title: Thoracic manual therapy in the management of non-specific shoulder pain: a systematic review.
abstract: OBJECTIVE
  Non-specific shoulder pain (NSSP) is often persistent and disabling leading to high socioeconomic costs. Cervical manipulation has demonstrated improvements in patients with NSSP, although risks associated with thrust techniques are documented. Thoracic manual therapy (TMT) may utilise similar neurophysiological effects with less risk. The current evidence for TMT in treating NSSP is limited to systematic reviews of manual therapy (MT) applied to the upper quadrant. These reviews included trials that used shoulder girdle manual therapy (SG-MT) in the TMT group. This limits the scope of their conclusions with regard to the exclusive effectiveness of TMT for NSSP.
  
  
  METHODS
  This review used a steering group for subject and methodological expertise and was reported in line with Preferred Reporting items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Key databases were searched (1990-2014) using relevant search terms and medical subject headings (MeSH); eligibility was evaluated independently by two reviewers based on pre-defined criteria. Study participants had NSSP including impingement syndrome and excluding cervical pain. Interventions included cervicothoracic junction and TMT with or without supplementary exercises. Studies that included MT applied to the shoulder girdle including the glenohumeral joint, acromioclavicular joint or sternoclavicular joint in the TMT group, without a control, were excluded. Included studies utilised outcome measures that monitored pain and disability scores. Randomized controlled trials (RCTs) and clinical studies were eligible. Using a standardised form, each reviewer independently extracted data. Risk of bias was assessed using GRADE and PEDro scale. Results were tabulated for semi-quantitative comparison.
  
  
  RESULTS
  Over 912 articles were retrieved: three RCTs, one single-arm trial and three pre-post test studies were eligible. Studies varied from poor to high quality. Three RCTs demonstrated that TMT reduced pain and disability at 6, 26 and 52 weeks compared with usual care. Two pre-post test studies found between 76% and 100% of patients experienced significant pain reduction immediately post-TMT. An additional pre-post test study and a single-arm trial showed reductions in pain and disability scores 48 hours post-TMT.
  
  
  CONCLUSIONS
  Thoracic manual therapy accelerated recovery and reduced pain and disability immediately and for up to 52 weeks compared with usual care for NSSP. Further, high-quality RCTs investigating the effect of TMT in isolation for the treatment of patients with NSSP are now required.
authors.affiliation: Musgrove Park Hospital Taunton, UK.
authors.forename: Aimie L
authors.initials: AL
authors.lastname: Peek
authors.affiliation: University Hospitals Birmingham NHS Foundation Trust, UK.
authors.forename: Caroline
authors.initials: C
authors.lastname: Miller
authors.affiliation: University of Birmingham, UK.
authors.forename: Nicola R
authors.initials: NR
authors.lastname: Heneghan
keywords: Manipulation; Manual therapy; Shoulder pain; Thoracic spine