title: The effectiveness of manual therapy for the management of musculoskeletal disorders of the upper and lower extremities: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.
abstract: BACKGROUND
  Musculoskeletal disorders (MSDs) of the upper and lower extremities are common in the general population and place a significant burden on the health care system. Manual therapy is recommended by clinical practice guidelines for the management of these injuries; however, there is limited evidence to support its effectiveness. The purpose of our review was to investigate the effectiveness of manual therapy in adults or children with MSDs of the upper or lower extremity.
  
  
  METHODS
  Randomized controlled trials (RCTs), cohort studies, and case-control studies evaluating the effectiveness of manual therapy were eligible. We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials from 1990 to 2015. Paired reviewers screened studies for relevance and critically appraised relevant studies using the Scottish Intercollegiate Guidelines Network criteria. Studies with low risk of bias were synthesized following best-evidence synthesis principles. Where available, we computed mean changes between groups, relative risks and 95 % CI.
  
  
  RESULTS
  We screened 6047 articles. Seven RCTs were critically appraised and three had low risk of bias. For adults with nonspecific shoulder pain of variable duration, cervicothoracic spinal manipulation and mobilization in addition to usual care may improve self-perceived recovery compared to usual care alone. For adults with subacromial impingement syndrome of variable duration, neck mobilization in addition to a multimodal shoulder program of care provides no added benefit. Finally, for adults with grade I-II ankle sprains of variable duration, lower extremity mobilization in addition to home exercise and advice provides greater short-term improvements in activities and function over home exercise and advice alone. No studies were included that evaluated the effectiveness of manual therapy in children or for the management of other extremity injuries in adults.
  
  
  CONCLUSIONS
  The current evidence on the effectiveness of manual therapy for MSDs of the upper and lower extremities is limited. The available evidence supports the use of manual therapy for non-specific shoulder pain and ankle sprains, but not for subacromial impingement syndrome in adults. Future research is needed to determine the effectiveness of manual therapy and guide clinical practice.
  CRD42014009899.
authors.affiliation: Rebecca MacDonald Centre for Arthritis and Autoimmune Disease, Mount Sinai Hospital, 600 University Avenue, Toronto, Ontario Canada M5G 1X5.
authors.forename: Danielle
authors.initials: D
authors.lastname: Southerst
authors.affiliation: UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1 ; Graduate Education and Research Programs, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1.
authors.forename: Hainan
authors.initials: H
authors.lastname: Yu
authors.affiliation: UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1 ; Graduate Education and Research Programs, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1 ; Division of Undergraduate Education, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1.
authors.forename: Kristi
authors.initials: K
authors.lastname: Randhawa
authors.affiliation: Canada Research Chair in Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT), 2000 Simcoe St N, Science building, Room 3000, Oshawa, Ontario Canada L1H 7K4 ; Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe St N, Science building, Room 3000, Oshawa, Ontario Canada L1H 7K4 ; UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, 6100 Leslie St, Toronto, Ontario Canada M2H 3J1.
authors.forename: Pierre
authors.initials: P
authors.lastname: Côté
authors.affiliation: Department of Graduate Studies, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1.
authors.forename: Kevin
authors.initials: K
authors.lastname: D'Angelo
authors.affiliation: UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1 ; Graduate Education and Research Programs, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1.
authors.forename: Heather M
authors.initials: HM
authors.lastname: Shearer
authors.affiliation: UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1 ; Graduate Education and Research Programs, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1 ; Department of Graduate Studies, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1.
authors.forename: Jessica J
authors.initials: JJ
authors.lastname: Wong
authors.affiliation: UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1 ; Graduate Education and Research Programs, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1.
authors.forename: Deborah
authors.initials: D
authors.lastname: Sutton
authors.affiliation: UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1 ; Graduate Education and Research Programs, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1 ; Division of Undergraduate Education, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1.
authors.forename: Sharanya
authors.initials: S
authors.lastname: Varatharajan
authors.affiliation: Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe St N, Science building, Room 3000, Oshawa, Ontario Canada L1H 7K4.
authors.forename: Rachel
authors.initials: R
authors.lastname: Goldgrub
authors.affiliation: Department of Graduate Studies, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1.
authors.forename: Sarah
authors.initials: S
authors.lastname: Dion
authors.affiliation: Department of Graduate Studies, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1.
authors.forename: Jocelyn
authors.initials: J
authors.lastname: Cox
authors.affiliation: Department of Graduate Studies, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1.
authors.forename: Roger
authors.initials: R
authors.lastname: Menta
authors.affiliation: Department of Graduate Studies, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1.
authors.forename: Courtney K
authors.initials: CK
authors.lastname: Brown
authors.affiliation: Graduate Education Program, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1 ; Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1.
authors.forename: Paula J
authors.initials: PJ
authors.lastname: Stern
authors.affiliation: UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1 ; Graduate Education and Research Programs, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1.
authors.forename: Maja
authors.initials: M
authors.lastname: Stupar
authors.affiliation: Injury Prevention Centre and School of Public Health, University of Alberta, 4075 Research Transition Facility, 8308-114 St, Edmonton, Alberta Canada T6G 2E1.
authors.forename: Linda J
authors.initials: LJ
authors.lastname: Carroll
authors.affiliation: UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1.
authors.forename: Anne
authors.initials: A
authors.lastname: Taylor-Vaisey
keywords: Manual therapy; Musculoskeletal disorders; Outcome; Recovery; Rehabilitation; Systematic review; Treatment; Upper and lower extremities