Efficacy of mobilization with movement (MWM) for shoulder conditions: a systematic review and meta-analysis
Kiran Satpute, Sue Reid, Thomas Mitchell, Grant Mackay & Toby Hall (2021): Efficacy of mobilization with movement (MWM) for shoulder conditions: a systematic review and meta-analysis, Journal of Manual & Manipulative Therapy, DOI: 10.1080/10669817.2021.1955181
The objective of this systematic review (SR) and meta-analysis was to determine if there were any additional benefits of using Mobilization with Movement (MWW) manual therapy for shoulder pain, flexion ROM, abduction ROM, and for disability when compared to other non-surgical forms of management; including other forms of manual therapy, electrotherapy, placebo, sham, or no treatment for shoulder musculoskeletal disorders in two sub-categories: frozen shoulder and shoulder pain with movement dysfunction.
Why was this study necessary?
Current guidelines for conservative management of shoulder conditions include exercise, patient education, manual therapy, activity modification, non-steroidal anti-inflammatory drugs, and cortisone injections. (1,2,3) The hierarchy in priority of these strategies suggests exercise as the first in line for management (4).
Multimodal care that includes combining exercise + manual therapy has been shown to be more effective than either one alone, although the application of manual therapy is often ambiguous due to the variety of techniques, dosages, duration of effect, technique progressions, and rationale for usage (4)
Often in SR of manual therapy, all varieties of manual techniques are synthesized, which may not allow for discrimination between techniques to help guide treatment. A goal in this study was to specifically evaluate the potential value of shoulder MWM for sub-categories of frozen shoulder and shoulder pain with movement dysfunction.
To determine which studies to include in the SR and meta-analysis a thorough eligibility screening process searched six databases. The search results revealed 1,637 potential studies to include. Additional inclusion screening evaluated study quality, risk of bias, a narrative synthesis, and qualitative synthesis.
The summation of the screening process allowed for a total of 21 studies available for meta-analysis; 12 studies in the frozen shoulder sub-category and 9 studies in the pain with movement dysfunction sub-category.
What Did the SR and Meta-analysis Reveal?
The results indicated MWM for the shoulder as having important benefits for all variables in each clinical sub-category (pain, flexion ROM, abduction ROM, and disability), although caution was required due to high levels of heterogeneity and risk bias.
MWM in isolation or in addition to exercise therapy and/or electrotherapy is superior in improving pain, ROM, and disability in patients with frozen shoulder and shoulder pain with movement dysfunction when compared with exercise therapy, electrotherapy alone, or other types of manual therapy.
The study claims to be “the first systematic review with meta-analysis to evaluate the clinical effectiveness of MWM in isolation or in addition to other physiotherapeutic modalities”. While there is never a single study that is the gold standard for all clinical interventions, evidence that potentially guides my ability to make patient care in the clinic both effective and efficient makes me happy.
This type of evidence deepens my bias to regularly attempt MWM because the techniques are always pain-free. Within 2-3 minutes I will know if an individual is a “responder” or “non-responder” to MWM manual therapy. This is diagnostically significant for clinical reasoning; if helpful the treatment becomes multimodal with exercise and manual therapy, if not treatment may be more of an exercise-only focus. I have little to lose, but much to miss if I do not assess MWM techniques.
This is one of the many reasons I am passionate about teaching and sharing MWM. It is fast, effective, and immediate.
Jarrod Brian, MCTA