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Research Review By Dr. Ceara Higgins©


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Date Posted:

June 2016

Study Title:

The effectiveness of soft-tissue therapy for the management of musculoskeletal disorders and injuries of the upper and lower extremities: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration


Piper S, Shearer HM, Cote P et al.

Author's Affiliations:

Canadian Memorial Chiropractic College, Toronto, ON; UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, Toronto, ON; University of Ontario Institute of Technology (UOIT), Oshawa, ON; NYU School of Medicine, New York University, New York; Toronto Health Economics and Technology Assessment (THETA) Collaborative, University of Toronto, Toronto, ON; Institute for Work and Health, Toronto, ON, Canada.

Publication Information:

Manual Therapy 2016; 21: 18-34.

Background Information:

Musculoskeletal (MSK) disorders are defined as injuries or disorders of the muscles, nerves, tendons, joints, cartilage and supporting structures of the upper and lower limbs, neck, and lower back by the Centers for Disease Control and Prevention (CDC) (2). Such disorders are common and place a substantial burden on the health care system, workplaces, and individuals. Two thirds of Canadians with sprains or strains seek medical attention and experience limitations in their activities (8). This medical attention commonly includes some form of complementary and alternative medicine (CAM) therapy, with 18.3% of Canadians over age 20 reporting using chiropractic and massage therapy as their primary treatment for MSK injuries and chronic arthritis (3). This study aimed to evaluate the effectiveness of soft-tissue therapy when compared to other interventions, placebo/sham interventions, or no intervention in the treatment of MSK disorders and injuries in the upper and lower extremities.

Pertinent Results:

Six articles investigating the treatment of lateral epicondylitis, shoulder impingement syndrome, carpal tunnel syndrome, and plantar fasciitis were included in the review. In these, the techniques studied included a device-assisted technique, manual soft tissue therapy, localized relaxation massage, movement re-education, and clinical massage. Results are presented according to condition studied.

Carpal Tunnel Syndrome:
One RCT looked at carpal tunnel and compared a multimodal care program consisting of a wearing a wrist-hand brace at night for 6 months, tendon and nerve gliding exercises, and analgesics as needed, to the same multimodal care program combined with 6 weeks of supervised self-applied massage to the hand and forearm and found clinically significant improvements in function and symptom severity favoring the addition of massage. Immediately post-intervention, there were also clinically and statistically significant improvements in patient- and physician-rated global assessment of pain and statistically significant improvements for grip strength in the massage added group.

Lateral Epicondylitis:
One RCT was found comparing four weeks of muscle energy technique (5 repetitions, twice a week of resisted forearm pronation starting from a maximally supinated position) to a single injection of 1 mL of triamcinolone acetone (40 mg/mL) plus 1 mL of 1% lidocaine into the subcutaneous tissue and muscle distal to the lateral epicondyle. At a six-week follow up there were statistically significant improvements favoring the corticosteroid injection, but at 26 weeks and 52 weeks, the muscle energy technique showed more favorable, clinically significant improvements in pain-free grip strength, arm function, and disability as well as statistically and clinically significant improvements in pain with hand gripping.

A second RCT showed that clinical massage using myofascial release to the forearm with a maximum of 12 sessions over 4 weeks showed clinically and statistically significant improvements in pain and disability when compared to sham ultrasound.

Subacromial Impingement Syndrome:
One RCT showed that six sessions of diacutaneous fibrolysis (DF) (a myofascial release technique using a metal hook) with multimodal care (clinic-based electrotherapy, therapeutic exercises, and cryotherapy for 3 weeks followed by 3 weeks of home exercises and icing) was no more effective than sham DF with multimodal care or multimodal care alone in improving pain intensity at any follow-up.

Plantar Fasciitis:
One RCT showed that 16 sessions over 1 month of trigger point soft tissue therapy to the gastrocnemius muscle and supervised self-stretching showed limited or no benefit over a supervised self-stretching protocol alone for unilateral plantar heel pain in the short-term.

A second RCT showed that adults with unilateral plantar heel pain showed clinically important and statistically significant improvements in foot function favoring 12 (30 minute) sessions of myofascial release to the gastrocnemius, soleus, and plantar fascia when compared to sham ultrasound over the same areas at 4- and 12-week follow-up. Statistically significant differences were also seen favoring myofascial release in pressure pain threshold at both follow-up periods.

Adverse Events:
No serious adverse events were noted in the four studies that reported on this possibility . Transient adverse events reported included: 1) increased pain post-treatment with myofascial release in the treatment of lateral epicondylitis; 2) temporary pain, loss of skin pigmentation, or subcutaneous atrophy after corticosteroid injection; and 3) temporary soreness following self-stretching and/or trigger point therapy.

Clinical Application & Conclusions:

Clinical massage (myofascial release) was shown to be effective for the management of plantar heel pain and lateral epicondylitis, but not for subacromial impingement syndrome. Trigger point therapy was shown to provide limited or no benefit for the treatment of plantar heel pain, movement re-education was shown to be effective for treating persistent lateral epicondylitis, and localized relaxation massage was shown to possibly provide short-term benefit for treating carpal tunnel syndrome when it is combined with multimodal care. However, the effectiveness of most types of soft tissue therapy needs to be more thoroughly investigated.

Study Methods:

Separate literature searches were completed for the lower extremity and upper extremity using the following inclusion/exclusion criteria.

Inclusion Criteria:
  • Studies of adults and children with MSK disorders and injuries, including nerve injuries/neuropathies, of the upper or lower extremities
  • Studies involving soft tissue therapy (defined as a manual form of therapy when soft tissue structures and passively pressed, kneaded, or stretched using physical contact with the hand or a mechanical device)
  • Studies where soft tissue therapy was compared to other non-invasive interventions, placebo/sham, waiting list, or no intervention
  • Studies including one or more of the following outcomes: 1) self-rated recovery; 2) functional recovery; 3) clinical outcomes; 4) administrative outcomes; or 5) adverse events
  • Published in English between Jan. 1st, 1990 and Feb. 21st, 2015
  • Randomized controlled trials (RCTs), cohort studies, or case-control studies
  • Studies with an inception cohort of a minimum of 30 participants per treatment arm for RCTs or 100 subjects per exposed group for cohort or case-control studies
Exclusion Criteria:
  • Studies involving pathology
  • Studies with any form of soft tissue therapy directed at acupuncture points
  • Guidelines, narrative reviews, letters, editorials, commentaries, unpublished manuscripts, dissertations, government reports, books and book chapters, conference proceedings, meeting abstracts, lectures and addresses, consensus development statements, or guideline statements
  • Cross-sectional studies, case reports, case series, qualitative studies, reviews, biomechanical studies, laboratory studies, or studies not reporting on methodology
  • Cadaveric or animal studies
Random pairs of reviewers screened titles and abstracts to classify articles as relevant, possibly relevant, or irrelevant and then reviewed the full articles of possibly relevant studies to make a final determination. Disagreements were resolved by discussion or by a third reviewer if discussion did not lead to agreement. Eligible studies were reviewed by random pairs of trained reviewers for internal validity using the Scottish Intercollegiate Guidelines Network (SIGN) criteria (4).

Two reviewers extracted data from studies with low risk of bias into evidence tables which were independently checked by a third reviewer. Results were separated by type of disorder, duration (recent [< 3 months] or persistent [≥ 3 months]), and types of soft tissue therapy. Minimally clinically important differences (MCIDs) were established as follows:
  1. 1.4/10 cm on the Visual Analog Scale (VAS) (12)
  2. 11/100 points on the Patient-rated Forearm Evaluation Questionnaire (PRTEE)(10)
  3. 6.0 Kg for grip strength using the Jamar Dynamometer (9)
  4. 10.2/100 points on the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire (11)
  5. 0.47 on the Boston Carpal Tunnel Questionnaire Functional Capacity Subscale (BFCS) (1)
  6. 0.16 on the Boston Carpal Tunnel Questionnaire Symptom Severity (BSSS) (1)
  7. 10 points on the SF-36 Bodily Pain sub-scale (6)
  8. 7/100 for total foot function and 12/100 for the pain sub-scale on the Foot Function Index (FFI)(5)

Study Strengths / Weaknesses:

  • Search strategies were developed with a health sciences librarian and reviewed by a second librarian for completeness and accuracy using the Peer Review of Electronic Search Strategies (PRESS) Checklist (7).
  • Detailed exclusion and inclusion criteria were used.
  • A standardized method was used to critically appraise relevant studies.
  • Terms used to categorize soft tissue therapy were clearly defined.
  • The search was limited to articles published in English.
  • Trials were assessed using quantitative outcome measures and therefore may not represent or capture more qualitative experiences or benefits from soft tissue therapy.

Additional References:

  1. Amirfeyz R, Pentlow A, Foote J, et al. Assessing the clinical significance of change scores following carpal tunnel surgery. Int Orthop 2009; 33(1): 181-185.
  2. Centers for Disease Control and Prevention. NIOSH program Portfolio. Musculoskeletal disorders 2015. Available from: http://www.cdc.gov/niosh/programs/msd/ (March 19, 2015).
  3. Foltz V, St Pierre Y, Rozenberg S, et al. Use of complementary and alternative therapies be patients with self-reported chronic back pain: a nationwide survey in Canada. Joint Bone Spine 2005; 72(6): 571-577.
  4. Harbour R, Miller J. A new system for grading recommendations in evidence based guidelines. BMJ 2001; 323(7308): 334-336.
  5. Andorf KB, Radford JA. Minimal important difference: values for the foot health status questionnaire, foot function index and visual analog scale. Foot 2008; 18: 15-19.
  6. Lauche R, Langhorst J, Dobos GJ, et al. Clinically meaningful differences in pain, disability and quality of life for nonspecific neck pain – a reanalysis of 4 randomized controlled trials of cupping therapy. Complement Ther Med 2013; 21(4): 342-347.
  7. McGowan J, Sampson M, Lefebvre C. An evidence based checklist for the Peer Review of Electronic Search Strategies (PRESS EBC). Evid Based Libr Inf Pract 2010; 5(1): 149-154.
  8. Mo F, Neutel IC, Morrison H, et al. A cohort study for the impact of activity-limiting injuries based on the Canadian National Population Health Survey 1994-2006. BMJ Open 2013; 3(3).
  9. Nitschke JE, McMeeken JM, Burry HC, et al. When is a change a genuine change? A clinically meaningful interpretation of grip strength measurements in healthy and disabled women. J Hand Ther 1999; 12(1): 25-30.
  10. Poltawski LWT. Measuring clinically important change with the patient-rated tennis elbow evaluation. Hand Ther 2011; 16(3): 52-57.
  11. Roy JS, MacDermid JC, Woodhouse LJ. Measuring shoulder function: a systematic review of four questionnaires. Arthritis Rheumatol 2009; 61(5): 623-632.
  12. Tashjian RZ, Deloach J, Porucznik CA, et al. Minimally clinically important differences (MCID) and patient acceptable symptomatic state (PASS) for visual analog scales (VAS) measuring pain in patients treated for rotator cuff disease. J Shoulder Elbow Surg 2009; 18(6): 927-932.

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