores (mean improvement 24.0 out of
100, 95% CI 7.4 to 40.6) with greater effectiveness for improv-
ing active abduction (mean improvement 44.5°, 95% CI 25.1 to
63.7°) compared with no treatment (figure 2).
In summary, based on the single study located with low risk
of bias, there was low-quality evidence that soft tissue massage
is effective for improving range of motion, function and pain
immediately following treatment.
Soft tissue massage to the gleno-humeral region versus active
controls
One study (risk-of-bias score=7)
31
with 59 participants com-
pared 15 sessions of sustained digital pressure to trigger points
in supraspinatus, deltoid, infraspinatus and biceps tendon with
sustained digital pressure to trigger points in the cervical and
upper thoracic regions. The authors found improvements in
combined pain and function scores in a combined pain and
functional rating scale (mean improvement 41.5 out of 100,
95% CI 15.7 to 34.9).
Thus, there is low-quality evidence that soft tissue massage
to the gleno-humeral region is more effective for improving
combined pain and function than soft tissue massage to the
cervical and upper thoracic region.
Another trial (risk-of-bias score=8)
32
demonstrated that
2 weeks of Cyriax-type deep frictions and mobilisation to the
supraspinatus and infraspinatus muscles failed to improve
active flexion but improved external rotation (mean improve-
ment 21.6°, 95% CI 9.3 to 33.9°), active internal rotation range
of motion (mean improvement 10.6°, 95% CI 2.8 to 18.4) and
pain on movement (mean improvement 12.1 out of 100, 95%
CI 0.0 to 27.3) immediately after treatment compared to treat-
ment of hot packs and short wave diathermy (figure 2).
In summary, there is low-quality evidence that Cyriax-type
deep frictions and mobilisation in combination are effective for
producing an immediate improvement in pain on movement,
external and internal rotation range of motion but not flexion
range of motion.
Effectiveness of exercise
Exercise versus no treatment/placebo
Eight papers
33–40
investigated the use of exercise for the treat-
ment of non-specific shoulder pain compared with no treat-
ment or placebo treatment. Two of these papers
33 34
(risk-of-bias score=9) described data from the same trial with
80 participants, resulting in six discrete studies
35–41
(risk-of-bias
Table 2 Risk-of-bias assessment
Risk-of-bias criteria
Author Year 123456789101112Total risk-of-bias score
Ainsworth et al 2009 YYYNYYYYYYYY11
Bennell et al 2010 YYYNYYYYYYYY11
Bron et al 2011 Y Y N N Y Y Y Y Y YYY10
Brox et al 1993 and 1999 Y NNNYYYYYYYY9
Citaker et al 2005 Y NNNNNNYYYYY6
Cohen et al 2005 Y NNNYYNYYYYY8
Diercks et al 2004 NNNNNYNY YYYY6
Engebretsen et al 2009 and 2011 Y Y N N Y Y Y Y Y YYY10
Hains et al 2010 YYYNNYNYYYYY9
Geraets et al 2006 and 2005 Y Y N N Y Y Y Y Y YYY10
Ginn et al 1997 Y Y N N Y Y Y Y Y YYY10
Godges et al 2003 Y NNNY NY YY YYY8
Guler-Uysal et al 2004 Y NNNYYNYYYYY8
Hains et al 2010 YYYNI YYYYYYY10
Lombardi et al 2008 Y Y N N Y Y Y Y Y YYY10
Ludewig et al 2003 Y Y NNNY Y YYYYY9
Senbursa et al 2011 Y I Y N N I I Y Y Y I Y 6
van den Dolder et al 2003 Y Y NNNY Y YYYYY9
Walther et al 2004 Y I NNNY Y YY YYY8
Weiner et al 2005 Y I N N I Y Y Y Y YYY8
Average risk-of-bias score 8.8
Range of risk-of-bias scores 6–11
Y, yes; N, no; I, inconclusive.
GRADE risk-of-bias criteria: 1, Was the method of randomisation adequate? 2, Was the treatment allocation concealed? 3, Was the patient blinded to the intervention? 4, Was
the care provider blinded to the intervention? 5, Was the outcome assessor blinded to the intervention? 6, Was the drop-out rate described and acceptable? 7, Were all
randomised participants analysed in the group to which they were allocated? 8, Are reports of the study free of suggestion of selective outcome reporting? 9, Were the groups
similar at baseline regarding the most important prognostic indicators? 10, Were co-interventions avoided or similar? 11, Was the compliance acceptable in all groups? 12, Was
the timing of the outcome assessment similar in all groups?
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scores 9, 10, 8, 7 and 6 respectively; participants range 9–77).
Where there were common outcome measures between these
studies and sufficient information was available, data were
extracted to perform meta-analysis (figure 3). One study
39
did
not provide any measures of variability for the outcomes while
another study
40
did not report baseline measures and thus were
both excluded from the meta-analysis.
Function
Six studies
35–40
with low risk of bias investigated the effective-
ness of exercise compared with no treatment, placebo treat-
ment or minimal care for improving function in the immediate
to short term. Two studies
36 40
included their functional scores
in overall measures of effectiveness, rendering extraction of
these results impossible. Meta-analysis of the remaining four
studies showed no statistical difference between exercise and
the comparison intervention (pooled mean 5.7 points on a
100-point scale, CI −3.3 to 14.7) for improving function
(figure 3).
Thus, there is high-quality evidence that exercise treatment
is not effective for producing improvements in function com-
pared to no treatment, placebo or minimal care in patients
with non-specific shoulder pain.
Pain
Five studies
35–39
with low risk of bias investigated the effective-
ness of exercise for pain reduction immediately after treatment
and in the short term. Data could not be extracted for one
study: Walther et al
38
provided data in a figure with no measure
of variability. Meta-analysis demonstrated improvement in pain
in the remaining studies (pooled mean 9.8 points on a 100
point scale, 95% CI 0.6 to 19.0) (figure 3). Thus, there is high-
quality evidence that exercise treatment is effective for produ-
cing small improvements in pain in the short term compared to
no treatment, placebo or minimal care for shoulder pain.
Table 3 Summary of trials of soft tissue massage for the treatment of shoulder pain
Author/year Condition Experimental group Comparison group(s) Outcome measures
Soft tissue massage versus no treatment
van den Dolder
and Roberts
(2003)
Patient group: unilateral shoulder pain
with tenderness on palpation to muscles
around shoulder
MOR: opaque envelopes
Two groups:
STM; no treatment
STM group
n=15 (11 males, 4 females)
Age=63.1±9.9 years
DOS=26 weeks (IQR 13–26)
Intervention: six sessions of STM aimed at
lateral border of scapula EOR flexion,
posterior deltoid EOR horizontal flexion,
anterior deltoid EOR hand behind back,
pectoralis major in stretch position over
2 weeks
No treatment group
n=14 (9 males, 5 females)
Age=65.9±9.2 years
DOS=30 weeks (IQR 23–91)
Intervention: no treatment for 2 weeks
Follow-up period
2 weeks
Outcome measures
Pain: Short Form McGill
Pain Questionnaire
Function:
Patient-Specific
Functional Disability
Score
ROM:
Flexion (from
photograph)
Abduction (from
photograph)
Hand behind back
(centimetre above/
below PSIS)
Soft tissue massage versus active controls
Guler-Uysal
and Kozanoglu
(2004)
Patient group: >2 months shoulder pain
with limited ROM and pain on movement
MOR: not stated
Two groups: Cyriax; Ph mobilisations use
low-grade/velocity, small or large
amplitude passive movement techniques
or neuromuscular techniques within the
patient’s ROM and within the patient’s
control. siotherapy group
Cyriax group
n=20 (5 males, 15 females)
Age=53.6±6.9 years
DOS=7.6±3.9 months
Intervention: Cyriax approach frictions and
mobilisations, active stretching and
pendulum exercises with PT, home
exercises—pendulum and passive ROM
Three weekly hour sessions for 2 weeks
Physiotherapy group
n=20 (7 males, 13 females)
Age=58.4±9.7 years
DOS=5.6±3.9 months
Intervention: hot packs, SWD, active
stretching and pendulum exercises with
PT, home exercises—pendulum and
passive ROM. Sessions five times per
week for 2 weeks.
Three weekly hour sessions for 2 weeks
Follow-up period
2 weeks
Outcome measures
Pain:
Spontaneous pain using
VAS
Night pain using VAS
Pain with motion using
VAS
Passive ROM: using
goniometer
Flexion
Abduction
Internal rotation
External rotation
Hains et al
(2010)
Patient group: Shoulder pain ≥5 out of
10 VAS score on a daily basis for
≥3 months
MOR: opaque envelopes with 2/3 even—
1/3 odd random numbers
Two groups: sustained pressure to trigger
points in shoulder; sustained trigger
points to cervical and upper thoracic
region
Sustained pressure to trigger points in
shoulder group
n=41 (21 males, 20 females)
Age=46.5±8.8 years
DOS=4.0±3.9 years
Intervention: 15 treatments (timeframe not
stated) of 15 s pressure on each trigger
points supraspinatus, deltoid, infraspinatus
muscles and biceps tendon. Position of
arm during treatment not specified
Sustained pressure to trigger points in
neck and upper thoracic region group
n=18 (5 males, 13 females)
Age=45.6±7.4 years
DOS=4.9±4.2 years
Intervention: 15 treatments (timeframe
not stated) of 15 s pressure on each
trigger points in neck and upper thoracic
regions
Follow-up period
Immediately following
15 treatments, 30 days,
6 months
Outcome measures
Pain and function:
using Shoulder Pain
and Disability Index
Perceived improvement:
using numerical scale
from 0% to 100%
ADL, activities of daily living; AROM, active range of movement; DOS, duration of symptoms; EOR, end of range; IQR, IQ range; IR/ER, internal rotation/external rotation; MOR,
method of randomisation; n, number of participants in group; PSIS, posterior superior iliac spine; PT, physiotherapy; ROM, range of motion; SWD, short wave diathermy; STM,
soft tissue massage; VAS, visual analogue scale.
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Table 4 Summary of trials of soft tissue massage and exercise combined for the treatment of shoulder pain
Author/
year
Condition Experimental group Comparison group(s) Outcomes
Soft tissue massage and exercise versus no treatment
Godges
et al (2003)
Patient group: limited shoulder
external rotation and overhead reach
MOR: block randomisation using
random number table
Two groups: STM+PNF; no
treatment control
STM + PNF group
n=10 (5 males, 5 females)
Age=60.8±22.3 years
DOS=not stated
Single treatment intervention
Intervention: STM to subscapularis,
contract–relax PNF for subscapularis and
other glenohumeral internal rotators
No treatment group
n=10 (5 males, 5 females)
Age=58.6±16.5 years
DOS=not stated
Intervention: no treatment
Follow-up period
Immediately following single
treatment
Outcome measures
External rotation (goniometer)
Flexion (centimetres reached
up wall)
Soft tissue massage+multimodal treatment versus placebo
Bennell
et al (2010)
Patient group: chronic rotator cuff
disease >3 months
MOR: permuted block
randomisation
Two groups: STM+exercise+taping
+mobilisation; placebo ultrasound
control
STM, scapular retraining, postural taping,
spinal mobilisation and home exercises
group
n=59 (34 males, 25 females)
Age=59.3±10.1 years
DOS=24months (IQR 6–54)
Intervention: STM, scapular retraining,
postural taping, gleno-humeral mobilisation
and home exercises
Ten treatment sessions over 10 weeks with
home exercise for an additional 12 weeks
after that
Placebo ultrasound group
n=61 (30 males, 31 females)
Age=60.8±12.4 years
DOS=14 months (IQR 6–24)
Intervention: sham ultrasound therapy to
the shoulder for 10 min for 10 treatment
sessions over 10 weeks
Follow-up period 11 and
22 weeks
Outcome measures
Pain and function: using
Shoulder Pain and Disability
Index
Pain: pain on movement
(11-point Likert scale)
Pain at rest (11-point Likert
scale)
Disability: weakness on
movement (11-point Likert
scale)
Stiffness on movement
(11-point Likert scale)
Interference with activity
(11-point Likert scale)
Quality of life: SF-36
questionnaire+
assessment of quality of life
instrument (−0.4 to 1.0)
Strength: abduction, external
rotation, internal rotation
(hand-held dynamometer (kg)
Bron et al
(2011)
Patient group: patients with
shoulder pain referred to a primary
care practice for physiotherapy
MOR: random number generator
Two groups: manual compression of
trigger points, stretching and
intermittent cold application;
waiting list control
Manual compression of trigger points,
stretching and intermittent cold application
n=34 (13 males, 21 females)
Age=42.8±11.7 years
DOS=29% 6–9 months, 12% 9–12 months,
23% 1–2 years, 36% >2 years
Intervention: manual compression of trigger
points, stretching and intermittent cold
application once weekly for maximum
12 weeks
Waiting list control group
n=31 (11 males, 23 females)
Age=45.0±13.2 years
DOS=16% 6–9 months, 26% 9–12 months,
19% 1–2 years, 39% >2 years
Intervention: no treatment control on
waiting list for 3 months
Follow-up period: 6 and
12 weeks
Outcome measures
Pain and function: using
Shoulder Pain and Disability
Index
Pain: current pain, average
pain past 7 days and worst
pain over past 7 days using a
10 cm VAS pain scale
Combined function, pain,
social and emotional:
Disabilities of the Shoulder
and Hand questionnaire)
ROM: passive ROM using
digital inclinometer
Number of trigger points:
manual count
Soft tissue massage and joint mobilisation and exercise versus active controls
Senbursa
et al (2011)
Patient group: partial supraspinatus
tear (stage 1) and/or supraspinatus
impingement syndrome
MOR: computer-generated random
numbers
Three groups: supervised exercise;
supervised exercise+joint and soft
tissue mobilisation; self-exercise
group
Supervised exercise + joint mobilisation and
soft tissue massage group
n=30 (gender not provided)
Age=50.5±10.6 years
DOS=not provided
Intervention: supervised stretching and
strengthening exercises for the rhomboid,
levator scapulae, serratus anterior and
rotator cuff muscles, deep friction massage
on the supraspinatus muscle, radial nerve
stretching, scapular mobilisation,
glenohumeral joint mobilisation and
proprioceptive neuromuscular facilitation
techniques three times a week for
12 weeks
Supervised exercise
n=25 (gender not provided)
Age=48.2±7.9 years
DOS=not provided
Intervention: supervised stretching and
strengthening exercises for the rhomboid,
levator scapulae, serratus anterior and
rotator cuff muscles three times a week for
12 weeks, under supervision of a
physiotherapist.
Self-exercise group
n=22 (gender not provided)
Age=48.0±9.0 years
DOS=not provided
Intervention: self-exercise programme for
the rhomboid, levator scapulae serratus
anterior and rotator cuff muscles at home
Follow-up period
4 weeks, 12 weeks
Outcome measures
Night pain, rest pain and pain
with movement on 10 cm
using VAS
Function: modified American
Shoulder and Elbow Surgeon’s
questionnaire
Strength: tested manually on
scale 0 (lowest) to 5 (highest)
ROM: using a goniometer
DOS, duration of symptoms; IQR, IQ range; MOR, method of randomisation; n, number of participants in group; PNF, proprioceptive neuromuscular facilitation; PT, physiotherapy;
ROM, range of motion; STM, soft tissue massage; VAS, visual analog scales. ±, figures are SD.
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Range of motion
Four studies
35–38
with low risk of bias investigated the effect-
iveness of exercise on pain in the immediate to short term.
Data could not be extracted for two studies, one because mean
pain data
38
were provided in a figure only with no measure of
variability, and the other
35
because data were combined in a
global rating scale and could not be extracted. For the two
remaining studies
36 37
meta-analysis was conducted on the
common outcome measures of flexion (pooled mean 11.2°, 95%
CI −0.1 to 22.5°) and abduction range of motion (pooled mean
17.9°, 95% CI −0.5 to 36.3°) (figure 3). Thus, there is high-
quality evidence that exercise is not effective for improving
range of motion in patients with shoulder pain compared to no
treatment.
Exercise versus passive control
One trial, reported over two papers
41 42
(risk-of-bias score=8),
with 104 participants investigated the effects of a
12-week-graded exercise programme based on relearning normal
movement patterns and endurance exercises compared with
4–6 weeks of physiotherapist administered extracorporeal
shockwave treatment (figure 4). There was no difference
between groups in outcomes for disability or pain between
these two approaches at 6, 12 and 18 weeks and 12 months.
Thus, there is moderate evidence that exercise therapy is no
more effective for improving pain or function than extracorpor-
eal shockwave therapy.
Exercise versus active control
One trial (risk-of-bias score=6)
43
with 40 participants with
shoulder impingement syndrome found no difference in
reported pain or flexion, abduction, internal or external rotation
range of motion between participants treated with hot packs
and strengthening exercises and participants treated with either
proprioceptive neuromuscular facilitation exercises or mobilisa-
tions to the shoulder ( figure 4). Thus, there is low-quality
evidence that exercises are not more effective than mobilisa-
tions or a combination of hot packs and theraband exercises for
the treatment of shoulder impingement syndrome.
Another trial (risk-of-bias score=8)
44
with 138 participants
found no differences in either pain or functional scores between
the use of a specific programme of exercises aimed at restoring
dynamic stabilising mechanisms and coordination at the shoul-
der and a combination of physical modalities (electrophysical
modalities, passive joint mobilisation and range of motion exer-
cises) over a 5-week period (figure 4). Thus, there is low-quality
evidence that exercises aimed at restoring dynamic stabilising
mechanisms and coordination at the shoulder are no more
effective than a combination of physical modalities.
Exercise and mobilisation versus no treatment
One study
45
(risk-of-bias score=6) with 87 participants with
idiopathic adhesive capsulitis were randomly allocated to either
a group prescribed active exercises up to and beyond pain
threshold, passive stretching and manipulation or to a
no-treatment control group. At the end of 2 years, 89% of parti-
cipants in the no-treatment group had normal or near-normal
painless shoulder function (Constant score ≥80). In contrast, of
the group receiving intensive physical therapy treatment, only
63% reached a Constant score of 80 or higher after 24 months.
Thus, there is low-quality evidence that no treatment pro-
vides better outcomes in patients with adhesive capsulitis than
intensive exercise and mobilisation.
Behavioural approach graded exercise programme versus active
control
One study, reported in two papers (risk-of-bias score=10
46 47
)
with 176 participants with chronic shoulder complaints
(>3 months) demonstrated that an operant behavioural and
time-contingent graded exercise therapy programme designed
Figure 2 Forest plot of effect sizes of STM studies. ROM scores are in degrees except for Godges 2003 where flexion was measured in
improvement in centimetre reached up a wall. Function and pain scores are out of 100. Figures are a comparison of scores at reassessment. The
centre of each shape represents the mean with the size of the shape indicating relative size of the study population. Horizontal lines for each result
indicate the 95% CI. PNF, proprioceptive neuromuscular facilitation; ROM, range of motion; STM, soft tissue massage.
Br J Sports Med 2012;0:1–12. doi:10.1136/bjsports-2011-090553 7
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to improve functional ability irrespective of pain provided no
additional improvement in self-rated functional ability, per-
ceived recovery, reported pain or quality of life at either
12 weeks or 1 year when compared to usual care from the
patient’s general practitioner (figure 4). There is, therefore, low-
quality evidence that a graded exercise programme does not
offer additional benefits to usual care from a general practi-
tioner for the management of chronic shoulder pain.
Effectiveness of soft tissue massage and exercise versus no
treatment
One trial (risk-of-bias score=7)
48
found improvements in active
external rotation range of motion (mean improvement 15.5°,
95% CI 12.0 to 19.0) but no improvement in forward reach up
a wall following a single treatment of soft tissue mobilisation
to the subscapularis and proprioceptive neuromuscular facilita-
tion exercises for the shoulder rotators when compared with a
no-treatment control group.
Thus, there is low-quality evidence that soft tissue massage
combined with proprioceptive neuromuscular facilitation
exercises improves external rotation range of motion but not
forward flexion.
Effectiveness of soft tissue massage and joint mobilisation
and exercise versus active control
One trial
49
(risk-of-bias score=6) with 77 participants found no
differences in night pain, rest pain or pain with movement,
reported function or strength between a supervised exercise
programme combined with joint and soft tissue mobilisation,
supervised exercise in isolation or a home-based rehabilitation
programme at either 4 or 12 weeks follow-up.
Thus, there is low-quality evidence that soft tissue massage
in combination with joint mobilisation and exercise does not
result in improvements in pain, reported function or strength
compared with exercise alone.
Effectiveness of soft tissue massage and multimodal
treatment versus placebo
Two studies
50 51
with low risk of bias were identified that
investigated the effects of soft tissue massage combined with
Figure 3 Exercise versus no treatment/placebo/minimal care—meta-analysis of improvements in the range of motion, functional scores and pain—
immediate to short term. ROM scores are in degrees. Function and pain scores are out of 100. Figures are a comparison of scores at reassessment.
The centre of each shape represents the mean with the size of the shape indicating relative size of the study population. Horizontal lines for each
result indicate the 95% CI. ROM, range of motion.
8Br J Sports Med 2012;0:1–12. doi:10.1136/bjsports-2011-090553
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exercise approaches in combination with other physical
modalities.
One study
50
(risk-of-bias score=11) with 120 participants
examined the effectiveness of soft tissue massage, scapular
retraining, postural taping, gleno-humeral mobilisation and
home exercises for the treatment of non-specific shoulder pain
compared to placebo ultrasound over a 10-week period. The
patients in this study had chronic shoulder pain, with those in
the massage group having pain for a median of 24 months (IQ
range (IQR) 6–54) and 14 months (IQR 6–24) in the placebo
group. At 11 weeks, no difference was found between groups
for either change in shoulder function or pain. At 22 weeks
follow-up there was a statistically significant improvement in
function in favour of soft tissue massage and exercise combined
(mean improvement 7.6 of 100, 95% CI 1.8 to 13.4). There was
no change at 22 weeks for pain (figure 5).
Another study
51
(risk-of bias score=10) with 65 participants
investigated the effectiveness of manual compression on trigger
points along with deep stroking massage, ice massage,
hold-relax stretches, stretches, relaxation exercises and home
heat packs compared with no treatment for 12 weeks. At the
end of the treatment period, pain (mean improvement 13.8 of
100, 95% CI 2.6 to 25.0) and function (mean improvement 7.7
of 100; 95% CI 1.2 to 14.2), were significantly improved in the
treatment group (figure 5).
In summary, there is high-quality evidence that soft tissue
massage in combination with exercise, passive joint
mobilisation and other physical modalities results in small
improvements in function with conflicting evidence concerning
improvements in pain compared with no treatment or placebo.
DISCUSSION
There is low-quality evidence that soft tissue massage is effect-
ive for improving the range of motion, function and pain in
patients with non-specific shoulder pain immediately following
treatment. Exercise approaches in the treatment of non-specific
shoulder pain improve pain immediately following treatment
and in the short term although this change does not appear to
be clinically worthwhile. Exercise does not improve reported
function or range of motion.
This review is the first to specifically examine the effective-
ness of soft tissue massage for the treatment of non-specific
shoulder pain.
52
We found that there were very few trials in
this area with all these trials having small sample sizes and
short follow-up period. The greatest improvements with soft
tissue massage, targeted treatment towards the lateral border of
the scapula in end-of-range flexion, the posterior deltoid region
in end-of-range horizontal flexion, anterior deltoid in
end-of-range external rotation (measured as hand behind back)
and pectoralis major in the stretch position.
30
This demon-
strated moderate improvements in active flexion (mean
improvement 22.6°) and abduction (mean improvement 42.2°)
ranges of motion, pain levels (mean improvement 26.5 mm on
Figure 4 Forest plot of effect sizes of exercise studies. ROM scores are in degrees. Function and pain scores are out of 100. Figures are a
comparison of scores at reassessment. The centre of each shape represents the mean with the size of the shape indicating relative size of the study
population. Horizontal lines for each result indicate the 95% CI. PNF, proprioceptive neuromuscular facilitation; ROM, range of motion.
Br J Sports Med 2012;0:1–12. doi:10.1136/bjsports-2011-090553 9
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a 100 mm visual analog scale) and functional scores (mean
improvement 28.7%). Soft tissue massage is also effective for
improving external range of motion in patients with adhesive
capsulitis. Thus, soft tissue massage techniques are able to
produce clinically significant improvements in patients with
non-specific shoulder pain in the short term and should be con-
sidered as an important form of therapy. No reports of adverse
effects of soft tissue massage treatment could be found.
The studies utilising soft tissue massage included in this
review described a range of techniques including stroking
massage, trigger point therapy and ice massage. It is difficult to
demonstrate how these techniques differ from each other, and
indeed how they may differ from other techniques, such as
manual therapy, as some authors have suggested.
53
Further
research into the similarities or differences between these tech-
niques and the structures they may affect would be beneficial
to therapists.
This review is the first to pool the results of exercise studies
for the treatment of non-specific shoulder pain in a
meta-analysis. This demonstrated that exercise produces
changes in pain of a magnitude less than that considered to be
clinically worthwhile by patients (mean pain improvement 9.8
of 100). Meta-analysis did not demonstrate that exercise was
effective in producing changes in either self-reported functional
scores or flexion or abduction range of motion. On the basis of
the trials available, we found no evidence that exercise therapy
is harmful or that it provoked harmful side effects. However,
these trials provided little or no information on the safety
aspects of exercise therapy. This may represent inadequate
reporting of adverse effects. Generally, the trials provided poor
description of specific exercise approaches and intensity of
training; however, the greatest improvements in pain were
demonstrated through the application of a strengthening exer-
cise regimen focusing on flexion, extension, and internal and
external rotation which was carried out twice weekly for
8 weeks up to 70% of the patient’s six repetition maximum
threshold.
38
This higher level of exercise dose concurs with a
recent study
54
which demonstrated that high-dose exercise
regimens were superior to low-dose exercise regimens for
improving both pain and function in patients with subacromial
pain. Other approaches that employed specific stretches to shor-
tened muscles around the glenohumeral joint and moderately
high-intensity strengthening exercises in multiple planes of
motion for muscles assessed as being weak
36 37
demonstrated
improvements in flexion and abduction range of motion but no
changes in functional scores and small improvements in pain
scores when compared with no treatment. This effect was not
seen when the same exercise approaches were compared to a
combination of electrophysical modalities, passive joint mobili-
sations and range of motion exercises.
From this review it still remains unknown as to whether
exercise therapy should be included in a supervised or an
unsupervised programme or a combination of the two. More
research is also needed to investigate how the short-term
effectiveness of exercise therapy can be maximised or how it
can be maintained in the long-term. Programmes or methods
with which clinicians could encourage greater compliance with
home exercises and motivate them to continue their exercises
into the future would also be very useful. Further studies
examining the effectiveness of both soft tissue massage and
exercise with longer follow-up periods and larger participant
numbers would assist in strengthening the work in this area.
Clearer description of treatment approaches would also be
beneficial.
CONCLUSION
Soft tissue massage to the gleno-humeral musculature appears
to be effective for improving pain, function and range of
motion in patients with non-specific shoulder pain in the short
term. Strengthening exercises are effective for producing small
changes in pain but not function or range of motion. The most
effective exercise therapy included high-dose strengthening exer-
cises in multiple planes of motion. Including soft tissue
massage in a treatment programme for non-specific shoulder
pain will improve the range of motion and pain.
Figure 5 Forest plot of effect size of STM and exercise combined studies. Function and pain scores are out of 100. Figures are a comparison of
scores at reassessment. The centre of each shape represents the mean with the size of the shape indicating relative size of the study population.
Horizontal lines for each result indicate the 95% CI. STM, soft tissue massage.
10 Br J Sports Med 2012;0:1–12. doi:10.1136/bjsports-2011-090553
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What is known about this topic
▸Between 7% and 26% of the population have shoulder pain
at any one time.
▸Almost 40% of patients who visited a general practitioner
for shoulder pain reported complaints that had persisted for
more than 12 months.
▸Up to 50% of patients with shoulder pain are referred to a
physiotherapist for treatment. Soft tissue massage and
exercise are the most common treatments.
▸A number of systematic reviews have evaluated the
effectiveness of exercise for shoulder disorders with
conflicting conclusions. None have conducted a
meta-analysis.
▸No systematic review has specifically evaluated the
effectiveness of soft tissue massage for shoulder disorders.
What this study adds
▸This study is the first systematic review to specifically
examine the effectiveness of soft tissue massage for
non-specific shoulder pain.
▸This is the first systematic review of the effectiveness of
exercise for treatment of shoulder pain that has conducted a
meta-analysis.
▸There is low-quality evidence that soft tissue massage is
effective for improving pain, function and range of motion in
patients with shoulder pain in the short term.
▸Exercise therapy is effective for producing small
improvements in pain but not in function or range of motion.
Acknowledgements The authors would like to acknowledge Professor
Robert Herbert for his assistance in the design of this systematic review.
Contributors PV and KMR had the idea for the article. PV performed the literature
search and wrote the article. KMR and PHF independently rated articles for the
review and provided guidance and editing. KMR is the guarantor for the article.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement Data extracted from the articles included in this
systematic review (means and measures of variability) is available to interested
researchers on request by contacting the corresponding author, PV at pvan0651@uni.
sydney.edu.au.
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doi: 10.1136/bjsports-2011-090553
published online July 26, 2012Br J Sports Med
Refshauge
Paul Andrew van den Dolder, Paulo H Ferreira and Kathryn M
meta-analysis
shoulder pain: a systematic review with
exercise for the treatment of non-specific
Effectiveness of soft tissue massage and
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