Efficacy of mobilization with movement MWM for shoulder conditions a systematic review and meta analysis

Prévia do material em texto

Full Terms & Conditions of access and use can be found at
https://www.tandfonline.com/action/journalInformation?journalCode=yjmt20
Journal of Manual & Manipulative Therapy
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/yjmt20
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
To cite this article: Kiran Satpute, Sue Reid, Thomas Mitchell, Grant Mackay & Toby Hall
(2022) Efficacy of mobilization with movement (MWM) for shoulder conditions: a systematic
review and meta-analysis, Journal of Manual & Manipulative Therapy, 30:1, 13-32, DOI:
10.1080/10669817.2021.1955181
To link to this article: https://doi.org/10.1080/10669817.2021.1955181
View supplementary material Published online: 01 Aug 2021.
Submit your article to this journal Article views: 1241
View related articles View Crossmark data
Citing articles: 5 View citing articles 
https://www.tandfonline.com/action/journalInformation?journalCode=yjmt20
https://www.tandfonline.com/loi/yjmt20
https://www.tandfonline.com/action/showCitFormats?doi=10.1080/10669817.2021.1955181
https://doi.org/10.1080/10669817.2021.1955181
https://www.tandfonline.com/doi/suppl/10.1080/10669817.2021.1955181
https://www.tandfonline.com/doi/suppl/10.1080/10669817.2021.1955181
https://www.tandfonline.com/action/authorSubmission?journalCode=yjmt20&show=instructions
https://www.tandfonline.com/action/authorSubmission?journalCode=yjmt20&show=instructions
https://www.tandfonline.com/doi/mlt/10.1080/10669817.2021.1955181
https://www.tandfonline.com/doi/mlt/10.1080/10669817.2021.1955181
http://crossmark.crossref.org/dialog/?doi=10.1080/10669817.2021.1955181&domain=pdf&date_stamp=2021-08-01
http://crossmark.crossref.org/dialog/?doi=10.1080/10669817.2021.1955181&domain=pdf&date_stamp=2021-08-01
https://www.tandfonline.com/doi/citedby/10.1080/10669817.2021.1955181#tabModule
https://www.tandfonline.com/doi/citedby/10.1080/10669817.2021.1955181#tabModule
Efficacy of mobilization with movement (MWM) for shoulder conditions: a 
systematic review and meta-analysis
Kiran Satputea, Sue Reid b, Thomas Mitchellc, Grant Mackayd and Toby Halle
aDepartment of Musculoskeletal Physiotherapy smt. Kashibai Navale College of Physiotherapy, Pune, India; bFaculty of Health Sciences, 
Australian Catholic University, North Sydney, Australia; cRemedy Physio, Sheffield, UK; dIOH, Wollongong, Australia; eSchool of 
Physiotherapy and Exercise Science, Curtin University, Perth, Australia
ABSTRACT
Objective: To assess the effects of mobilization with movement (MWM) on pain, range of 
motion (ROM), and disability in the management of shoulder musculoskeletal disorders.
Methods: Six databases and Scopus, were searched for randomized control trials. The ROB 2.0 
tool was used to determine risk-of-bias and GRADE used for quality of evidence. Meta-analyses 
were performed for the sub-category of frozen shoulder and shoulder pain with movement 
dysfunction to evaluate the effect of MWM in isolation or in addition to exercise therapy and/or 
electrotherapy when compared with other conservative interventions.
Results: Out of 25 studies, 21 were included in eight separate meta-analyses for pain, ROM, and 
disability in the two sub-categories. For frozen shoulder, the addition of MWM significantly 
improved pain (SMD −1.23, 95% CI −1.96, −0.51)), flexion ROM (MD −11.73, 95% CI −17.83, 
−5.64), abduction ROM (mean difference −13.14, 95% CI −19.42, −6.87), and disability (SMD 
−1.50, 95% CI (−2.30, −0.7). For shoulder pain with movement dysfunction, the addition of 
MWM significantly improved pain (SMD −1.07, 95% CI −1.87, −0.26), flexion ROM (mean 
difference −18.48, 95% CI- 32.43, −4.54), abduction ROM (MD −32.46, 95% CI – 69.76, 4.84), 
and disability (SMD −0.88, 95% CI −2.18, 0.43). The majority of studies were found to have 
a high risk of bias.
Discussion: MWM is associated with improved pain, mobility, and function in patients with 
a range of shoulder musculoskeletal disorders and the effects clinically meaningful. However, 
these findings need to be interpreted with caution due to the high levels of heterogeneity and 
risk of bias.
Level of Evidence: Treatment, level 1a.
KEYWORDS 
Mulligan’s mobilization with 
movement; manual therapy; 
systematic review; shoulder 
dysfunction
Introduction
Demand for effective conservative management of 
shoulder conditions reflects its prevalence as the 
third most common musculoskeletal (MSK) condition 
seen in United Kingdom (UK) [1] with one-year preva-
lence among a global survey reported to be between 
4.7 and 46.7% [2]. Clinicians may be challenged by the 
scope of possible structural diagnoses, the changing 
nomenclature used to describe the experience of pain, 
distress and loss of function, and the application of 
recommended management strategies [3].
Current guidelines for the conservative manage-
ment of shoulder conditions include exercise, patient 
education, manual therapy, activity modification, non- 
steroidal anti-inflammatory drugs, and corticosteroid 
injections [4,5]. The hierarchy in the priority of these 
strategies suggests exercise as the first in line for man-
agement [6]. Multimodal care has also been promoted 
[7], as having strong recommendations for exercise 
combined with manual therapy in a recent literature 
review [6].
The application of effective manual therapy is 
ambiguous due to the variety of techniques, dosage, 
duration of affect, progressions, and rational for its 
usage [6]. In systematic reviews, all varieties of manual 
therapy are synthesized [6–9], which often does not 
allow discrimination between techniques or help 
guide clinicians. Mobilization with movement (MWM) 
is one specific form of manual therapy gaining increas-
ing popularity with a number of studies showing treat-
ment benefit for a range of shoulder conditions [9–12]. 
MWM involves the application of sustained gliding 
force (passive mobilization component) with 
a concurrent active movement performed by the 
patient (active movement component). The applica-
tion of MWM, when precisely indicated, has beneficial 
effects on painful movement and thereby function is 
immediately improved. Thus, MWM can be distin-
guished from passive, practitioner-applied manual 
therapy which is based on a test-treat-retest model of 
application [13]. The immediate symptom modification 
feature of MWM may allow greater clarity to allow 
CONTACT Kiran Satpute kiran_ptist@yahoo.co.in Department of Musculoskeletal Physiotherapy Smt, Kashibai Navale College of Physiotherapy, 
Off Westerly by Pass, Narhe, Pune, Maharashatra 411041, India
Supplemental data for this article can be accessed here.
JOURNAL OF MANUAL & MANIPULATIVE THERAPY 
2022, VOL. 30, NO. 1, 13–32 
https://doi.org/10.1080/10669817.2021.1955181
© 2021 Informa UK Limited, trading as Taylor & Francis Group
http://orcid.org/0000-0002-4928-4636
https://doi.org/10.1080/10669817.2021.1955181
http://www.tandfonline.com
https://crossmark.crossref.org/dialog/?doi=10.1080/10669817.2021.1955181&domain=pdf&date_stamp=2022-02-20
clinicians to discriminate between manual therapy 
selections.
Previous systematic reviews evaluating the effec-
tiveness of MWM lack the precise work on shoulder 
[14] and excluded many studies focused on a shoulder- 
specific population [15]. Although a recent systematic 
review for shoulder conditions has been undertaken 
[16], the current review is indicated as the previous 
work lacked robustness due to, identification and 
exclusion of studies selected, the presence of new 
studies since its release, and no pre-registration of its 
proposal. Therefore, we undertook a systematic review 
with meta-analysis to determine the additional bene-
fits of MWM when compared to other non-surgical 
forms of management, including other forms of man-
ual therapy, electrotherapy, placebo, sham, or no treat-
ment for shoulder musculoskeletal disordersin two 
categories: frozen shoulder or shoulder pain with 
movement dysfunction. Frozen shoulder is a readily 
identifiable syndrome, but the diagnosis of other 
shoulder-specific disorders is problematic. Hence, we 
chose to separate frozen shoulder from other 
unknown shoulder disorders.
Methods
This review was conducted according to Preferred 
Reporting Items for Systematic Reviews and Meta- 
Analyses (PRISMA) guidelines. The systematic review 
was prospectively registered on PROSPERO: 
CRD42020210618.
Data sources and searches
The following databases were searched: PubMed 
(MEDLINE), CINAHL, SPORTDiscus, PEDro, Cochrane 
library, and Scopus, from inception to January 2021 
(appendix 1). Appropriate search and MeSH terms 
were adapted and applied to each database. To sup-
plement the initial database searches, a manual search 
of the references listed in identified systematic reviews 
was also conducted.
Eligibility criteria
We included randomized-controlled trials (RCTs) and 
randomized cross-over studies evaluating the effects 
of MWM or self-MWM on shoulder conditions, either 
alone or in combination with other interventions. The 
comparator group comprised no intervention, any 
other form of conservative intervention including 
‘wait and see’, usual care, standard care, sham, or 
placebo but not including MWM intervention. Studies 
were considered if they included adults aged 18 years 
and above of either gender and used outcome mea-
sures of pain severity, range of motion (ROM), and 
disability scores.
Studies were excluded if the full text was not avail-
able and if the language was not English.
Duplicate studies identified as a result of searching 
multiple databases were removed using EndNoteX8 
software. The titles and abstracts were screened by 
two assessors independently (KS and GM), according 
to predetermined eligibility criteria. Full-text articles 
were assessed and, if there was uncertainty over the 
inclusion of a study, a third reviewer (SR) was consulted 
until consensus was reached.
Quality assessment and data extraction
Each study’s risk of bias was assessed using the 
ROB 2.0 tool [17]. This tool evaluates the risk of 
bias across five domains: the randomization pro-
cess, deviations from intended interventions, miss-
ing outcome data, measurement of outcomes, and 
selection of reported results. The tool includes 
algorithms that map responses to signaling ques-
tions onto a proposed risk-of-bias judgment for 
each domain, leading reviewers to make 
a judgment of ‘Low risk of bias’, ‘Some concerns’, 
or ‘High risk of bias’ both for each domain and as 
an overall risk-of-bias judgment for each study. 
Two reviewers (KS, GM) independently performed 
risk of bias assessments on all studies and any 
discrepancies were resolved by consensus 
discussion.
The approach proposed by the Grading of 
Recommendations, Assessment, Development, and 
Evaluation (GRADE) Working Group for rating the qual-
ity of the best available evidence and developing 
health care recommendations [18] was used to rate 
the quality of the evidence and grade the certainty of 
outcomes in the meta-analysis. Using the GRADE 
approach, the quality of evidence was rated indepen-
dently by two reviewers (KS and GM) according to four 
levels ranging from high to very low (Box 1). 
Box 1. Quality of evidence ratings using the GRADE approach.
High We are very confident that the true effect lies close to that 
of the estimate of the effect.
Moderate We are moderately confident in the effect estimate: The true 
effect is likely to be close to the estimate of the effect, but 
there is a possibility that it is substantially different
Low Our confidence in the effect estimate is limited: The true 
effect may be substantially different from the estimate of 
the effect.
Very Low We have very little confidence in the effect estimate: The 
true effect is likely to be substantially different from the 
estimate of effect
Two independent reviewers extracted data using 
a data extraction form. Other review members were 
consulted if necessary. If all information was not readily 
available in the studies, numerical data were requested 
from author groups.
14 K. SATPUTE ET AL.
Data synthesis
A narrative synthesis of aggregate data was provided 
within the review by describing the population char-
acteristics, methodology, and results of included 
studies.
The trials were compared for homogeneity through 
visual examination (Tables 1 and 2). If trials were suffi-
ciently homogenous and could be grouped according 
to outcome measures, that is, range of motion, pain, 
and disability scores, a meta-analysis was performed to 
provide a quantitative synthesis of aggregate data 
from the included studies. If only one study was avail-
able in the grouping, meta-analysis could not be per-
formed and the statistics from that single study were 
reported. Review Manager 5.3 (Cochrane 
Collaboration) software was used for the statistical 
analysis. If all included trials used the same outcome 
measure, a summary of intervention effects was 
reported as a weighted mean difference with 95% 
confidence intervals and p-value. If the included trials 
used different outcome measures, a summary of inter-
vention effects was reported as a standardized mean 
difference with 95% confidence intervals and p-value. 
A fixed-effect model was used when there was no 
evidence of heterogeneity between studies, otherwise, 
a random-effects model was applied. Clinical variation 
and heterogeneity between studies were examined 
and evaluated using Q statistic and I2 tests. Forest 
plots were used to illustrate the outcomes of meta- 
analysis. The I2 statistic, an expression of inconsistency 
of studies’ results, describes the percentage of varia-
tion across studies because of heterogeneity rather 
than by chance. A high values of I2 (>50%) and 
P < .05 indicate statistically significant heterogeneity 
among the studies for an outcome. The reasons for 
high heterogeneity were explored. The 
interpretations for trivial, small, medium, and large 
effect sizes (≤0.2 trivial effect, 0.2–0.49 small effect; 
0.5–0.79 medium effect; ≥0.8, large effect) were chosen 
[19].
Results
Results of the literature search
A literature search was conducted in six databases 
from inception to January 2021 and identified a total 
of 1956 studies (Appendix 1). After removing dupli-
cates 1620 studies remained for title and abstract 
screening. Seventeen additional studies were identi-
fied through hand searching reference lists. Thus, the 
title and abstract of 1637 studies were screened. From 
these, 31 potentially eligible studies for full-text assess-
ment were identified, and 25 [10–12,20–41] studies 
were included based on the inclusion and exclusion 
criteria (Figure 1).
The characteristics of included studies are summar-
ized in Table 1 (frozen shoulder sub-category) and 
Table 2 (shoulder pain and movement dysfunction 
sub-category).
Qualitative synthesis
All included studies were RCTs. Two of the RCT’s 
were a crossover design [25,39] and two were pilot 
studies [10,27]. Only six studies were registered 
with a clinical trial registry [10,12,23,25,35,37]. In 
the evaluated studies, there were a total of 1014 
participants. Fourteen studies evaluated 665 
patients with frozen shoulder and 11 studies eval-
uated 349 patients with shoulder pain and move-
ment dysfunction. Among the frozen shoulder sub- 
category, all studies except two [11,33] evaluated 
MWM in combination with exercise therapy. MWM 
was compared with other manual therapy techni-
ques including Maitland mobilization (seven stu-
dies) and Kaltenborn mobilization (two studies). 
All studies included patients with unilateral stage- 
II frozen shoulder except three studies, where the 
stage of frozen shoulder was not reported 
[24,26,40]. Three studies included patients with 
frozen shoulder who had a history of diabetes 
mellitus [20,34,41]. In the shoulder pain and move-
ment dysfunctionsub-category, three studies eval-
uated MWM in isolation which was compared with 
a sham intervention [12,25,39]. In seven studies, 
MWM was used in conjunction with electrothera-
peutic modalities such as the heat therapy, 
cryotherapy, therapeutic ultrasound, and transcuta-
neous electrical nerve stimulation (TENS). There 
was wide variability in the MWM treatment dosage 
such as the number of treatment sessions utilized 
during the study period, which ranged from 
a minimum of three sessions to a maximum of 24 
sessions. MWM intervention was applied for 
a minimum of 1 week and a maximum of 2 months 
and only three studies followed patients over 
a longer time course, with a maximum of 3-months 
follow-up [10,11,34]. None of the studies followed 
the Mulligan Concept treatment guidelines of only 
applying MWM in patients who had a beneficial 
effect following a trial MWM. The most commonly 
reported MWM technique was a postero-lateral 
glide combined with active arm elevation. Only 
two studies evaluated an inferior glide, which was 
combined with movement of hand behind back 
[22,35]. One study evaluated scapulothoracic 
MWM in a weight-bearing position [38].
Risk of bias assessment
The results of the risk of bias assessment are seen in 
Figure 2. Of the 25 studies assessed, three were rated 
JOURNAL OF MANUAL & MANIPULATIVE THERAPY 15
Ta
bl
e 
1.
 C
ha
ra
ct
er
is
tic
s 
of
 in
cl
ud
ed
 s
tu
di
es
 (f
ro
ze
n 
sh
ou
ld
er
 s
ub
-c
at
eg
or
y)
.
St
ud
y(
Au
th
or
, 
Ye
ar
, D
es
ig
n,
)
Pa
rt
ic
ip
an
ts
 (n
, 
M
:F
, A
ge
)
Ex
pe
rim
en
ta
l 
In
te
rv
en
tio
n
Co
m
pa
ra
to
r 
in
te
rv
en
tio
n
D
os
e
O
ut
co
m
e 
m
ea
su
re
s 
an
d 
Ti
m
e 
po
in
ts
M
ai
n 
Fi
nd
in
gs
Bo
ru
ah
 e
t 
al
. 
20
15
, R
CT
Ex
p:
 n
 =
 2
5,
 7
:1
8,
 
49
.7
6 
(3
.4
9)
M
W
M
 +
 E
xe
rc
is
e 
+
 H
ea
t 
th
er
ap
y
Sc
ap
ul
ar
 M
ob
ili
za
tio
n 
+
 
Ex
er
ci
se
 +
 H
ea
t
5 
pe
r 
w
ee
k 
X 
3 
w
ee
ks
RO
M
, S
PA
D
I- 
pa
in
. B
as
el
in
e,
 3
 w
ee
ks
Si
gn
ifi
ca
nt
 
im
pr
ov
em
en
t 
in
 a
ll 
ou
tc
om
es
 fo
r 
M
W
M
 g
ro
up
 
co
m
pa
re
d 
to
 
co
nt
ro
l g
ro
up
Co
n:
 n
 =
 2
5,
 
11
:1
4,
 
50
.0
4 
(3
.3
4)
D
ili
p 
et
 a
l. 
20
16
, R
CT
Ex
p:
 n
 =
 2
0,
 9
:1
1,
 
53
.5
5 
(7
.5
7)
M
W
M
+
 E
xe
rc
is
e
G
on
g’
s 
M
ob
ili
za
tio
n 
+
 E
xe
rc
is
e
5 
pe
r 
w
ee
k 
X 
2 
w
ee
ks
RO
M
, P
ai
n 
in
te
ns
ity
. 
Ba
se
lin
e,
 2
 w
ee
ks
Si
gn
ifi
ca
nt
 
im
pr
ov
em
en
t 
in
 p
ai
n 
in
te
ns
ity
 fo
r 
G
on
g’
s 
m
ob
ili
za
tio
n 
an
d 
in
 R
O
M
 
fo
r 
M
W
M
Co
n:
 n
 =
 2
0,
 
9:
11
, 5
1.
00
 
(6
.8
2)
G
oy
al
 e
t 
al
. 
20
13
, R
CT
Ex
p:
 n
 =
 1
0,
 6
:4
, 
50
.4
0 
(5
.8
5)
M
W
M
 +
 E
xe
rc
is
e
1.
 E
nd
 r
an
ge
 M
ob
ili
za
tio
n 
+
 
Ex
er
ci
se
 
2.
 E
nd
 r
an
ge
 M
ob
ili
za
tio
n 
+
 
M
W
M
 +
 E
xe
rc
is
e
2 
pe
r 
w
ee
k 
X 
3 
w
ee
ks
RO
M
, S
PA
D
I. 
Ba
se
lin
e,
 3
 w
ee
ks
Si
gn
ifi
ca
nt
 
im
pr
ov
em
en
t 
in
 a
ll 
ou
tc
om
es
 fo
r 
M
W
M
 +
 E
nd
 
ra
ng
e 
M
ob
ili
za
tio
n 
gr
ou
p 
+
 
Ex
er
ci
se
s 
co
m
pa
re
d 
to
 
ot
he
r 
gr
ou
ps
1.
 C
on
: n
 =
 1
0,
 6
:4
, 4
8.
60
 (5
.3
7)
 2
.
Co
n:
 n
 =
 1
0,
 
4:
6,
 4
7.
90
 
(4
.3
5)
Kh
ya
th
i e
t 
al
. 
20
15
, R
CT
Ex
p:
 n
 =
 2
0,
 1
2:
8,
 
50
.4
0 
(5
.4
2)
M
W
M
 +
 E
xe
rc
is
e
Sp
en
ce
r 
te
ch
ni
qu
e 
+
 E
xe
rc
is
e
5 
pe
r 
w
ee
k 
X 
1 
w
ee
k
RO
M
, P
ai
n 
in
te
ns
ity
, S
PA
D
I. 
Ba
se
lin
e,
 5
 s
es
si
on
s 
(1
 w
ee
k)
Si
gn
ifi
ca
nt
 im
pr
ov
em
en
t i
n 
RO
M
 a
nd
 S
PA
D
I b
ut
 n
ot
 p
ai
n 
in
te
ns
ity
 fo
r 
M
W
M
 g
ro
up
 c
om
pa
re
d 
to
 S
pe
nc
er
 t
ec
hn
iq
ue
 g
ro
up
Co
n:
 n
 =
 2
0,
 1
1:
9,
 
50
.8
5 
(5
.1
4)
M
in
er
va
 e
t 
al
. 
20
16
, R
C
Ex
p:
 n
 =
 3
0,
 N
A,
 
N
A
M
W
M
 +
 E
xe
rc
is
e
M
ai
tla
nd
 M
ob
ili
za
tio
n 
+
 
Ex
er
ci
se
3 
pe
r 
w
ee
k 
X 
4 
w
ee
ks
RO
M
, S
PA
D
I. 
Ba
se
 li
ne
, 4
 w
ee
ks
Si
gn
ifi
ca
nt
 
im
pr
ov
em
en
t 
in
 a
ll 
ou
tc
om
es
 fo
r 
M
W
M
 g
ro
up
 
co
m
pa
re
d 
to
 
M
ai
tla
nd
 
M
ob
ili
za
tio
n 
gr
ou
p
Co
n:
 n
 =
 3
0,
 
N
A,
 N
A
(C
on
tin
ue
d)
16 K. SATPUTE ET AL.
Ta
bl
e 
1.
 (C
on
tin
ue
d)
.
St
ud
y(
Au
th
or
, 
Ye
ar
, D
es
ig
n,
)
Pa
rt
ic
ip
an
ts
 (n
, 
M
:F
, A
ge
)
Ex
pe
rim
en
ta
l 
In
te
rv
en
tio
n
Co
m
pa
ra
to
r 
in
te
rv
en
tio
n
D
os
e
O
ut
co
m
e 
m
ea
su
re
s 
an
d 
Ti
m
e 
po
in
ts
M
ai
n 
Fi
nd
in
gs
Ra
th
od
 e
t 
al
. 
20
19
, R
CT
Ex
p:
 n
 =
 2
0,
 N
A,
 
N
A
M
W
M
 +
 H
ea
t
Ka
lte
nb
or
n 
M
ob
ili
za
tio
n 
+
 H
ea
t
10
 s
es
si
on
s 
X 
3 
w
ee
ks
RO
M
, P
ai
n 
in
te
ns
ity
, S
PA
D
I. 
Ba
se
lin
e,
 1
0 
se
ss
io
ns
Si
gn
ifi
ca
nt
 
im
pr
ov
em
en
t 
in
 a
ll 
ou
tc
om
es
 fo
r 
M
W
M
 g
ro
up
 
co
m
pa
re
d 
to
 
Ka
lte
nb
or
n 
M
ob
ili
za
tio
n 
gr
ou
p
Co
n:
 n
 =
 2
0,
 
N
A,
N
A
Sh
riv
as
ta
va
 
et
 a
l. 
20
11
, 
RC
T
Ex
p:
 n
 =
 2
0,
 1
2:
8,
 
59
.2
 (7
.1
8)
M
W
M
 +
 E
xe
rc
is
e
M
ai
tla
nd
 M
ob
ili
za
tio
n 
+
 
Ex
er
ci
se
6 
pe
r 
w
ee
k 
x 
2 
w
ee
ks
,
RO
M
, P
ai
n 
in
te
ns
ity
, S
PA
D
I. 
Ba
se
lin
e,
 4
 w
ee
ks
Si
gn
ifi
ca
nt
 
im
pr
ov
em
en
t 
in
 p
ai
n 
in
te
ns
ity
 fo
r 
M
W
M
 g
ro
up
 
co
m
pa
re
d 
to
 
M
ai
tla
nd
 
gr
ou
p
Co
n:
 n
 =
 2
0,
 
7:
13
, 5
1.
15
 
(8
.5
3)
D
on
er
 e
t 
al
. 
20
12
, R
CT
Ex
p:
 n
 =
 2
0,
 7
:1
3,
 
59
.2
5 
(9
.1
7)
M
W
M
 +
 H
ea
t 
+
 T
EN
S
H
ea
t 
+
 E
xe
rc
is
e 
+
TE
N
S
5 
pe
r 
w
ee
k 
X 
3 
w
ee
ks
RO
M
, P
ai
n 
in
te
ns
ity
, C
on
st
an
t 
sc
or
e,
 S
ho
ul
de
r 
D
is
ab
ili
ty
 
Q
ue
st
io
nn
ai
re
 B
as
el
in
e,
 3
 w
ee
ks
, 3
 m
on
th
s
Si
gn
ifi
ca
nt
 
im
pr
ov
em
en
t 
in
 a
ll 
ou
tc
om
es
 fo
r 
M
W
M
 g
ro
up
 
co
m
pa
re
d 
to
 
co
nt
ro
l g
ro
up
Co
n:
 n
 =
 2
0,
 
2:
18
, 5
8.
55
 
(8
.5
7)
Sa
i e
t 
al
. 
20
15
, R
CT
Ex
p:
 n
 =
 3
0,
 
14
:2
0,
 5
0.
5 
(5
.9
)
M
W
M
 +
 E
xe
rc
is
e
Ex
er
ci
se
2 
pe
r 
w
ee
k 
x 
12
 w
ee
ks
RO
M
, P
ai
n 
in
te
ns
ity
, D
AS
H
. 
Ba
se
lin
e,
 3
 w
ee
ks
, 6
 w
ee
ks
, 3
 m
on
th
s
Si
gn
ifi
ca
nt
 
im
pr
ov
em
en
t 
in
 a
ll 
ou
tc
om
es
 fo
r 
M
W
M
 g
ro
up
 
co
m
pa
re
d 
to
 
co
nt
ro
l g
ro
up
Co
n:
 n
 =
 3
0,
 
15
:1
9,
 5
1.
0 
(7
.7
)
(C
on
tin
ue
d)
JOURNAL OF MANUAL & MANIPULATIVE THERAPY 17
Ta
bl
e 
1.
 (C
on
tin
ue
d)
.
St
ud
y(
Au
th
or
, 
Ye
ar
, D
es
ig
n,
)
Pa
rt
ic
ip
an
ts
 (n
, 
M
:F
, A
ge
)
Ex
pe
rim
en
ta
l 
In
te
rv
en
tio
n
Co
m
pa
ra
to
r 
in
te
rv
en
tio
n
D
os
e
O
ut
co
m
e 
m
ea
su
re
s 
an
d 
Ti
m
e 
po
in
ts
M
ai
n 
Fi
nd
in
gs
Ra
nj
an
a 
et
 a
l. 
20
17
, R
CT
Ex
p:
 n
 =
 1
5,
 N
A,
 
N
A
M
W
M
 +
 E
xe
rc
is
e
1.
 M
ai
tla
nd
 M
ob
ili
za
tio
n 
+
 
Ex
er
ci
se
 
2.
 E
xe
rc
is
e
3 
pe
r 
w
ee
k 
x 
4 
w
ee
ks
RO
M
, P
ai
n 
in
te
ns
ity
, S
PA
D
I. 
Ba
se
lin
e,
 4
 w
ee
ks
, 6
 w
ee
ks
Si
gn
ifi
ca
nt
 
im
pr
ov
em
en
t 
in
 a
ll 
ou
tc
om
es
 
ex
ce
pt
 
ex
te
rn
al
 
ro
ta
tio
n 
RO
M
 
fo
r 
M
W
M
 
gr
ou
p 
co
m
pa
re
d 
to
 
M
ai
tla
nd
 a
nd
 
on
ly
 e
xe
rc
is
e 
gr
ou
p
1.
 C
on
: n
 =
 1
5,
 N
A,
N
A
2.
 C
on
: 
n 
=
 1
5,
 N
A,
 
N
A
Ar
sh
ad
 e
t 
al
. 
20
15
, R
CT
Ex
p:
 n
 =
 5
0,
 N
A,
 
N
A
M
W
M
 +
 E
xe
rc
is
e 
+
 
U
ltr
as
ou
nd
 +
 T
EN
S 
+
 
H
om
e 
Ex
er
ci
se
M
ai
tla
nd
 M
ob
ili
za
tio
n 
+
 
U
ltr
as
ou
nd
 +
 T
EN
S 
+H
om
e 
Ex
er
ci
se
2 
pe
r 
w
ee
k 
X 
2 
m
on
th
s
RO
M
, P
ai
n 
in
te
ns
ity
. 
Ba
se
lin
e,
 2
 m
on
th
s
N
o 
si
gn
ifi
ca
nt
 
di
ffe
re
nc
e 
in
 
an
y 
ou
tc
om
e 
fo
r 
M
W
M
 
gr
ou
p 
co
m
pa
re
d 
to
 
M
ai
tla
nd
 
gr
ou
p
Co
n:
 n
 =
 5
0,
 
N
A,
N
A
H
ai
de
r 
et
 a
l. 
20
14
, R
CT
Ex
p:
 n
 =
 3
0,
 
10
:2
0,
 4
7 
(9
.2
1)
M
W
M
M
ai
tla
nd
 M
ob
ili
za
tio
n
N
A
RO
M
 
Ba
se
lin
e,
 2
 w
ee
ks
, 4
 w
ee
ks
, 6
 w
ee
ks
Si
gn
ifi
ca
nt
 im
pr
ov
em
en
t 
in
 a
ll 
ou
tc
om
es
 fo
r 
M
W
M
 g
ro
up
 c
om
pa
re
d 
to
 M
ai
tla
nd
 g
ro
up
Co
n:
 n
 =
 3
0,
 7
:2
3,
 
46
.2
3 
(9
.7
1)
Ye
ol
e 
et
 a
l. 
20
17
, R
CT
Ex
p:
 n
 =
 1
5,
 N
A,
 
N
A
M
W
M
 +
 E
xe
rc
is
e
Ex
er
ci
se
7 
se
ss
io
ns
RO
M
, P
ai
n 
in
te
ns
ity
, S
PA
D
I. 
Ba
se
lin
e,
 1
 w
ee
k
Si
gn
ifi
ca
nt
 im
pr
ov
em
en
t 
in
 a
ll 
ou
tc
om
es
 fo
r 
M
W
M
 g
ro
up
 c
om
pa
re
d 
to
 c
on
tr
ol
 g
ro
up
Co
n:
 n
 =
 1
5,
 N
A,
 
N
A
Yo
us
se
f e
t 
al
. 
20
15
, R
CT
Ex
p:
 n
 =
 1
5,
 N
A,
 
54
.8
 (5
.8
5)
M
W
M
 +
 E
xe
rc
is
e
M
ai
tla
nd
 M
ob
ili
za
tio
n 
+
 
Ex
er
ci
se
3 
pe
r 
w
ee
k 
X 
6 
w
ee
ks
RO
M
, S
PA
D
I. 
Ba
se
lin
e,
 6
 w
ee
ks
Si
gn
ifi
ca
nt
 
im
pr
ov
em
en
t 
in
 a
ll 
ou
tc
om
es
 fo
r 
M
W
M
 g
ro
up
 
co
m
pa
re
d 
to
 
M
ai
tla
nd
 
gr
ou
p
Co
n:
 n
 =
 1
5,
 
N
A,
 5
3.
4 
(5
.2
3)
Ex
p:
 E
xp
er
im
en
ta
l g
ro
up
, C
on
: C
on
tr
ol
 g
ro
up
, R
CT
: R
an
do
m
iz
ed
 c
lin
ic
al
 tr
ia
l, 
M
W
M
: M
ob
ili
za
tio
n 
w
ith
 m
ov
em
en
t, 
RO
M
: r
an
ge
 o
f m
ot
io
n,
 S
PA
D
I: 
Sh
ou
ld
er
 P
ai
n 
an
d 
D
is
ab
ili
ty
 In
de
x,
 T
EN
S:
 tr
an
sc
ut
an
eo
us
 e
le
ct
ric
al
 n
er
ve
 s
tim
ul
at
io
n,
 D
AS
H
: 
D
is
ab
ili
ty
 o
f A
rm
 S
ho
ul
de
r 
an
d 
H
an
d,
 N
A:
 N
ot
 a
va
ila
bl
e,
 U
S:
 U
ltr
as
ou
nd
, V
AS
: V
is
ua
l a
na
lo
gu
e 
sc
al
e
18 K. SATPUTE ET AL.
Ta
bl
e 
2.
 C
ha
ra
ct
er
is
tic
s 
of
 in
cl
ud
ed
 s
tu
di
es
 (S
ho
ul
de
r 
pa
in
 w
ith
 m
ov
em
en
t 
dy
sf
un
ct
io
n 
su
b-
ca
te
go
ry
).
St
ud
y(
Au
th
or
, 
Ye
ar
, D
es
ig
n)
Pa
rt
ic
ip
an
ts
 (n
, 
M
:F
, A
ge
)
Ex
pe
rim
en
ta
l 
in
te
rv
en
tio
n
Co
m
pa
ra
to
r 
in
te
rv
en
tio
n
D
os
e
O
ut
co
m
e 
m
ea
su
re
s 
an
d 
Ti
m
e 
po
in
ts
M
ai
n 
Fi
nd
in
gs
Ka
ch
in
gw
e 
20
08
, P
ilo
t 
RC
T
Ex
p:
 n
 =
 9
, 5
:4
, 
48
.9
 (1
3.
7)
M
W
M
 +
 E
xe
rc
is
e
1.
 K
al
te
nb
or
n 
m
ob
ili
za
tio
n 
+
 
Ex
er
ci
se
 
2.
 E
xe
rc
is
e 
3.
 C
on
tr
ol
1 
pe
r 
w
ee
k 
x 
6 
w
ee
ks
RO
M
, P
ai
n 
in
te
ns
ity
, S
PA
D
I. 
Ba
se
lin
e,
 3
 w
ee
ks
N
o 
si
gn
ifi
ca
nt
 d
iff
er
en
ce
 in
 a
ny
 o
ut
co
m
e 
be
tw
ee
n 
th
e 
gr
ou
ps
 p
os
t 
in
te
rv
en
tio
n
1.
 C
on
: n
 =
 9
, 
4:
5,
 4
3.
4 
(1
4.
7)
2.
 C
on
: n
 =
 8
, 
4:
4,
 4
7.
3 
(2
0.
1)
3.
 C
on
: n
 =
 7
, 
4:
3 
45
.6
 
(1
3.
0)
D
jo
rd
je
vi
c 
20
12
, R
CT
Ex
p:
 n
 =
 1
0,
 
4:
6,
 5
1.
80
 
(5
.3
)
M
W
M
 +
 
ki
ne
si
ot
ap
in
g
Ex
er
ci
se
10
 s
es
si
on
s
RO
M
. 
Ba
se
lin
e,
 5
 &
 1
0 
da
ys
Si
gn
ifi
ca
nt
 im
pr
ov
em
en
t 
in
 R
O
M
 fo
r 
M
W
M
 +
 k
in
es
io
ta
pi
ng
 g
ro
up
 c
om
pa
re
d 
to
 
co
nt
ro
l g
ro
up
Co
n:
 n
 =
 1
0,
 
3:
7,
 5
4.
10
 
(6
.8
)
Sr
iv
as
ta
va
 
20
18
, R
CT
Ex
p:
 n
 =
 1
1,
 
N
A,
 5
0.
09
 
(1
1.
36
)
M
W
M
 +
 E
xe
rc
is
e
Cr
yo
th
er
ap
y 
+
 
Ex
er
ci
se
6 
se
ss
io
ns
RO
M
, P
ai
n 
in
te
ns
ity
, S
PA
D
I. 
Ba
se
lin
e,
 a
ft
er
 1
st
 
an
d 
6t
h
 in
te
rv
en
tio
n
N
o 
si
gn
ifi
ca
nt
 d
iff
er
en
ce
 in
 a
ny
 o
ut
co
m
e 
fo
r 
M
W
M
 g
ro
up
 c
om
pa
re
d 
to
 C
ry
ot
he
ra
py
 
gr
ou
p
Co
n:
 n
 =
 1
1,
 
N
A,
 4
1.
91
 
(1
1.
22
)
D
el
ga
do
 2
01
5,
 
RC
T
Ex
p:
 n
 =
 2
1,
 
4:
17
, 5
5.
4 
(7
.8
)
M
W
M
Sh
am
2p
er
 w
ee
k 
X 
2 
w
ee
ks
RO
M
, P
ai
n 
in
te
ns
ity
. 
Ba
se
lin
e,
 2
 w
ee
ks
Si
gn
ifi
ca
nt
 im
pr
ov
em
en
t 
in
 a
ll 
ou
tc
om
es
 fo
r 
M
W
M
 g
ro
up
 c
om
pa
re
d 
to
 s
ha
m
 g
ro
up
Co
n:
 n
 =
 2
1,
 
4:
17
, 5
4.
3 
(1
0)
G
ui
m
ar
ãe
s 
20
16
, 
Cr
os
so
ve
r 
RC
T
Ex
p:
 n
 =
 1
4,
 
6:
8,
 N
A
M
W
M
Sh
am
4 
x 
se
ss
io
ns
 t
o 
cr
os
so
ve
r 
48
 h
ou
rs
 a
pa
rt
RO
M
, P
ai
n 
in
te
ns
ity
, S
PA
D
I, 
D
AS
H
, M
us
cl
e 
st
re
ng
th
. B
as
el
in
e,
 a
ft
er
 4
x 
se
ss
io
ns
 (a
ro
un
d 
8–
10
 d
ay
s)
N
o 
si
gn
ifi
ca
nt
 d
iff
er
en
ce
 in
 a
ny
 o
ut
co
m
e 
fo
r 
M
W
M
 g
ro
up
 c
om
pa
re
d 
to
 s
ha
m
 g
ro
up
Co
n:
 n
 =
 1
3,
 
6:
7,
 N
A
Te
ys
 2
00
6,
 
Cr
os
so
ve
r 
RC
T
n 
=
 2
4,
11
:3
, 
46
.1
 (9
.8
6)
M
W
M
Sh
am
 
co
nt
ro
l
3 
se
ss
io
ns
RO
M
, p
re
ss
ur
e 
pa
in
 t
hr
es
ho
ld
. B
as
el
in
e 
– 
3 
se
ss
io
ns
 w
ith
 2
4 
hr
 in
te
rv
al
Si
gn
ifi
ca
nt
 im
pr
ov
em
en
t 
in
 a
ll 
ou
tc
om
es
 fo
r 
M
W
M
 g
ro
up
 c
om
pa
re
d 
to
 s
ha
m
 a
nd
 
co
nt
ro
l g
ro
up
Ex
p:
 n
 =
 1
5,
 
11
:4
, 4
0.
23
 
(1
0.
55
)
N
ee
la
pa
la
 
20
16
, R
CT
Co
n:
 n
 =
 1
6,
 
12
:4
, 4
2.
41
 
(1
0.
38
)
M
W
M
 +
 E
xe
rc
is
e
Ex
er
ci
se
3 
se
ss
io
ns
Pa
in
, m
us
cl
e 
st
re
ng
th
, S
ca
pu
la
r u
pw
ar
d 
ro
ta
tio
n.
 
Ba
se
lin
e,
 a
ft
er
 3
 s
es
si
on
s
Si
gn
ifi
ca
nt
 im
pr
ov
em
en
t 
in
 p
ai
n 
an
d 
ex
te
rn
al
 r
ot
at
io
n 
st
re
ng
th
 fo
r 
M
W
M
 g
ro
up
 
co
m
pa
re
d 
to
 c
on
tr
ol
 g
ro
up
Ro
m
er
o 
20
15
, 
Pi
lo
t 
RC
T
Ex
p:
 n
 =
 2
2,
 
11
:1
1,
 8
4.
7 
(8
.7
)
M
W
M
 +
 p
os
tu
ra
l 
ad
vi
ce
 +
 E
xe
rc
is
e
Po
st
ur
al
 a
dv
ic
e 
+
 
Ex
er
ci
se
3 
pe
r 
w
ee
k 
x 
2 
w
ee
ks
Ba
se
lin
e,
 2
 w
ee
ks
, 1
 a
nd
 3
 m
on
th
s
N
o 
si
gn
ifi
ca
nt
 b
et
w
ee
n 
an
d 
w
ith
in
 g
ro
up
s 
di
ffe
re
nc
es
 in
 a
ny
 o
ut
co
m
e
Co
n:
 n
 =
 2
2,
 
11
:1
1,
 8
3.
1 
(7
.8
)
(C
on
tin
ue
d)
JOURNAL OF MANUAL & MANIPULATIVE THERAPY 19
Ta
bl
e 
2.
 (C
on
tin
ue
d)
.
St
ud
y(
Au
th
or
, 
Ye
ar
, D
es
ig
n)
Pa
rt
ic
ip
an
ts
 (n
, 
M
:F
, A
ge
)
Ex
pe
rim
en
ta
l 
in
te
rv
en
tio
n
Co
m
pa
ra
to
r 
in
te
rv
en
tio
n
D
os
e
O
ut
co
m
e 
m
ea
su
re
s 
an
d 
Ti
m
e 
po
in
ts
M
ai
n 
Fi
nd
in
gs
Sa
tp
ut
e 
20
15
, 
RC
T
Ex
p:
 n
 =
 2
2,
 
10
:1
2,
 5
3.
41
 
(7
.0
8)
M
W
M
+
 E
xe
rc
is
e 
+
 
H
ea
t
Ex
er
ci
se
 +
 H
ea
t
3 
pe
r 
w
ee
k 
X 
3 
w
ee
ks
RO
M
, P
ai
n 
in
te
ns
ity
, S
PA
D
I, 
Ba
se
lin
e,
 3
 w
ee
ks
Si
gn
ifi
ca
nt
 im
pr
ov
em
en
t i
n 
al
l o
ut
co
m
es
 fo
r M
W
M
 g
ro
up
 c
om
pa
re
d 
to
 c
on
tr
ol
 g
ro
up
Co
n:
 
n 
=
 2
2,
15
:7
, 
52
.4
1 
(7
.0
6)
Su
bh
as
h 
20
20
, 
RC
T
Ex
p:
 n
 =
 1
6,
 
N
A,
 3
0.
87
 
(9
.3
7)
M
W
M
 +
 E
xe
rc
is
e 
+
 
H
ea
t
Ex
er
ci
se
 +
 H
ea
t
6 
se
ss
io
ns
 o
ve
r 
2 
w
ee
ks
RO
M
, P
ai
n 
in
te
ns
ity
, S
PA
D
I, 
Ba
se
lin
e,
 2
 w
ee
ks
Si
gn
ifi
ca
nt
 im
pr
ov
em
en
t 
in
 p
ai
n 
in
te
ns
ity
 a
nd
 fl
ex
io
n 
RO
M
 fo
r 
M
W
M
 g
ro
up
 
co
m
pa
re
d 
to
 c
on
tr
ol
 g
ro
up
. N
o 
si
gn
ifi
ca
nt
 d
iff
er
en
ce
 b
et
w
ee
n 
gr
ou
ps
 fo
r 
an
y 
ot
he
r 
ou
tc
om
es
Co
n:
 n
 =
 1
6,
 
N
A,
 3
2.
37
 
(9
.7
4)
M
en
ek
 2
01
9,
 
RC
T
Ex
p:
 n
 =
 1
5,
 
8:
7,
 5
1.
73
 
(6
.6
4)
M
W
M
+
 E
xe
rc
is
e 
+
 
Cr
yo
th
er
ap
y 
+
 
TE
N
S+
U
S
Ex
er
ci
se
 +
 
Cr
yo
th
er
ap
y 
+
 
TEN
S+
U
S
5 
pe
r 
w
ee
k 
X 
6 
w
ee
ks
RO
M
, P
ai
n 
in
te
ns
ity
, D
AS
H
, S
F-
36
 
Ba
se
 li
ne
, 6
 w
ee
ks
Si
gn
ifi
ca
nt
 im
pr
ov
em
en
t i
n 
al
l o
ut
co
m
es
 fo
r M
W
M
 g
ro
up
 c
om
pa
re
d 
to
 c
on
tr
ol
 g
ro
up
Co
n:
 n
 =
 1
5,
 
10
:5
, 5
0.
26
 
(4
.2
8)
Ex
p:
 E
xp
er
im
en
ta
l g
ro
up
, C
on
: C
on
tr
ol
 g
ro
up
, R
CT
: R
an
do
m
iz
ed
 c
lin
ic
al
 tr
ia
l, 
M
W
M
: M
ob
ili
za
tio
n 
w
ith
 m
ov
em
en
t, 
RO
M
: r
an
ge
 o
f m
ot
io
n,
 S
PA
D
I: 
Sh
ou
ld
er
 P
ai
n 
an
d 
D
is
ab
ili
ty
 In
de
x,
 T
EN
S:
 T
ra
ns
cu
ta
ne
ou
s 
el
ec
tr
ic
al
 n
er
ve
 s
tim
ul
at
io
n,
 D
AS
H
: 
D
is
ab
ili
ty
 o
f A
rm
 S
ho
ul
de
r 
an
d 
H
an
d,
 N
A:
 N
ot
 a
va
ila
bl
e,
 U
S:
 U
ltr
as
ou
nd
, V
AS
: V
is
ua
l a
na
lo
gu
e 
sc
al
e,
 S
F-
36
: S
ho
rt
 F
or
m
-3
6.
20 K. SATPUTE ET AL.
as an overall risk of bias of ‘low risk’, four were rated as 
‘some concerns’ and 18 were rated as having ‘high risk’. 
The most common methodological problems in the 
included studies resulting in a high risk of bias were 
a lack of concealed allocation (14 studies) and failure to 
blind outcome assessors (13 studies). As most studies 
were not registered prospectively, there was often no 
study protocol, leading to a decision of ‘some con-
cerns’ for domain two and domain five for most 
studies.
Meta-analysis
Meta-analysis was carried out on the results from 21 stu-
dies using the post-intervention scores for experimental 
and control groups. For studies comparing MWM with 
more than one control group, control groups were com-
bined into a single group. Analyzed studies displayed high 
levels of heterogeneity (I2 > 75%); hence, the results are 
presented based on the random effects model. Meta- 
analysis was not possible in four studies for the following 
reasons: mean values and SD were not reported [10,27]; or 
inadequate data were available [30,36]. Authors of studies 
with missing data were contacted but no response was 
received except for Romero et al [10] where data were not 
available.
Meta-analyses were performed for the sub-category 
of frozen shoulder (12 studies available) and for the 
sub-category shoulder pain with movement dysfunc-
tion (nine studies available) to assess the immediate 
effects of MWM on pain, flexion, and abduction ROM, 
as well as disability up to 2-month post-intervention. 
For both sub-categories, meta-analyses were per-
formed to evaluate the effect of MWM, either in addi-
tion to exercise therapy and/or electrotherapy or MWM 
alone (experimental group) when compared to either 
exercise therapy and electrotherapy alone or other 
type of manual therapy (control group). The random 
effects model was chosen as a conservative measure to 
account for heterogeneity among included studies. 
Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram.
JOURNAL OF MANUAL & MANIPULATIVE THERAPY 21
Figure 2. ROB 2.0 judgements according to domain and overall risk of bias for each study
22 K. SATPUTE ET AL.
Standardized mean differences (SMD) with 95% con-
fidence intervals (CIs) were calculated for pain and 
disability. Mean differences (MD) with 95% confidence 
intervals (CIs) were calculated separately for flexion 
and abduction ROM.
Frozen shoulder
Pooled data from eight studies with 345 participants 
were combined for analysis of the effects of MWM on 
pain. Statistically significant improvement was present 
post-intervention favoring MWM (SMD [95% CI]: −1.23 
[−1.96, −0.51] Z = 3.35 (P = 0.0008) with high levels of 
heterogeneity (I2 = 89%) (Figure 3(A)). Pooled data from 
nine studies with 430 participants were grouped for 
analysis of the effects of MWM on flexion ROM. 
Statistically significant improvement was present post- 
intervention favoring MWM (mean difference [95% CI]: 
−11.73 [−17.83, −5.64] Z = 3.77 (P = 0.0002) with high 
levels of heterogeneity (I2 = 82%) (Figure 3(B)). Pooled 
data from nine studies with 465 participants were 
grouped for analysis of the effects of MWM on abduc-
tion ROM. Statistically significant improvement was pre-
sent post-intervention favoring MWM (mean difference 
[95% CI]: −13.14 [−19.42, −6.87] Z = 4.10 (P < 0.0001) 
with high levels of heterogeneity (I2 = 85%) (Figure 3(C)). 
Pooled data from eight studies with 305 participants 
were grouped for analysis of the effects of MWM on 
disability. Statistically significant improvement was pre-
sent post-intervention favoring MWM (SMD [95% CI]: 
−1.50 [−2.30, −0.71] Z = 3.69 (P = 0.0002) with high 
levels of heterogeneity (I2 = 89%) (Figure 3(D)).
Shoulder pain with movement dysfunction
Pooled data from seven studies with 228 participants 
were grouped for analysis of the effects of MWM on 
pain. Statistically significant improvement was present 
post-intervention favoring MWM (SMD [95% CI]: −1.07 
[−1.87, −0.26] Z = 2.61 (P = 0.009) with high levels of 
heterogeneity (I2 = 86%) (Figure 4(A)). Pooled data from 
seven studies with 173 participants were grouped for 
analysis of the effects of MWM on flexion ROM. 
Statistically significant improvement was present post- 
intervention favoring MWM (mean difference [95% CI]: 
−18.48 [−32.43, −4.54] Z = 2.60 (P = 0.009) with high 
levels of heterogeneity (I2 = 90%) (Figure 4(B)). Pooled 
data from five studies with 151 participants were 
grouped for analysis of the effects of MWM on abduction 
ROM. Statistically significant improvement was present 
post-intervention favoring MWM (mean difference [95% 
CI]: −32.46 [−69.76, 4.84] Z = 1.71 (P = 0.09) with high 
levels of heterogeneity (I2 = 97%) (Figure 4(C)). Pooled 
data from five studies with 155 participants were 
grouped for analysis of the effects of MWM on disability. 
Statistically significant improvement was present post- 
intervention favoring MWM (SMD [95% CI]: −0.88 [−2.18, 
0.43] Z = 1.32 (P = 0.19) with high levels of heterogeneity 
(I2 = 92%) (Figure 4(D)). Improvement in shoulder flexion 
and abduction ROM in both sub-categories is clinically 
relevant, as improvement was greater than the reported 
MDC of 11ο for patients with shoulder pathologies [42].
GRADE analysis for frozen shoulder sub-category
For the frozen shoulder sub-group, the certainty of the 
effect estimate was rated as very low for all four variables 
analyzed in the meta-analysis (Table 3). For the shoulder 
pain with movement dysfunction sub-group, the cer-
tainty of the effect estimate was rated as very low for 
all four variables analyzed in the meta-analysis (Table 4).
Discussion
The objective of this systematic review and meta-analysis 
was to determine the additional benefits of MWM in 
terms of pain, flexion, and abduction ROM, as well as 
disability when compared to other non-surgical forms 
of management, including other forms of manual ther-
apy, electrotherapy, placebo, sham, or no treatment for 
shoulder musculoskeletal disorders in two categories: 
frozen shoulder or shoulder pain with movement 
dysfunction.
Findings
Our results indicate important benefits of MWM for all 
variables in each category, although caution is 
required in interpretation due to high levels of hetero-
geneity and risk of bias.
This is the first systematic review with meta-analysis 
to evaluate the clinical effectiveness of MWM in isolation 
or in addition to other physiotherapeutic modalities on 
pain, ROM and disability for commonly encountered 
shoulder conditions in clinical practice. The only other 
systematic review of MWM for shoulder did not include 
meta-analysis. Most of the included studies in our 
review evaluated MWM techniques designed to 
increase shoulder flexion and abduction ROM, thus stu-
dies that evaluated these movements were considered 
for meta-analysis. MWM demonstrated statistically sig-
nificant and clinically relevant benefits in patients with 
stage-II frozen shoulder when compared to exercise,passive manual therapy or electrotherapy. Similarly, for 
patients with shoulder pain and movement dysfunction, 
MWM demonstrated statistically significant and clini-
cally relevant benefits when compared to exercise 
alone, electrotherapy, or sham interventions. In addition 
to ROM, MWM conferred a statistically significant 
improvement in pain intensity over a control condition 
in both frozen shoulder and shoulder pain and move-
ment dysfunction sub-categories.
The SMD score was −1.23 (95% CI −1.96, −0.51) in 
patients with frozen shoulder, and −1.07 (95% CI −1.87, 
JOURNAL OF MANUAL & MANIPULATIVE THERAPY 23
−0.26) in patients with shoulder pain and movement 
dysfunction. Improvement in pain was statistically sig-
nificant and favored MWM even when the control group 
included other passive joint mobilization techniques or 
sham interventions. This would suggest that pain relief 
with MWM may be attributed more to neurophysiologi-
cal effects rather than biomechanical effects of stretch-
ing local articular structures [43] since MWM is applied 
with minimal force, being always pain-free.
In patients with frozen shoulder, flexion ROM 
improved significantly more following MWM than the 
control condition (including Maitland, Kaltenborn, and 
Spencer techniques among others shown in Table 1) 
with mean difference of −11.73 (95% CI −17.83, −5.64). 
For abduction, the mean difference was −13.14 (95% CI 
−19.42, −6.87). In patients with shoulder pain and move-
ment dysfunction, the mean difference in flexion and 
abduction ROM was −18.48 (95% CI −32.43, −4.54) and 
−32.46 (95% CI −69.76, 4.84), respectively. These effects 
were not only statistically significant but also clinically 
relevant as the improvements in ROM were greater than 
the MCID of 11° for these two measures [42]. Similar to 
pain, improvement in ROM was statistically significant 
even when the control group included other passive 
joint mobilization techniques. MWM is likely to involve 
less force than other forms of manual therapy. Again this 
suggests that improvements in ROM after MWM may be 
related to neurophysiological effects rather than 
a mechanical influence on capsular and ligamentous 
extensibility.
Figure 3. Forest plots for frozen shoulder sub category (a) Standardized Mean Difference Scores for pain. (b) Mean Difference 
Scores for flexion range of motion. (c) Mean Difference Scores for abduction range of motion. (d) Standardized Mean Difference 
Scores for disability.
24 K. SATPUTE ET AL.
Disability improved significantly more following 
MWM than the control condition (Table 1) with 
a SMD of −1.50 (95% CI −2.30, −0.71) and SMD of 
−0.88 (95% CI −2.18, 0.43) in the category’s frozen 
shoulder and shoulder pain and movement dysfunc-
tion, respectively. Direct comparisons with the MCID 
are not possible due to the standardization of the 
disability measures used in the studies included in 
meta-analysis. The effect sizes for all outcomes were 
large (> 0.8) for both sub-categories [19]. However, 
the studies included in meta-analysis displayed high 
levels of heterogeneity (I2 > 75%), and the GRADE 
certainty of effect estimate was rated as very low for 
all variables in both categories, challenging the 
strength of these results [44] . Pain relief and clinically 
relevant improvement in shoulder ROM may allow 
Figure 4. Forest plots for shoulder pain with movement dysfunction sub-category. (a) Standardized Mean Difference Scores for 
pain. (b) Mean Difference Scores for flexion range of motion. (c) Mean Difference Scores for abduction range of motion. (d) 
Standardized Mean Difference Scores for disability.
JOURNAL OF MANUAL & MANIPULATIVE THERAPY 25
Ta
bl
e 
3.
 G
RA
D
E 
as
se
ss
m
en
t 
fo
r 
th
e 
fr
oz
en
 s
ho
ul
de
r 
su
b-
ca
te
go
ry
.
Ce
rt
ai
nt
y 
as
se
ss
m
en
t
№
 o
f p
at
ie
nt
s
Eff
ec
t
Ce
rt
ai
nt
y
Im
po
rt
an
ce
№
 o
f 
st
ud
ie
s
St
ud
y 
de
si
gn
Ri
sk
 o
f b
ia
s
In
co
ns
is
te
nc
y
In
di
re
ct
ne
ss
Im
pr
ec
is
io
n
O
th
er
 
co
ns
id
er
at
io
ns
M
W
M
ot
he
r 
in
te
rv
en
tio
ns
 o
r 
no
 
in
te
rv
en
tio
n
Re
la
tiv
e(
95
%
 
CI
)
Ab
so
lu
te
(9
5%
 C
I)
Pa
in
 (a
ss
es
se
d 
w
ith
: V
AS
, N
PR
S 
or
 S
PA
D
I-P
ai
n)
8
ra
nd
om
iz
ed
 
tr
ia
ls
ve
ry
 
se
rio
us
 a
se
rio
us
 b
no
t 
se
rio
us
se
rio
us
 c
no
ne
16
5
18
0
-
SM
D
 1
.2
3 
lo
w
er
(1
.9
6 
lo
w
er
 t
o 
0.
51
 
lo
w
er
)
�
�
�
�
VE
RY
 
LO
W
Fl
ex
io
n 
RO
M
 (a
ss
es
se
d 
w
ith
: d
eg
re
es
)
9
ra
nd
om
iz
ed
 
tr
ia
ls
ve
ry
 
se
rio
us
 d
se
rio
us
 b
no
t 
se
rio
us
se
rio
us
 e
no
ne
21
5
21
5
-
M
D
 1
1.
73
 lo
w
er
(1
7.
81
 lo
w
er
 t
o 
5.
64
 
lo
w
er
)
�
�
�
�
VE
RY
 
LO
W
Ab
du
ct
io
n 
RO
M
 (a
ss
es
se
d 
w
ith
: d
eg
re
es
)
10
ra
nd
om
iz
ed
 
tr
ia
ls
ve
ry
 
se
rio
us
 f
se
rio
us
 b
no
t 
se
rio
us
se
rio
us
 e
no
ne
24
0
22
5
-
M
D
 1
3.
14
 lo
w
er
(1
9.
42
 lo
w
er
 t
o 
6.
87
 
lo
w
er
)
�
�
�
�
VE
RY
 
LO
W
D
is
ab
ili
ty
 (a
ss
es
se
d 
w
ith
: D
AS
H
, S
PA
D
I, 
Sh
ou
ld
er
 C
on
st
an
t)
8
ra
nd
om
iz
ed
 
tr
ia
ls
ve
ry
 
se
rio
us
 a
se
rio
us
 b
no
t 
se
rio
us
se
rio
us
 c
no
ne
14
5
16
0
-
SM
D
 1
.5
 lo
w
er
(2
.3
 lo
w
er
 t
o 
0.
71
 
lo
w
er
)
�
�
�
�
VE
RY
 
LO
W
G
RA
D
E:
 G
ra
di
ng
 o
f R
ec
om
m
en
da
tio
ns
 A
ss
es
sm
en
t, 
D
ev
el
op
m
en
t a
nd
 E
va
lu
at
io
n,
 C
I: 
Co
nfi
de
nc
e 
in
te
rv
al
; S
M
D
: S
ta
nd
ar
di
ze
d 
m
ea
n 
di
ffe
re
nc
e;
 M
D
: M
ea
n 
di
ffe
re
nc
e,
 V
AS
: V
is
ua
l a
na
lo
gu
e 
sc
al
e,
 N
PR
S:
 N
um
er
ic
 p
ai
n 
ra
tin
g 
sc
al
e,
 S
PA
D
I: 
Sh
ou
ld
er
 
Pa
in
 a
nd
 D
is
ab
ili
ty
 In
de
x 
Ex
pl
an
at
io
ns
 
a.
 O
f t
he
 e
ig
ht
 s
tu
di
es
 in
cl
ud
ed
 in
 t
he
 a
na
ly
si
s,
 s
ev
en
 w
er
e 
sc
or
ed
 a
s 
a 
hi
gh
 r
is
k 
of
 b
ia
s 
w
he
n 
us
in
g 
th
e 
RO
B 
2.
0 
to
ol
. M
os
t 
st
ud
ie
s 
di
d 
no
t 
ha
ve
 c
on
ce
al
ed
 a
llo
ca
tio
n,
 b
lin
de
d 
as
se
ss
or
s 
or
 a
 p
re
-p
ub
lis
he
d 
pr
ot
oc
ol
. 
b.
 C
on
si
de
ra
bl
e 
he
te
ro
ge
ne
ity
 w
as
 e
vi
de
nt
 a
s 
m
ea
su
re
d 
by
 a
n 
I s
qu
ar
ed
 s
co
re
 o
f >
 8
0%
. 
c.
 T
ot
al
 s
am
pl
e 
si
ze
 fo
r 
pa
in
 a
nd
 d
is
ab
ili
ty
 is
 fe
w
er
 t
ha
n 
th
e 
re
co
m
m
en
de
d 
nu
m
be
r 
of
 4
00
 fo
r 
an
al
ys
es
 u
si
ng
 t
he
 s
ta
nd
ar
di
ze
d 
m
ea
n 
di
ffe
re
nc
e.
 
d.
 O
f t
he
 n
in
e 
st
ud
ie
s 
in
cl
ud
ed
 in
 t
he
 a
na
ly
si
s,
 e
ig
ht
 w
er
e 
sc
or
ed
 a
s 
a 
hi
gh
 r
is
k 
of
 b
ia
s 
w
he
n 
us
in
g 
th
e 
RO
B 
2.
0 
to
ol
. M
os
t 
st
ud
ie
s 
di
d 
no
t 
ha
ve
 c
on
ce
al
ed
 a
llo
ca
tio
n,
 b
lin
de
d 
as
se
ss
or
s 
or
 a
 p
re
-p
ub
lis
he
d 
pr
ot
oc
ol
. 
e.
 T
he
 lo
w
er
 b
ou
nd
ar
y 
of
 t
he
 9
5%
 c
on
fid
en
ce
 in
te
rv
al
 d
oe
s 
no
t 
ex
ce
ed
 t
he
 m
in
im
al
 c
lin
ic
al
ly
 im
po
rt
an
t 
di
ffe
re
nc
e 
of
 1
2 
de
gr
ee
s.
 
f. 
O
f t
he
 t
en
 s
tu
di
es
 in
cl
ud
ed
 in
 t
he
 a
na
ly
si
s,
 n
in
e 
w
er
e 
sc
or
ed
 a
s 
a 
hi
gh
 r
is
k 
of
 b
ia
s 
w
he
n 
us
in
g 
th
e 
RO
B 
2.
0 
to
ol
. M
os
t 
st
ud
ie
s 
di
d 
no
t 
ha
ve
 c
on
ce
al
ed
 a
llo
ca
tio
n,
 b
lin
de
d 
as
se
ss
or
s 
or
 a
 p
re
-p
ub
lis
he
d 
pr
ot
oc
ol
.
26 K. SATPUTE ET AL.
Ta
bl
e 
4.
 G
RA
D
E 
as
se
ss
m
en
t 
fo
r 
th
e 
sh
ou
ld
er
 p
ai
n 
w
ith
 m
ov
em
en
t 
dy
sf
un
ct
io
n 
su
b-
ca
te
go
ry
.
Ce
rt
ai
nt
y 
as
se
ss
m
en
t
№
 o
f p
at
ie
nt
s
Eff
ec
t
Ce
rt
ai
nt
y
Im
po
rt
an
ce
№
 o
f 
st
ud
ie
s
St
ud
y 
de
si
gn
Ri
sk
 o
f b
ia
s
In
co
ns
is
te
nc
y
In
di
re
ct
ne
ss
Im
pr
ec
is
io
nO
th
er
 
co
ns
id
er
at
io
ns
M
W
M
ot
he
r 
in
te
rv
en
tio
ns
 o
r 
no
 
in
te
rv
en
tio
ns
Re
la
tiv
e(
95
%
 
CI
)
Ab
so
lu
te
(9
5%
 C
I)
Pa
in
 (a
ss
es
se
d 
w
ith
: V
AS
 o
r 
N
PR
S)
7
ra
nd
om
iz
ed
 
tr
ia
ls
se
rio
us
 a
se
rio
us
 b
no
t 
se
rio
us
se
rio
us
 c
no
ne
11
4
11
4
-
SM
D
 1
.0
7 
lo
w
er
(1
.8
7 
lo
w
er
 t
o 
0.
26
 
lo
w
er
)
�
�
�
�
VE
RY
 
LO
W
Fl
ex
io
n 
RO
M
 (a
ss
es
se
d 
w
ith
: g
on
io
m
et
ry
 (d
eg
re
es
))
7
ra
nd
om
iz
ed
 
tr
ia
ls
se
rio
us
 d
se
rio
us
 b
no
t 
se
rio
us
se
rio
us
 e
no
ne
13
4
11
1
-
M
D
 1
8.
48
 lo
w
er
(3
2.
43
 lo
w
er
 t
o 
4.
54
 
lo
w
er
)
�
�
�
�
VE
RY
 
LO
W
Ab
du
ct
io
n 
RO
M
 (a
ss
es
se
d 
w
ith
: g
on
io
m
et
ry
 (d
eg
re
es
))
5
ra
nd
om
iz
ed
 
tr
ia
ls
se
rio
us
 f
se
rio
us
 b
no
t 
se
rio
us
se
rio
us
 e
no
ne
75
76
-
M
D
 3
2.
46
 lo
w
er
(6
9.
76
 lo
w
er
 t
o 
4.
84
 
hi
gh
er
)
�
�
�
�
VE
RY
 
LO
W
D
is
ab
ili
ty
 (a
ss
es
se
d 
w
ith
: D
AS
H
 o
r 
SP
AD
I)
5
ra
nd
om
iz
ed
 
tr
ia
ls
ve
ry
 
se
rio
us
 g
se
rio
us
 b
no
t 
se
rio
us
se
rio
us
 h
no
ne
78
77
-
SM
D
 0
.8
8 
lo
w
er
(2
.1
8 
lo
w
er
 t
o 
0.
43
 
hi
gh
er
)
�
�
�
�
VE
RY
 
LO
W
G
RA
D
E:
 G
ra
di
ng
 o
f R
ec
om
m
en
da
tio
ns
 A
ss
es
sm
en
t, 
D
ev
el
op
m
en
t a
nd
 E
va
lu
at
io
n,
 C
I: 
Co
nfi
de
nc
e 
in
te
rv
al
; S
M
D
: S
ta
nd
ar
di
ze
d 
m
ea
n 
di
ffe
re
nc
e;
 M
D
: M
ea
n 
di
ffe
re
nc
e,
 D
AS
H
: D
is
ab
ili
tie
s 
of
 th
e 
Ar
m
, S
ho
ul
de
r a
nd
 H
an
d,
 S
PA
D
I: 
sh
ou
ld
er
 P
ai
n 
an
d 
D
is
ab
ili
ty
 In
de
x,
 
Ex
pl
an
at
io
ns
 
a.
 O
f t
he
 s
ev
en
 s
tu
di
es
 in
cl
ud
ed
 in
 th
e 
an
al
ys
is
, f
ou
r w
er
e 
sc
or
ed
 a
s 
a 
hi
gh
 ri
sk
 o
f b
ia
s 
an
d 
tw
o 
w
er
e 
sc
or
ed
 a
s 
so
m
e 
co
nc
er
ns
 w
he
n 
us
in
g 
th
e 
RO
B 
2.
0 
to
ol
. T
hr
ee
 s
tu
di
es
 fa
ile
d 
to
 h
av
e 
co
nc
ea
le
d 
al
lo
ca
tio
n 
an
d 
tw
o 
st
ud
ie
s 
fa
ile
d 
to
 h
av
e 
bl
in
de
d 
ou
tc
om
e 
as
se
ss
or
s 
w
hi
le
 t
he
re
 w
er
e 
co
nc
er
ns
 w
ith
 s
el
ec
tio
n 
of
 t
he
 r
ep
or
te
d 
re
su
lt 
w
ith
 o
ne
 s
tu
dy
. 
b.
 C
on
si
de
ra
bl
e 
he
te
ro
ge
ne
ity
 w
as
 e
vi
de
nt
 a
s 
m
ea
su
re
d 
by
 a
n 
I2
 s
co
re
 o
f >
85
%
 
c.
 T
ot
al
 s
am
pl
e 
si
ze
 fo
r 
pa
in
 a
nd
 d
is
ab
ili
ty
 is
 fe
w
er
 t
ha
n 
th
e 
re
co
m
m
en
de
d 
nu
m
be
r 
of
 4
00
 fo
r 
an
al
ys
es
 u
si
ng
 t
he
 s
ta
nd
ar
di
ze
d 
m
ea
n 
di
ffe
re
nc
e 
d.
 O
f t
he
 s
ev
en
 s
tu
di
es
 in
cl
ud
ed
 in
 th
e 
an
al
ys
is
, f
ou
r w
er
e 
sc
or
ed
 a
s 
a 
hi
gh
 ri
sk
 o
f b
ia
s 
an
d 
on
e 
w
as
 s
co
re
d 
as
 s
om
e 
co
nc
er
ns
 w
he
n 
us
in
g 
th
e 
RO
B 
2.
0 
to
ol
. T
hr
ee
 s
tu
di
es
 fa
ile
d 
to
 h
av
e 
co
nc
ea
le
d 
al
lo
ca
tio
n,
 tw
o 
st
ud
ie
s 
fa
ile
d 
to
 h
av
e 
bl
in
de
d 
ou
tc
om
e 
as
se
ss
or
s 
w
hi
le
 t
he
re
 w
er
e 
co
nc
er
ns
 w
ith
 s
el
ec
tio
n 
of
 t
he
 r
ep
or
te
d 
re
su
lt 
w
ith
 o
ne
 s
tu
dy
. 
e.
 T
he
 lo
w
er
 b
ou
nd
ar
y 
of
 t
he
 9
5%
 c
on
fid
en
ce
 in
te
rv
al
 d
oe
s 
no
t 
ex
ce
ed
 t
he
 m
in
im
al
 c
lin
ic
al
ly
 im
po
rt
an
t 
di
ffe
re
nc
e 
of
 1
2 
de
gr
ee
s 
f. 
O
f t
he
 fi
ve
 s
tu
di
es
 in
cl
ud
ed
 in
 th
e 
an
al
ys
is
, t
w
o 
w
er
e 
sc
or
ed
 a
s 
a 
hi
gh
 ri
sk
 o
f b
ia
s 
an
d 
on
e 
w
as
 s
co
re
d 
as
 s
om
e 
co
nc
er
ns
 w
he
n 
us
in
g 
th
e 
RO
B 
2.
0 
to
ol
. O
ne
 s
tu
dy
 fa
ile
d 
to
 h
av
e 
co
nc
ea
le
d 
al
lo
ca
tio
n 
an
d 
th
er
e 
w
er
e 
co
nc
er
ns
 
w
ith
 s
el
ec
tio
n 
of
 t
he
 r
ep
or
te
d 
re
su
lt 
in
 o
ne
 s
tu
dy
. 
g.
 O
f t
he
 fi
ve
 st
ud
ie
s 
in
cl
ud
ed
 in
 th
e 
an
al
ys
is
, f
ou
r w
er
e 
sc
or
ed
 a
s a
 h
ig
h 
ris
k 
of
 b
ia
s a
nd
 o
ne
 w
as
 sc
or
ed
 a
s 
so
m
e 
co
nc
er
ns
 w
he
n 
us
in
g 
th
e 
RO
B 
2.
0 
to
ol
. T
hr
ee
 st
ud
ie
s 
fa
ile
d 
to
 h
av
e 
co
nc
ea
le
d 
al
lo
ca
tio
n 
an
d 
tw
o 
st
ud
ie
s 
fa
ile
d 
to
 h
av
e 
bl
in
de
d 
ou
tc
om
e 
as
se
ss
or
s 
w
hi
le
 t
he
re
 w
er
e 
co
nc
er
ns
 w
ith
 s
el
ec
tio
n 
of
 t
he
 r
ep
or
te
d 
re
su
lt 
in
 o
ne
 s
tu
dy
. 
h.
 T
ot
al
 s
am
pl
e 
si
ze
 fo
r 
pa
in
 a
nd
 d
is
ab
ili
ty
 is
 fe
w
er
 t
ha
n 
th
e 
re
co
m
m
en
de
d 
nu
m
be
r 
of
 4
00
 fo
r 
an
al
ys
es
 u
si
ng
 t
he
 s
ta
nd
ar
di
ze
d 
m
ea
n 
di
ffe
re
nc
e.
JOURNAL OF MANUAL & MANIPULATIVE THERAPY 27
patients to exercises more effectively during their 
rehabilitation and could explain the significant 
improvement seen in disability.
The results are in accordance with previous sys-
tematic reviews reporting on the efficacy of MWM for 
peripheral joint disorders including the shoulder, in 
terms of pain [15,16,45] and ROM [14–16]. However, 
there was disagreement with respect to disability. Our 
analysis compared MWM to any other intervention 
including sham as well as other forms of manual ther-
apy. A previous review of MWM for peripheral joints 
found no effect on disability when comparing MWM 
with other forms of manual therapy [45]. In any case, 
both reviews found high levels of heterogeneity, so we 
should be cautious about the results.
Heterogeneity displayed in the results of included 
trials could be explained by the choice of outcomes. It 
follows that the outcome measure of ROM is very valid 
for a patient with significant functional stiffness seen in 
a type-II frozen shoulder, but would be of little value in 
a patient presenting with subacromial pain syndrome, 
where pain intensity with load, disability, or other 
measures are more meaningful [46].
Divergent methods of application of MWM are also 
suggested in accounting for heterogeneity in results. It 
is recommended MWM is both an assessment tool and 
treatment artifact. Its use as a treatment should only 
follow when an immediate positive modification to 
a patient’s affected movement or function occurs 
[46,47]. If a trial MWM proves ineffective, varying the 
weight-bearing status of the patient using different 
functional positions, or trialing the use of other forms 
of MWM are attempted until all avenues are exhausted. 
The studies found applied RCT and RCT crossover 
models, assessing standardized adjuncts alone, which 
lack the finesse to adopt the above guideline. This can 
be viewed as antithetical to the clinical setting. 
Interestingly, RCTs evaluating the effects of MWM for 
lumbar radiculopathy [48] and post ankle sprain [49] 
using the advised guidelines have been untaken. In 
Nguyen’s work, despite the fact that there was an 
overall 84% positive response rate to MWM for ankle 
sprain, not all patients responded to the first applied 
MWM technique. The authors postulate this to be 
a likely outcome in the shoulder, where MWM’s for 
the scapulothoracic joint, glenohumeral joint, acromio-
clavicular joint, and spine can be attempted. It is sug-
gested that each patient may require a different 
approach that is clinically reasoned, patient-centered, 
and modifiable to achieve the best outcome for the 
patient [50]. This resonates with guidelines emphasiz-
ing the importance of individualized care within 
a holistic package of multi-modal management in 
musculoskeletal conditions [4,6] and is useful to the 
clinician as it represents a truer reflection of the treat-
ment interaction.
Strength and limitations
A strength of this systematic review is that more studies 
were included than a recent systematic review with 
similar inclusion criteria evaluating the effect of MWM 
on shoulder conditions[16]. The additional studies were 
identified by searching reference lists and non-indexed 
journals. Additionally, our review provides statistical 
pooling of data through meta-analysis, which is gener-
ally considered to be more precise [51]. In addition, the 
GRADE approach was used to assess the quality of 
results. A weakness of this review is that most of the 
included studies only evaluated the effects of MWM 
post-intervention, thus it was not possible to report on 
the long-term effects. Included studies demonstrated 
significant clinical, methodological, and statistical het-
erogeneity and most of the included studies showed 
high risk of bias due to their methodological weak-
nesses; hence, improvements observed in all outcomes 
cannot be solely attributed to MWM intervention and 
caution is required when considering the results.
Future research scope
The authors recommend future studies follow a more 
pragmatic clinically reasoned and patient-centered 
approach to the use of the MWM with long-term follow- 
up. More detailed description of the MWM technique 
used in clinical trials, and effects of trial MWM’s with 
details of positive responders are advised. Progression of 
MWM to include greater load, potentially with over- 
pressure, should be considered, as should the use of self- 
MWM and the application of tape, especially within the 
context of effective patient communication, building 
patient resilience and providing self-management strate-
gies. As found with exercise in the management of 
shoulder conditions, the type, dosage, duration, and 
application of manual therapy in shoulder conditions is 
ambiguous [6]. By distinguishing between passive man-
ual therapy and MWM, clinicians may be aided in their 
selection and application of techniques, whereas synthe-
sizing data for manual therapy as a whole is likely to only 
give insight into the impact of physical touch in the 
therapeutic relationship. The authors recommend future 
systematic reviews into shoulder manual therapy make 
this division.
Conclusion
This systematic review revealed that MWM in isolation or 
in addition to exercise therapy and/or electrotherapy is 
superior in improving pain, ROM, and disability in patients 
with shoulder dysfunction when compared with either 
exercise therapy and electrotherapy alone or other type 
of manual therapy. However, the evidence is of low qual-
ity owing to high levels of heterogeneity among included 
studies and inclusion of studies with high risk of bias.
28 K. SATPUTE ET AL.
Disclosure statement
Kiran Satpute, Grant Mackay, Thomas Mitchell, and Toby Hall 
teach the Mulligan Concept on postgraduate physiotherapy 
courses, for which they receive a teaching fee.
Notes on contributors
Kiran Satpute holds postgraduate qualification in 
Musculoskeletal Physiotherapy. He is Associate Professor and 
Head of the Musculoskeletal Department at Smt. Kashibai 
Navale College of Physiotherapy, India. He is currently a PhD 
Scholar at Sancheti College of Physiotherapy, India.
Dr Sue Reid has been a titledmusculoskeletal physiothera-
pist for 30 years, and is a Certified Mulligan Practitioner and 
Honorary Member of the Mulligan Concept Teachers 
Association. She is currently a senior lecturer at the Australian 
Catholic University, prior to which she taught at the University 
of Newcastle in Australia for 14 years. Her clinical and research 
interests include the treatment of cervical spine dysfunction, 
headaches, tempero-manibular pain, concussion and dizzi-
ness. She has an extensive publication list, presented her 
research at several international conferences, and run numer-
ous workshops on concussion management internationally.
Thomas Mitchell is a wrist and hand specialist, First Contact 
Practitioner clinical supervisor and private practitioner in 
Sheffield UK.
Grant Mackay is an Australian Physiotherapy Association titled 
Musculoskeletal Physiotherapist and works in clinical practice 
in Wollongong, Australia. He completed his Bachelor of 
Applied Science (Physiotherapy) with honours at the 
University of Sydney and his Master of Clinical Physiotherapy 
(Manipulative Therapy) at Curtin University. As a teaching 
member of the Mulligan Concept Teacher Association, Grant 
provides postgraduate training courses in the Mulligan 
Concept. Grant is a faculty staff member of Manual Concepts.
Toby Hall is a Specialist Musculoskeletal Physiotherapist, 
Adjunct Associate Professor at Curtin University, and director 
of Manual Concepts. He graduated as a physiotherapist in the 
UK in 1985, completing an MSc in 1996 and a PhD in 2010. He 
has published more than 20 book chapters and more than 140 
peer-reviewed articles. He has co-authored 3 books 
“Mobilisation with Movement, The Art and the Science” & 
The Mulligan Concept of Manual Therapy: Textbook of 
Techniques” in 1st & 2nd Edn. He regularly reviews for many 
journals, is on the international advisory panel of the Journal 
Musculoskeletal Science & Practice, and is an Associate Editor 
for the Journal of Manual and Manipulative Therapy.
ORCID
Sue Reid http://orcid.org/0000-0002-4928-4636
References
[1] Urwin M, Symmons D, Allison T, et al. Estimating the 
burden of musculoskeletal disorders in the community: 
the comparative prevalence of symptoms at different 
anatomical sites, and the relation to social deprivation. 
Ann Rheum Dis. 1998 Nov;57(11):649–655. .
[2] Luime JJ, Koes BW, Hendriksen IJM, et al. Prevalence and 
incidence of shoulder pain in the general population; 
a systematic review. Scand J Rheumatol. 2004;33 
(2):73–81. .
[3] Littlewood C, Bateman M, Connor C, et al. 
Physiotherapists’ recommendations for examination and 
treatment of rotator cuff related shoulder pain: 
a consensus exercise. Physiother Pract Res. 2019;40 
(2):87–94. .
[4] NICE guidelines ‘Management of shoulder pain’ 2017. 
[accessed 2021 Mar 01]. Available from: https://cks. 
nice.org.uk/topics/shoulder-pain/management/initial- 
management/#initial-management .
[5] sitecore\lewis.ashman@rcseng.ac.uk. Subacromial 
Shoulder Pain - Commissioning Guide [Internet]. 
Royal College of Surgeons. [accessed 2021 Mar 01]. 
Available from: https://www.rcseng.ac.uk/library-and- 
publications/rcs-publications/docs/subacromial- 
shoulder-pain/ 
[6] Pieters L, Lewis J, Kuppens K, et al. An update of 
systematic reviews examining the effectiveness of 
conservative physical therapy interventions for suba-
cromial shoulder pain. J Orthop Sports Phys Ther. 2020 
Mar;50(3):131–141. .
[7] Littlewood C, May S, Walters S. A review of systematic 
reviews of the effectiveness of conservative interventions 
for rotator cuff tendinopathy. Shoulder Elbow. 2013;5 
(3):151–167.
[8] Cliona JM, Hill JC, Hay EM, et al. Identifying potential 
moderators of first-line treatment effect in patients 
with musculoskeletal shoulder pain: a systematic 
review. Eur J Physiother. 2020;1–15.
[9] Lowe CM, Barrett E, McCreesh K, et al. Clinical effec-
tiveness of non-surgical interventions for primary fro-
zen shoulder: a systematic review. J Rehabil Med. 
2019;51(8):539–556.
[10] Lirio Romero C, Torres Lacomba M, Castilla Montoro Y, 
et al. Mobilization with movement for shoulder dys-
function in older adults: a pilot trial. J Chiropr Med. 
2015;14(4):249–258. .
[11] Doner G, Guven Z, Atalay A, et al. Evalution of 
Mulligan’s technique for adhesive capsulitis of the 
shoulder. J Rehabil Med. 2013 Jan;45(1):87–91.
[12] Delgado-Gil JA, Prado-Robles E, Rodrigues-de-Souza DP, 
et al. Effects of mobilization with movement on pain and 
range of motion in patients with unilateral shoulder 
impingement syndrome: a randomized controlled trial. 
J Manipulative Physiol Ther. 2015;38(4):245–252.
[13] Hing W, Hall T, Mulligan B. The Mulligan Concept of 
Manual Therapy. 2nd ed. 2019. Chatswood, Australia: 
Elsevier.
[14] Stathopoulos N, Dimitriadis Z, Koumantakis GA. 
Effectiveness of Mulligan’s mobilization with move-
ment techniques on range of motion in peripheral 
jointpathologies: a systematic review with meta- 
analysis between 2008 and 2018. J Manipulative 
Physiol Ther. 2019;42(6):439–449.
[15] Westad K, Tjoestolvsen F, Hebron C. The effectiveness of 
Mulligan’s mobilisation with movement (MWM) on per-
ipheral joints in musculoskeletal (MSK) conditions: 
a systematic review. Musculoskeletal Sci Pract. 
2019;39:157–163.
[16] Varghese MV, George J. Effectiveness of Mulligans 
mobilisation with movement on shoulder dysfunction: 
a systematic review. Journal of Clinical and Diagnostic 
Research. 2020;14(10):1–5.
[17] Sterne JAC, Savović J, Page MJ, et al. RoB 2: a revised 
tool for assessing risk of bias in randomised trials. BMJ. 
2019;366:l4898.
JOURNAL OF MANUAL & MANIPULATIVE THERAPY 29
https://cks.nice.org.uk/topics/shoulder-pain/management/initial-management/#initial-management
https://cks.nice.org.uk/topics/shoulder-pain/management/initial-management/#initial-management
https://cks.nice.org.uk/topics/shoulder-pain/management/initial-management/#initial-management
https://www.rcseng.ac.uk/library-and-publications/rcs-publications/docs/subacromial-shoulder-pain/
https://www.rcseng.ac.uk/library-and-publications/rcs-publications/docs/subacromial-shoulder-pain/
https://www.rcseng.ac.uk/library-and-publications/rcs-publications/docs/subacromial-shoulder-pain/
[18] GRADE handbook [Internet]. [cited 2021 Mar 15]. 
Available from: https://gdt.gradepro.org/app/hand 
book/handbook.html 
[19] Cohen J. Statistical Power Analysis for the Behavioral 
Sciences. New York: Academic Press; 2013. p. 459.
[20] Arshad HS, Shah IH, Nasir RH. Comparison of Mulligan 
mobilization with movement and end-range mobiliza-
tion following Maitland techniques in patients with fro-
zen shoulder in improving range of motion. International 
Journal of Science and Research. 2013;4(4):7.
[21] Boruah L, Dutta A, Deka P, et al. To study the effect of 
scapular mobilization versus mobilization with move-
ment to reduce pain and improve gleno-humeral 
range of motion in adhesive capsulitis of shoulder: 
a comparative study. Int J Physiother. 2015;2(5). 
DOI:10.15621/ijphy/2015/v2i5/78239
[22] Dilip JR. Effect of Gong’s mobilization versus Mulligan’s 
mobilization on shoulder pain and shoulder medial rota-
tion mobility in frozen shoulder. Int J Physiother. 2016;3 
(1). DOI:10.15621/ijphy/2016/v3i1/88928
[23] Djordjevic OC, Vukicevic D, Katunac L, et al. 
Mobilization with movement and kinesiotaping com-
pared with a supervised exercise program for painful 
shoulder: results of a clinical trial. J Manipulative 
Physiol Ther. 2012 Jul;35(6):454–463.
[24] Goyal R, Jindal P, Khurana G. A comparison of granise-
tron and nitroglycerine for attenuating rocuronium 
pain: a double-blinded randomized, placebo con-
trolled trial. Saudi J Anaesth. 2014;8(1):83-87.
[25] Guimarães JF, Salvini TF, Siqueira ALJ, et al. Effects of 
mobilization with movement vs Sham technique on 
range of motion, strength, and function in patients 
with shoulder impingement syndrome: randomized 
clinical trial. J Manipulative Physiol Ther. 2016;39 
(9):605–615.
[26] Haider R, Bashir MS, Adeel M, et al. Comparison of 
conservative exercise therapy with and without 
Maitland Thoracic Manipulative therapy in patients 
with subacromial pain: clinical trial. J Pak Med Assoc. 
2018;68(3):381–387.
[27] Kachingwe AF, Phillips B, Sletten E, et al. Comparison 
of manual therapy techniques with therapeutic exer-
cise in the treatment of shoulder impingement: 
a randomized controlled pilot clinical trial. J Man 
Manip Ther. 2008;16(4):238–247.
[28] Khyathi P, Babu KV, Kumar NSDA. Comparative effect 
of spencer technique versus mulligans technique for 
subjects with frozen shoulder a single blind study. 
Int J Physiother. 2015;2(2):448–458.
[29] Menek B, Tarakci D, Algun ZC. The effect of Mulligan 
mobilization on pain and life quality of patients with 
Rotator cuff syndrome: a randomized controlled trial. 
J Back Musculoskelet Rehabil. 2019;32(1):171–178.
[30] Minerva RK, Alagingi NK, Apparao P. To Compare the 
effectiveness of Maitland versus Mulligan mobilisation 
in idiopathic adhesive capsulitis of shoulder. 
Int J Health Sci (Qassim). 2016;2:9.
[31] Neelapala YVR, Reddy YRS, Danait R. Effect of Mulligan’s 
posterolateral glide on shoulder rotator strength, scapu-
lar upward rotation in shoulder pain subjects - 
a randomized controlled trial. J Musculoskeletal Res. 
2016;19(3):1. .
[32] Ranjana SP, Banerjee D, Bhushan V, et al. Long term 
efficacy of Maitland mobilization versus Mulligan 
mobilization in idiopathic adhesive capsulitis of 
shoulder: a randomized controlled trial. Indian 
J Physiother Occup Ther. 2016;10(4):91–97.
[33] Rathod D, Priyanka G, Palkar A. Comparative study of 
Kaltenborn mobilisation versus Mulligan mobilisation 
in patients with frozen shoulder. Int J Health Sci 
(Qassim). 2019;9(9):320–324.
[34] Sai KV, Kumar JNS. Effects of Mulligan’s mobilisa-
tion with movement on pain and range of motion 
in diabetic frozen shoulder a randomized clinical 
trail. Indian J Physiother Occup Ther. 2015;9 
(4):187–193.
[35] Satpute KH, Bhandari P, Hall T. Efficacy of hand behind 
back mobilization with movement for acute shoulder 
pain and movement impairment: a randomized con-
trolled trial. J Manipulative Physiol Ther. 2015;38 
(5):324–334.
[36] Shrivastava A, Shyam AK, Sabnis S, et al. Randomised 
controlled study of Mulligan’s Vs. Maitland’s mobili-
zation technique in adhesive capsulitis of shoulder 
joint. Indian J Physiother Occup Ther. 2011;5 
(4):12–15.
[37] Srivastava N, Joshi S. Comparision between the 
Effectiveness of Mobilization with Movement and 
End Range Mobilization along with Conventional 
Therapy for Management of Frozen Shoulder. Indian 
J Physiother Occup Ther. 2017;11(4):176-179.
[38] Subhash R, Makhija M. Effectiveness of mobilization 
with movement in weight bearing position on pain, 
shoulder range of motion and function in patients 
with shoulder dysfunction. Indian J Public Health Res 
Dev. 2020;11(6):912-916.
[39] Teys P, Bisset L, Vicenzino B. The initial effects of 
a Mulligan’s mobilization with movement technique 
on range of movement and pressure pain threshold 
in pain-limited shoulders. Man Ther. 2008;13 
(1):37–42.
[40] Yeole U, DrP D, Gharote G, et al. Effectiveness of move-
ment with mobilization in adhesive capsulitis of 
shoulder: randomized controlled trial. Indian Journal 
of Medical Research and Pharmaceutical Sciences. 
2017;4(2):1–8.
[41] Youssef AR, Ibrahim AMA, Ayad KE. Mulligan mobiliza-
tion is more effective in treating diabetic frozen 
shoulder than the Maitland technique. 
Int J Physiother. 2015;804–810.
[42] Mullaney MJ, McHugh MP, Johnson CP, et al. Reliability of 
shoulder range of motion comparing a goniometer to 
a digital level. Physiother Theory Pract. 2010;26 
(5):327–333.
[43] Bialosky J, Beneciuk J, Bishop M, et al. Unraveling the 
mechanisms of manual therapy: modeling an 
approach. Journal of Orthopaedic and Sports Physical 
Therapy. 2018;48(1):8–18.
[44] Higgins JPT, Thompson SG, Deeks JJ, et al. Measuring 
inconsistency in meta-analyses. BMJ. 2003 Sep 6;327 
(7414):557–560.
[45] Stathopoulos N, Dimitriadis Z, Koumantakis GA. 
Effectiveness of Mulligan’s mobilization with move-
ment techniques on pain and disability of peripheral 
joints: a systematic review with meta-analysis between 
2008-2017. Physiotherapy. 2019;105(1):1–9.
[46] Vicenzino B, Hing W, Rivett D, et al. Mobilisation with 
Movement The Art and the Science. 1st ed. 2011. 
Chatswood, Australia: Elsevier.
[47] Lehman GJ. The role and value of symptom-modification 
approaches in musculoskeletal practice. J Orthop Sports 
Phys Ther. 2018;48(6):430–435.
[48] Satpute K, Hall T, Bisen R, et al. The effect of spinal 
mobilization with leg movement in patients with lumbar 
30 K. SATPUTE ET AL.
https://gdt.gradepro.org/app/handbook/handbook.html
https://gdt.gradepro.org/app/handbook/handbook.html
https://doi.org/10.15621/ijphy/2015/v2i5/78239
https://doi.org/10.15621/ijphy/2016/v3i1/88928radiculopathy-a double-blind randomized controlled 
trial. Arch Phys Med Rehabil. 2019;100(5):828–836.
[49] Nguyen AP, Pitance L, Mahaudens P, et al. Effects of 
Mulligan mobilization with movement in subacute 
lateral ankle sprains: a pragmatic randomized trial. 
J Man Manip Ther. 2021;1–12. doi:10.1080/106698 
17.2021.1889165
[50] Zeppieri Jr G, Bialosky J, George SZ. Importance 
of outcome domain for patients with 
musculoskeletal pain: characterizing subgroups 
and their response to treatment. Phys Ther. 
2020;100(5):829–845.
[51] Bartolucci AA, Hillegass WB. Overview, Strengths, and 
Limitations of Systematic Reviews and Meta-Analyses. 
In: Chiappelli F, editor. Evidence-Based Practice: 
toward Optimizing Clinical Outcomes. Berlin, 
Heidelberg: Springer; 2010; 251–252.
JOURNAL OF MANUAL & MANIPULATIVE THERAPY 31
https://doi.org/10.1080/10669817.2021.1889165
https://doi.org/10.1080/10669817.2021.1889165
Appendix 1. The following databases were searched: PubMed (MEDLINE), CINAHL, SPORTDiscus, 
PEDro, Cochrane library, and Scopus, from inception to 8 January 2021
Database (n) Search terms
Pubmed (MEDLINE) 
728
‘Shoulder’[All Fields] OR ‘Acromion’[All Fields] OR ‘Rotator Cuff’[All Fields] OR ‘Acromioclavicular Joint’[All Fields] AND ‘Shoulder 
Impingement Syndrome’[All Fields] OR ‘Rotator Cuff Injuries’[All Fields] OR ‘Rotator Cuff Tear Arthropathy’[All Fields] OR 
‘Bursitis’[All Fields] OR ‘Tendinopathy’[All Fields] OR ‘Osteoarthritis’[All Fields] OR ‘shoulder pain’[MeSH Terms] OR ‘Shoulder’[All 
Fields] AND ‘pain’[All Fields] OR ‘shoulder pain’[All Fields] AND ‘movement’[MeSH Terms] OR ‘movement’[All Fields] OR 
‘movements’[All Fields] OR ‘movement s’[All Fields] AND ‘impair’[All Fields] OR ‘impaired’[All Fields] OR ‘impairment’[All Fields] 
OR ‘impairments’[All Fields] OR ‘impairing’[All Fields] OR ‘impairment’[All Fields] OR ‘impairments’[All Fields] OR ‘impairs’[All 
Fields] OR ‘stiff’[All Fields] OR ‘stiffness’[All Fields] OR ‘stiffnesses’[All Fields] AND ‘Exercise Movement Techniques’[All Fields] 
AND ‘Musculoskeletal Manipulations’[All Fields] OR ‘MWM’[All Fields] OR ‘Mobilisation with movement’[All Fields] OR 
‘mobilization with movement’[All Fields] OR ‘Mulligan concept’[All Fields] OR ‘Manual therapies’ [All Fields] OR ‘Manual 
therapy’[All Fields] AND (‘clinical trial’[Publication Type] OR ‘randomized controlled trial’[Publication Type])
CINAHL 
157
(1) Shoulder OR Acromion OR rotator cuff OR Acromioclavicular Joint
(2) Shoulder Impingement Syndrome OR Rotator Cuff Injuries OR Rotator Cuff Tear Arthropathy OR Bursitis OR Tendinopathy OR 
Osteoarthritis OR shoulder pain OR Shoulder AND pain OR shoulder pain AND movement OR movement OR movements AND 
impair OR impaired OR impairment OR impairments OR impairing OR impairment OR impairments OR impairs OR stiff OR 
stiffness OR stiffness
(3) 1 and 2
(4) Exercise Movement Techniques AND Musculoskeletal Manipulations OR MWM OR Mobilization with movement OR mobiliza-
tion with movement OR Mulligan concept OR Manual therapies OR Manual therapy
(5) 3 AND 4
(6) clinical trial OR randomized-controlled trial
(7) 5 AND 6
Sports Discus: 
102
(1) Shoulder OR Acromion OR rotator cuff OR Acromioclavicular Joint
AND
(1) Shoulder Impingement Syndrome OR Rotator Cuff Injuries OR Rotator Cuff Tear Arthropathy OR Bursitis OR Tendinopathy OR 
Osteoarthritis OR shoulder pain OR Shoulder AND pain OR shoulder pain AND movement OR movement OR movements AND 
impair OR impaired OR impairment OR impairments OR impairing OR impairment OR impairments OR impairs OR stiff OR 
stiffness OR stiffness
AND
(1) Exercise Movement Techniques AND Musculoskeletal Manipulations OR MWM OR Mobilization with movement OR mobiliza-
tion with movement OR Mulligan concept OR Manual therapies OR Manual therapy
AND
(1) clinical trial OR randomized-controlled trial
PEDro 27 Mobilization with Movement and shoulder
Scopus – 432 (shoulder) OR (acromion) OR (rotator AND cuff) OR (acromioclavicular AND joint) AND (”Shoulder Impingement Syndrome”) OR 
(”Rotator Cuff Injuries”) OR (”Rotator Cuff Tear Arthropathy”) OR (bursitis) OR (tendinopathy) OR (osteoarthritis) OR (”Shoulder pain 
with movement impairment”) OR (stiffness) AND (exercise AND movement AND techniques) AND (musculoskeletal AND 
manipulations) OR (MWM) OR (”Mobilization with movement”) OR (”mobilization with movement”) OR (”Mulligan concept”) AND 
(LIMIT-TO (DOCTYPE, ”ar”)) AND (LIMIT-TO (LANGUAGE, ”English”))
Cochrane Library – 
510
#1 Shoulder OR Acromion OR rotator cuff OR Acromioclavicular Joint 
#2 Shoulder Impingement Syndrome OR Rotator Cuff Injuries OR Rotator Cuff Tear Arthropathy OR Bursitis OR Tendinopathy OR 
Osteoarthritis OR shoulder pain OR Shoulder AND pain OR shoulder pain AND movement OR movement OR movements AND 
impair OR impaired OR impairment OR impairments OR impairing OR impairment OR impairments OR impairs OR stiff OR 
stiffness OR stiffness 
3# Exercise Movement Techniques AND Musculoskeletal Manipulations OR MWM OR Mobilization with movement OR 
mobilization with movement OR Mulligan concept OR Manual therapies OR Manual therapy 
#1 AND #2 AND #3
32 K. SATPUTE ET AL.
	Abstract
	Introduction
	Methods
	Data sources and searches
	Eligibility criteria
	Quality assessment and data extraction
	Data synthesis
	Results
	Results of the literature search
	Qualitative synthesis
	Risk of bias assessment
	Meta-analysis
	Frozen shoulder
	Shoulder pain with movement dysfunction
	GRADE analysis for frozen shoulder sub-category
	Discussion
	Findings
	Strength and limitations
	Future research scope
	Conclusion
	Disclosure statement
	Notes on contributors
	ORCID
	References
	Appendix 1. The following databases were searched: PubMed (MEDLINE), CINAHL, SPORTDiscus, PEDro, Cochrane library, and Scopus, from inception to 8 January 2021